[Case Studies] Managing a complex male pelvic pain case with Bill Taylor

In this episode with Bill Taylor, we discuss his recent case study on a young male cyclist with urologic chronic pelvic pain syndrome. Bill takes us through: 

• Key differential diagnoses around the pelvic region
• Key subjective findings around the pelvic region
• Treatment of a complex perineal case
• Subjective and Objective Examination
• Pelvic floor cueing tips
• Additional testing to have checked for symptoms such as incomplete bladder emptying, urinary frequency etc. 

This episode is closely tied to Bill’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

 👉🏻 Watch Bill’s case study here with our 7-day free trial:
https://physio.network/casestudy-taylor

Bill Taylor is a physiotherapist with almost 40 years of experience, including more than 25 years specialising in pelvic health. Internationally recognised as a leading expert in male pelvic floor dysfunction and chronic pelvic pain, he combines manual therapy and exercise-based rehabilitation and has contributed to several key textbooks in the field. Based in Edinburgh, Bill is Clinical Director of his own pelvic health clinic, teaches at multiple universities, has worked with elite dance organisations including Scottish Ballet for over 20 years, and serves on the boards of both the Pelvic Obstetric and Gynaecological Physiotherapy group and Prostate Scotland.

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Our host is @James_Armstrong_Physio from Physio Network

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Transcript

SPEAKER_01 0:02

Welcome to this episode of Case Studies by Physio Network. Today I'm joined by Bill Taylor to discuss a real case of urologic chronic pelvic pain syndrome in a young male. Bill is an Edinburgh-based physiotherapist with over 30 years' experience in pelvic dysfunction and is widely recognised for his work in male pelvic health, chronic pelvic pain, and the use of manulent exercise therapy in complex pelvic floor presentations. He also is currently undertaking a PhD, further adding to his expertise in this specialist area. In this episode, we work through a real case step by step from initial subjective assessment through to differential diagnosis and treatment. We explore how clinicians can differentiate pelvic floor dysfunction, chronic pelvic pain syndrome, pedundal neuralgia, and urological pathology when assessing a man with persistent pelvic pain. Bill then talks us through the rehabilitation approach, including the role of exercise therapy, movement retraining, pelvic floor muscle rehabilitation, and reducing pain, improving confidence and restoring function. This episode really will be particularly useful for clinicians working with persistent pelvic pain, complex male pelvic health presentations, and patients whose symptoms just don't quite fit neatly into that diagnostic box. I'm James Armstrong and this is Case Studies. Bill, great to have you back on the podcast this time on the case studies. How have you been?

SPEAKER_00 1:28

Yeah, thank you very much for having me. Yeah, I've been good, thank you. Just busy as usual, but nice to be here. Thank you.

SPEAKER_01 1:34

As we were speaking off-air, it's great to be busy, and especially in an area that you're very passionate about, and our listeners are going to gain an awful lot from what you've got to share with us. So, Bill, we're going to be investigating the case study that you've recently done for the Physio Network. Obviously, we're not going to be able to go into as much detail as the case study itself goes into. So we'll direct listeners down to the show notes to check that out. But um, let's kick start and we've definitely got some pearls of wisdom in this one. Introduce the patient and through the subjective for us, Bill, would you?

SPEAKER_00 2:04

Sure. So this uh chap that I saw, he was the 30-year-old old male, he's a cyclist, he's a professional IT consultant, he's married, he had one kid. He cycled usually about 150 to 100 kilometres a week. He had an 18-month history of perineal and suprapubic pain when he came to the clinic. And he reported that it was worse sitting, also worse when he had stress. It was better when he was moving. He did have a high-stress job, which he found really increased his symptoms. Interestingly enough, his intimacy was affected, which he kind of gave up quite early on. Cycling increases his symptoms, and it kind of almost like cycling was one of his big things. That's what reduced his stress. So he was quite distressed by it, and the fact that a lot of his management strategies to reduce his stress really had ramped up his symptoms. He also found that weight training, which was his other stress reduction, really increased his symptoms. When we looked at his perineal superpubic ache, his initial VAS score was about three out of ten minimum, eight out of ten maximum, which is quite a high score on visual analog scale. Was worse on sitting, which with an immediate onset, which actually really interfered with his ability to do his job, really. He couldn't sit down very comfortably. And then he was quite emotional, I think, when he came to see me, when he was telling you this story, because I feel he'd had it for quite a long time, he'd seen quite a lot of different people and hadn't really had very much success with any interventions. From a lower urinary tract uh symptom kind of point of view, he had uh frequency of urination, so he was going to the toilet way more often than he probably would expect to go. So maybe we would go three, four, five times a day. He was going up to maybe eight to ten times a day. And he also had urgency, which meant when he had to go, he had to go, so there was no hanging about. And then after he'd peed, he basically had incomplete emptying. So he basically found that he would do a pee, but he would always feel there was something in there that that wouldn't come out. With regards to his sexual kind of function, he'd really find he had reduced libido because of the pain aid or occasional erectile dysfunction. And this is quite a young guy, so these things can be really can be really, really distressing in a young person, I think. You don't expect it, you know, you don't expect at this age that you're going to be getting these lower the urinary tract dysfunction and sexual dysfunction for sure. He had a lot of anxiety, distress, and actually his symptoms weren't improved by rest, and he'd tried stretching and basically had really no change. And that's when he he showed up in the clinic.

