Trigger Points - Sometimes Difficult to Find

[Fisher]

Just got back from a cystoscopy and the uro noted an enlarged median lobe. Is this common with prostatitis or is it bph. I am 35 years old and have had chronic prostatitis / chronic pelvic pain syndrome symptoms for the past 10 years. Am I too young for bph?

[alprost]

Just got back from a cystoscopy and the uro noted an enlarged median lobe. Is this common with prostatitis or is it bph.

Not sure - sorry. Ask you Uro.

I am 35 years old and have had chronic prostatitis / chronic pelvic pain syndrome symptoms for the past 10 years.

Have you ever had your pelvic floor muscles examined during this time? These are the chief cause of symptoms in around 90% of chronic prostatitis / chronic pelvic pain syndrome sufferers.

Read this link: https://ucpps.men/chronic-prostatitis-is-a-psychoneuromuscular-condition

Am I too young for bph?

BPH is unliklely.

[dshoskes]

Have you ever had your pelvic floor muscles examined during this time? These are the chief cause of symptoms in around 90% of chronic prostatitis / chronic pelvic pain syndrome sufferers.

That is an amazing statement which I don't think can be supported by any scientific evidence. I routinely palpate the pelvic muscles, which incidentally can be in spasm secondary to bacterial prostatitis (and gets better with antibiotics) or inflammatory prostatitis and detect such spasm (which again can be a primary or secondary problem) in fewer than 1/3 of my patients. I'm not saying that pelvic floor muscle spasm doesn't exist and indeed some patients do get better with treatment targetted to the pelvic floor. But claiming that it is the chief cause of symptoms in 90% of chronic prostatitis / chronic pelvic pain syndrome patients is as "out there" as the claims of others that it is 90% bacterial or 90% autoimmune.

I'm at the AUA right now and have spent a lot of time talking with Rodney Anderson and I have never heard him quote a figure like this.

Finally, that pesky median lobe can cause obstruction in younger men (although I doubt it was there when the patient was in his early 20's) and is certainly easy to treat with TUNA or a TURP. Of course, the need for treatment can only be decided by an in person assessment by your Urologist.

[webslave]

That's quite right: the Pain in the Pelvis approach to male chronic pelvic pain does not have clear scientific underpinnings yet, and quoting figures like 90% may be misleading. The component parts of the pelvic myoneuropathy (our term) theory are reasonably well established (neurogenic inflammation, mast cell involvement etc), but tying it all down to:

Anxiety/trauma/infection (and other triggers) --> pelvic muscle spasm --> neurogenic inflammation --> pain

has yet to be put together in a study.

I'm not sure how it can be sufficiently proven, given the broad range of the theory, and the requirement for double blinding and placebos. Probably the best thing would be to take a cohort of refractory men through the Stanford treatment as a first step, and see what results we get.

[alprost]

Have you ever had your pelvic floor muscles examined during this time? These are the chief cause of symptoms in around 90% of chronic prostatitis / chronic pelvic pain syndrome sufferers.

That is an amazing statement which I don't think can be supported by any scientific evidence.

I was basing this statement on the paper by Zermann et. al. (1999) which did find myofascial tenderness in 88% of Type IIIB chronic prostatitis / chronic pelvic pain syndrome patients.
(Chronic Prostatitis: A Myofascial Pain Syndrome? Dirk-Henrik Zermann, MD, Manabu Ishigooka, MD, Ragi Doggweiler, MD, Richard A.Schmidt, MD, University of Colorado Health Sciences Center, Denver: Infect Urol 12(3):84-88, 92, 1999)

There is therefore some good evidence to back up this statement.

Obviously, there are a whole host of factors which can cause 'prostatitis' symprtoms - I should have been more specific, and stated that myofascial tenderness is likely to be the main suspect sfter a full Urological work up has been completed, and all other factors, such as infection, have been ruled out.

I routinely palpate the pelvic muscles, which incidentally can be in spasm secondary to bacterial prostatitis (and gets better with antibiotics)

Yes, but if the infection is prolonged, and myofascial trigger points have developed in the pelvic floor due to overload from the spasm, the infection clears up with ABX, but the pelvic pain from the trigger points/muscle spasm does not and the patient is left with symptoms - This is exactly what happened to me.

Rohnda Kotarinos, A physio who serves as a consultant to the Stanford Group, notes this in IC patients:

A patient who has never had any symptoms before develops an awful bladder infection, culture positive. She is treated with antibiotics, as she should be. Symptoms are, as we all know, frequency, urgency and pain on urination. Maybe the first round of antibiotics does not help, so she goes on a second round. They work. But she has now walked around for 2, maybe 3 weeks with horrible symptoms. Her pelvic floor would be working very hard to turn off the constant sense of urge. This could create overload in the pelvic floor. A trigger point develops, that can now cause a referral of symptoms back to her bladder, making her think she still has a bladder infection. Her cultures are negative..

