Manual Therapy Intervention in Men With Chronic Pelvic Pain Syndrome or Chronic Prostatitis: An Exploratory Prospective Case-Series

Participants

• Number: 23 men.

• Criteria of inclusion: men, age > 20 years, diagnosis of chronic pelvic pain syndrome or chronic prostatitis type IIIB according to the US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) classification, prostate soreness during the first clinic visit, and negative urine and semen culture.

• Criteria of exclusion: presence of clinical conditions that can explain the pain (eg, herniated disk, urinary tract infection, rectal pathology, anal fissure, hemorrhoids), having received physiotherapy specifically directed at chronic pelvic pain syndrome in the past 6 months.
• Groups of study:
  • Group 1: manual therapy, 23 men (mean age 47.35 years)
    • on average, 2 years since the diagnosis of chronic pelvic pain syndrome and 3 years since the onset of the symptoms.

Interventions and evaluations

• Assessment of symptoms associated with chronic pelvic pain syndrome through NIH-CPSI, of urinary function through IPSS, anxiety/depressive state through HADS, and pain by VAS, at baseline, at the visit after the end of treatments, and then 6 weeks and 12 weeks after the end of the study.
• 6 sessions of manual therapy: 3 weekly and then 3 fortnightly.
• Manual treatment: protocol designed to work on muscle structures, fascial mechanics, neurovegetative system and vascularizaton.
  • Techniques used: Global Technique of the pelvis, fascial correction of sacrum, T12 lift;  psoas pumping, suboccipital inhibition, peritoneal equilibration, manual muscle stimulation, coccyx and perineum release, ischioanal fossa, myofascial release; global abdominal hemodynamic maneuver, techniques directed at the abdominal aorta, mesenteric and iliac arteries, and celiac plexus.
• Management of emotional factors and discussion of information related to the syndrome was added to manual therapy
• Evaluation performed by a urologist; treatment performed by a physiotherapist.
• Patients mantained their drug treatments (where applicable).

Results

• Primary outcome: manual therapy showed a statistically and clinically significant reduction in symptoms measured through NIH-CPSI at the end of the 6 treatment sessions. After the 6-week follow-up, symptoms increased slightly. Nevertheless they remained low compared to baseline, showing a clinically significant difference most of the times (statistical significance was always achieved).
• Secondary outcomes: manual therapy induced a statistically and clinically significant improvement in urinary function measured by IPPS immediately at the end of the treatments, a result that was maintained both 6 and 12 weeks later. This result was related to an improvement in quality of life.
  Anxiety/depression states measured by HADS showed statistically and clinically significant changes at the 6-week follow-up. Specifically, anxiety symptoms reached their greatest reduction at this time and then recurred at the second follow-up, while depression symptoms reached their greatest reduction at the second follow-up, that is after 12 weeks.
  Finally, there was also a statistically and clinically significant improvement in pain by the end of the treatments, a result that was maintained for at least 6 weeks. At the second follow-up, the pain had increased slightly but remained lower compared to baseline.

Discussion

Given the achievement of clinically significant results recorded by analysing the scores of the different questionnaires used, and in particular the NIH-CPSI, manual therapy could be a viable therapeutic approach in chronic pelvic pain syndrome.

In this study, techniques directed at regularizing joint structures, reducing muscle stress, promoting fascial flexibility, and improving vascularity and local nerve transmission were evaluated.

Particularly interesting is the magnitude of the reduction in the NIH-CPSI questionnaire score – ie, 7.69 at the end of the treatment sessions, and then 5.82 and 5.11 at the two follow-ups – as it is comparable to, if not higher than, the treatments considered in the guidelines established by the European Association of Urology. In fact it ranges from a reduction of 0.87 points using 5α-reductase inhibitors, to one of 5.01 points with β-blockers and from one of 5.79 points with acupuncture to a reduction of 11.2 points with anterior tibial stimulation.

The result of this study is in line with previous studies that have evaluated specific techniques (eg, myofascial release) or comprehensive approaches (eg, manipulation, relaxation techniques, and psychotherapy).

However, studies of higher quality with reference to manual therapies and with a more robust and shared methodology are needed in order to make comparisons between different studies more easily.