SPEAKER_01 4:41

Gosh, there's an awful lot to unpick there, Bill. I'm sure listeners are probably thinking, How on earth would they well what would they be thinking if this turned up on their door? There's a lot of complexity in there. There's a lot that some might be thinking, how does this sit into an MSK clinician's caseload? How on earth did you unpick this? Obviously, this is an area of specialism of interest and of knowledge for you, Bill. But for the listeners that maybe aren't that up to speed with male pelvic health, talk us through some of your thinking at this point.

SPEAKER_00 5:14

You've obviously got some kind of differential diagnosis thinking here. You're thinking, do they have a chronic bacterial infection, prostatitis, for example, or one of the other conditions is benign prostatic hyperplasia, which is where you get growth in the prostate, which limits your urinary function, but can also give you dysfunction and discomfort? Could it be the pirenal nerve sensitization because he's a cyclist, so he's on that nerve quite a lot, he's up to 150 kilometers a week. Is it purely something to do with his pelvic floor and maybe the fact that his pelvic floor isn't relaxing enough, that it's always staying contracted? And then maybe because he's had it for quite a long time, is there some central sensitization, functional pain soon going on because it's been there, it's become almost like a chronic situation. And you're right, I think it is a tough thing if you're an if you're an MSK physio and you're presented with somebody with urinary tract um uh or incontinence or changes in their continence function because you think it's kind of a little bit outside your remit. And maybe it is, but often this guy had when he came to see me, had already been to see a couple of urologists, he'd had a lot of blood work done, a lot of a urological scan to basically eliminate any kind of red flags or anything that we'd have to be concerned about. He'd also been to see a couple of other physiotherapists to look at whether he had some, you know, because people think um you know adductor strains, incessional hamstring strain, inflammation of the symphys pupus, those kind of things are all the things that I'd kind of considered really, and then often ruled out by the time they come to see me. So I think in my mind I'm thinking, you know, like, does he perhaps have some chronic pelvic pain syndrome, which is really defined as being pelvic pain greater than three months in any six-month period? It presents with variable urinary sexual bowel symptoms, there's no clear infection, flares with stress, sitting, cycling, or ejaculation. So he did fit into a little bit of that. It's not just often one thing, so he almost it's a bit like pelvic floor twister. So he has one foot in one uh arena and then maybe another hand in another. So he had some peripheral dysfunction, his pelvic, he had periphore tenderness, urinary hesitancy, all those kind of things. Pedendal neuralgia is another thing we need to kind of consider. And again, elimination ideas about these are around like do they have burning tingling in the p. And things like if you are looking at this patient thinking, well, where do I even start with this? You want to make sure that there are no signs of infection, no, no blood in the urine, you no retention of urine, and probably no testicular prostate and pathology. That's maybe been ruled out by the medics by that point. There's a big kind of shift towards cyclists often that have saddle pain, often just automatically quakes with p-denal neuralgia, but it can really be more pelvic floor overactivity, nerve tissue sensitivity, and maybe load intolerance of the pelvic floor from exercise and sitting on it.

SPEAKER_01 8:29

Brilliant, brilliant. That's a good, really good insight. So, where do you go next in terms of what are you looking to try and take your differentials, narrow that funnel down into something that you can then start planning a treatment for?