I routinely palpate the pelvic muscles, which incidentally can be in spasm secondary to bacterial prostatitis (and gets better with antibiotics) or inflammatory prostatitis and detect such spasm (which again can be a primary or secondary problem) in fewer than 1/3 of my patients.

This is a very timely point for me personally. Up until 6 weeks ago I had had my pelvic floor muscles palpated by TWO physiotherapists, both specifically trained in assessment of pelvic floor muscle spasm and myofascial release. They couldn't find any more trigger points, and I couldn't work out why I was still in pain. I then had them checked by someone else who has found more that 15 (yes fifteen!) trigger points in my pelvic floor, many of which were beside the prostate, towards my pubic bone. In the space of 6 weeks, I've gone from having to get up several times a night and being unable to exercise, to sleeping through the night, and, for the first time in 2 1/2 years, being able to take part in strenuous exercise with no ill effects. My point - trigger points can be easy to miss, even if you are specifcially trainied in their location and treatment, and it is compeletely different to feeling an entire muscle which may be tight and inflamed as a result of being in spasm. David wise seems to have a similar opinioin:

It is the normal course that the discomfort diminishes over time during and after physical therapy. If it doesn't, in my experience, the problem is often that the physical therapist is missing something.

I'm at the AUA right now and have spent a lot of time talking with Rodney Anderson and I have never heard him quote a figure like this.

I'd be interested to hear his take on the Zerman et. al. (1999) paper.

As Mark has pointed out, there is obviously a whole lot of research that needs to be done. But, the limited evidene that is available suggests, to me at least, that when other factors have been ruled out, and someone has the diagnosis of Category III CPPS, pelvic pain of myofascial origin is a likely cause which must be investigated.

[DX]

Dr. Shoskes, you say:"I routinely palpate the pelvic muscles, which incidentally can be in spasm secondary to bacterial prostatitis (and gets better with antibiotics) or inflammatory prostatitis and detect such spasm (which again can be a primary or secondary problem) in fewer than 1/3 of my patients"

Dr. Shoskes, you palpated my muscles number of times and said that there is no muscular cause to my symptoms. However, physical therapist found numerous trigger points and areas of spasm. Physical therapy with relaxation gave me tremendous improvement, which stood for the past 7 months. The main symptoms that I have are related to side effects of quinolone antibiotics, which you prescribed to me (intense cramps in my feet, arms and even neck, tingling, tendon pain).
I am not defending 90% figure, just pointing out the fact that you don't seem to have a great success in determining musclular cause. I say that because areas of spasm and trigger points in my pelvis and abdomen, were described as obvious by the physical therapist.

[alprost]

Dr. Shoskes, you say:"I routinely palpate the pelvic muscles, which incidentally can be in spasm secondary to bacterial prostatitis (and gets better with antibiotics) or inflammatory prostatitis and detect such spasm (which again can be a primary or secondary problem) in fewer than 1/3 of my patients"

Dr. Shoskes, you palpated my muscles number of times and said that there is no muscular cause to my symptoms. However, physical therapist found numerous trigger points and areas of spasm. Physical therapy with relaxation gave me tremendous improvement, which stood for the past 7 months. The main symptoms that I have are related to side effects of quinolone antibiotics, which you prescribed to me (intense cramps in my feet, arms and even neck, tingling, tendon pain).
I am not defending 90% figure, just pointing out the fact that you don't seem to have a great success in determining musclular cause. I say that because areas of spasm and trigger points in my pelvis and abdomen, were described as obvious by the physical therapist.

This supports my point above 100%.

[dshoskes]

Dr. Shoskes, you say:"I routinely palpate the pelvic muscles, which incidentally can be in spasm secondary to bacterial prostatitis (and gets better with antibiotics) or inflammatory prostatitis and detect such spasm (which again can be a primary or secondary problem) in fewer than 1/3 of my patients"

Dr. Shoskes, you palpated my muscles number of times and said that there is no muscular cause to my symptoms. However, physical therapist found numerous trigger points and areas of spasm. Physical therapy with relaxation gave me tremendous improvement, which stood for the past 7 months. The main symptoms that I have are related to side effects of quinolone antibiotics, which you prescribed to me (intense cramps in my feet, arms and even neck, tingling, tendon pain).
I am not defending 90% figure, just pointing out the fact that you don't seem to have a great success in determining musclular cause. I say that because areas of spasm and trigger points in my pelvis and abdomen, were described as obvious by the physical therapist.