SPEAKER_00 8:42

My subjective questions are you know, like what has he had urine semen culture tests? What's his prostatic, specific antigen values? Has he had an MRI of his pelvis? Has he had a cystoscopy? If he's gone down the urological route, a lot of these things rule out infection, malignancy, or obstruction from prostate growth. And I think once we've got those things out of the way, we can kind of look a little bit more at the physio exam, really, and that and how does this all tie in? How does it fit together? And so for me, coming from a an MSK point of view, I'm really looking probably outside the pelvic floor, not being so pelvic floor specific, but I'm interested in what is his range of motion looking in his lumbar spine, his thoracic spine, and then what does the movement look like again in his perineum on ultrasound imaging? I want to know what is his hip range of motion like, what's happening in obtreta internus, what's happening in the genus the femoral nerve, so I'm looking quite broadly to see that there's movement in there, there's if you like macroscopic movement as well as more microscopic movement. I'm interested in how his pressure system management is working, because it's not just about powerful tone, but how does that coordinate and tie in with how he manages his pressure system rather than just what's his breathing like? So does he have increased tone in his diaphragm? Does he have increased tone in his abdominal oblique? So I'm collecting this data really, what's his breathing strategy? And then I suppose then we move a bit more into the kind of more direct assessment of the pelv floor itself, looking at things like skin observation, what's his skin like? Because he you know you can get a lot of changes in cyclists that can either be from friction and abrasions, but you can also get changes if the pendal nerve is involved, and one looks a little bit dry and kind of chafed if it's just a skin issue, whereas if the nerve's involved, it looks a bit more irritated, red, angry. It can even have skin breakdown with kind of some bleeding on the superficial skin. We're looking at kind of when he actually moves his contracts his perfect floor. Do you actually see the palp floor, the perineum lift and de ascend and descend? And then things like but then again for me, I guess if you if you're an MSK physio, at that point you've got quite a lot of information. Is there an issue between him contracting his palp floor and breathing? And that might be where you stop. It might well be that you then go on to assess what your findings would be, or you might at that point think, well, actually, I think there's more of a pelvic floor issue here than a hip lumbar spine problem. So I'm maybe going to refer him on to get a pelvic health physio to have a look at this. Because the the I think the next stage in the game for me would be to do like an internal pelvic floor exam where looking at the sphincter tone and levatorenae, what the strength, the power, and the endurance of those muscles look like. And that's obviously that's probably out of the scope of most MSK physios. That's not something that you have in your skill set unless you've gone down the pelvic floor avenue. The thing that I do often, because some patients don't want that, they don't want that intimate internal exam. So a point of care ultrasound or real-time ultrasound imaging can be really useful to analyze what the pelvic floor muscles are doing with breathing, what does the contraction look like, what's the relaxation look like. Also, we're able to by and that and we use a lot of transabdominal scanning for that, but if you want to look more in depth, you can use transparineal to look at the anterior posterior aspect of the pelvic floor, external urethral sphincter contractions, rectal sphincter, you can look at really what these muscles are actually functionally doing, which then gives us a really good start to where we would go next in the treatment.

SPEAKER_01 12:38

Ever wished you could see how experts treat real patients of theirs? With case studies by Physio Network, you can watch presentations where top clinicians break down real-life patient cases step by step, showing how they assess and treat even the trickiest of conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click link in the show notes to start your free trial today. Marvellous, marvelous. So, in brief, what did you find in this case to allow you to start moving forward?