Of course I have no idea who you are (nor am I asking you to reveal your name) but I am delighted you are feeling better. I suspect you were not examined on the same day by me and by the physiotherapist. There are a sufficiently large number of patients I have treated with modalities other than physical therapy or acupuncture who, despite having palpable muscle spasm, do get better with other medical treatments to make me feel comfortable in my assessments (which will never be 100%). Furthermore, having performed exams on thousands of men who have NO pain, I appreciate that most men will have areas of point tenderness to palpation during a rectal exam, which does not have any relationship to pelvic pain. We are hampered in our geographic area by a lack of qualified physiotherapists however.

I still stick by my general treatment plan to treat infection when present, treat inflammation when present and treat muscle spasm when present, at least until we have a better way to assess the etiology of the patient's pain syndrome.

[latte]

This is a very interesting topic. When I went to UCLA the doctor examined me and asked me if I was feeling any pain while he pressed on my pelvic floor muscles rectally. I said no and he said, well I guess the pain is all coming from the prostate. This was about two years ago and I have not aggressively pursued the PT route for that reason. It was a very simple test and not nearly a full evaluation of the pelvic floor but it was enough to keep from seeing a qualified PT. Maybe I will now. Interesting that this ailment is so elusive.

[Richard.N]

And isn't it great to see a lively debate?

[webslave]

Surely.

I am concerned about this issue of trigger points and how difficult they are to find. I'm not keen on voodoo or special knowledge in diagnosis. I want to see more on exactly what has to be done to isolate these points in and around the rectum and pelvic floor.

I don't like the notion that a urologist may not be able to find trigger points. How much specialized training is involved in finding them? How truly difficult are they to find? What exact techniques should be used? Where is this technique written down? Where are the diagrams to illustrate? I know DW is working on something, but we need it yesterday.

[DX]

The issue whether the trigger points can be isolated scientifically is interesting and important, but there are two crucial points that have to be mentioned
1. Trigger points are not always found even by PT. Sometimes it's just areas of spasm that are caused by bracing. In fact, most of my trigger points were in the abdomen, and spasm was in the pelvis.
2. PT/Relaxation protocol so far is the only treatment that shows promise (I believe that it had one trial and a ton of anecdotal evidence) AND doesn't have dangerous side effects.
If someone would tell me what I know about the results of placebo trials of antibiotics and serious adverse reactions to them (OK some of it is written on prescribing information and I didn't take it seriously enough) and anecdotal evidence on physical therapy, I would say:

One would have to be out of their mind (or just in intense pain and believe the doctor) to take antibiotics, do injections, take Neurontin, Flomax or whatever before pursuing side effect free treatment of physical therapy/relaxation and seeing how it works out after 3 months or so.

[Richard.N]

One would have to be out of their mind (or just in intense pain and believe the doctor)...

Or maybe not have knowledge of or access to physical treatment?

[alprost]

This is a very important issue, and I'd like to make a few comments relating to some of the above points:

I don't like the notion that a urologist may not be able to find trigger points.

The point is that even those few Urologists who are knowledgable enough to palpate the pelvic floor, have likely not received specific training in how to locate myofascial trigger points. As both Dr. Shoskes and Richard point out, finding a trained physio can be a problem.

How much specialized training is involved in finding them? How truly difficult are they to find?

I've had a think about this since yesterday, and my honest opinion is that they are not all that difficult to find IF someone knows what they are FEELING for. As soon as someone has palpated a normal pelvic floor, and then they palpate a trigger point with their finger tip, note what it feels like, and then, most importantly, feel it release after several seconds due to the golgi-tendon reflex, they know what a trigger point is. Until someone has felt this, under the guidance of a trained AND experienced physio, they simply will have no reference for what they are looking for. As soon has they have this point of reference, and they 'know what they are looking (sorry, feeling!) for, careful examination of the entire pelvic floor coupled with close communication with the patient, pelvic floor trigger points are not all that difficult to find. It would be really useful if we could get one of the Stanford physios to comment on this issue.....

Furthermore, having performed exams on thousands of men who have NO pain, I appreciate that most men will have areas of point tenderness to palpation during a rectal exam, which does not have any relationship to pelvic pain

I agree - I know from the number of internal sessions I have had (A new hobby I could have done without!) that it is a sensitive area. However, in my experience, these 'points of tenderness' are not trigger points, which have a very distinctive feeling to both therapist and patient, and reflexively release after several seconds of pressure.

I still stick by my general treatment plan to treat infection when present, treat inflammation when present and treat muscle spasm when present, at least until we have a better way to assess the etiology of the patient's pain syndrome.

I agree 100%. It was this logical and systematic approach to treatment outlined on your web page, along with all of your posts I could find on the Google newsgroup, that originally formed the basis for the treatment strategy I have pursued. The question is how can Urologists (and Physiotherapists) better assess the contribution of pelvic floor trigger points and muscle spasm to a persons symptoms.

[webslave]

This is an interesting thread. I'm moving it to the Best Posts forum.