SPEAKER_00 13:12

Yeah, so this guy, he basically his lumbar spine was full and pain-free. So you're kind of ticking that box going, okay, so it's probably less likely it's going to be being driven by his lumbar spine. But he had some pain at his thoraco lumbar junction with rotation. And one of the reasons we want to be looking at that is because if somebody's got some anterior hip pain or pain into their testicle or pain into that region, your ileo-inguinal genital femoral nerves kind of have a root from there. Our testicles embryologically start there in embryo and then distend through our pelvic floor. So we've got this kind of retained anatomical connection. So you want to be clearing that area if there's any anterior hip pain or pelvic floor pain. We finally had reduced internal rotation of his hip. He also had increased tone in his obtator internus. And obtetor internus is an external rotator of the hip, but it's about two-thirds inside the pelvic floor, one-third out. So, and it's quite closely connected to function and dysfunction of what the pelvic floor muscles are doing. He also had reduced mobility in his genital femoral nerve in the ilia inguinal canal. So there's a few things here already pointing towards neural mobility issues locally and distant from the point of pain. When we looked at his breathing, his he had changed his pattern of breathing, he had reduced diaphragm excursion, he had reduced lateral rib excursion. So basically, he wasn't really using or managing his breathing or his pressure system really very well. When we looked at the external pelvic floor, his skin was healthy. He did have reduced perineal movement. There was tender and palpation externally on the perineum, and he had increased tone in a couple of muscles that you can valpate along the perineum, with also an inability to let everything go. I went on and did an internal examinum. We find that it increased analsphinctor tone, increased tone in pubococcigeus and ischiococcus, here, which are the kind of muscles that run. One of them runs in the sad stole plane, pubococcus runs back to forward, back to front, ischio runs in the coronal plane, and he had this ability, reduced ability to contract and relax, as well as measurable reduction in strength, power, and endurance. When I actually tried to palpate his perennial nerve, we could find that it was quite sensitive. He had a he actually had a positive Tinel sign on the nerve and a reduced nerve mobility. And it's it's the principles around this really still are kind of embedded in peripheral neuropathy assessment, if you like, and peripheral nerve reduction of mobility. And just taking those principles and just applying them into this case to kind of like, if you like, reinforce those findings or to underline them a little bit, using ultrasound trans abdominally again showed reduced diaphragm descent, reduced pelvic floor descent. And then transparent really showed this alteration between the front and the back of the pelvic floor and reduced muscle contraction around the bulb of the penis, which is where where we're kind of looking for decent function in men. And men's pelvic floor works quite differently to female pelvic floor. So this, and I suppose if I summarised that, he basically had pain at his therapy lumbar junction with rotation, reduced hip internal rotation, mechanical restriction, obturator on tennis, increased tone, decreased strength, breathing and diaphragm changes in his pressure management, external power flow with increased tone. So I'm collecting all this data thinking he's got muscles that are not switching off, he's got muscles that aren't contracting properly, that are not producing all the force that he needs. Internal periphery increased tension, increased tenderness, increased tone in the muscle, and decreased pudendal nerve mobility, all confirmed a little bit using the ultrasound imaging. So that kind of takes me to a point where like we've got pelp floor overactivity, impaired relaxation, a secondary issues of reduced strength and endurance and power with compromised functional support. And then the contributing factors probably were thorough luminal dysfunction, hip restriction. And we don't know whether what the driver here is. We're just looking at collecting all this data and then maybe deciding what factors we think are the most important to go for to see if we can change things. So we had this overall picture of a mixed presentation of increased muscle tension, weakness, and impaired pressure, neuromuscular control.

SPEAKER_01 17:30

And again, still lots to unpick. Absolutely. So, in terms of the treatment, obviously we haven't got time to go into huge detail about that, but you have done in great detail um in the case study. But what was your sort of overarching treatment plan with this patient?

SPEAKER_00 17:48

I think one of the things about these patients, and I think it is it's a bit overwhelming when you have this list of all of these things right in front of you. And what are you going to do? Where are you going to start? And I think I have a little bit in my mind, I have this kind of pelvic floor rehabilitation continuum, really, that starts at one end where you're going to do down training, relaxation, patient education, trying to explain to the patient they've got this pelvic floor that is just overworking and not relaxing. So the first thing is to do pressure management, re-education, so breathing, retraining, diaphragmatic breathing, or lateral costal breathing or belly breathing. And usually the type of breathing that you teach them is the type that they're not doing. So you give them something different to do. A little bit of gluteal relaxation, mindfulness strategies, and that can just be by lying on spiky balls or lying on a foam roller. But it's a little bit about getting switching everything off and trying to upregulate parasympathetic nervous system in a way by getting everything to be down trained rather than up and ready to go sympathetically. I think manual therapy mobilization for thoracumbo junction, mobilization, like mechanical desensitization of obturated internus, and that starts usually externally. Soft tissue work around again externally on pubococcus or ischiococcus to try to reduce tenderness or reduced increased tone on those muscles just by applying mechanical force and keeping it there until the muscle relaxes. And then things like immediately trying to introduce pelvic floor relaxation training, so drop in release strategies, use of imagery of how you get that to go, because it's quite hard to. I would say this a bit, most guys don't really know they've got a pelvic floor, most guys don't connect with their pelvic floor very much until it stops working or until it starts giving them bother. So it's quite a hard thing to do. And ultrasound biofeedback is a really useful way of showing them that. If you don't show have that, it's a bit more, it's a bit more difficult, but you can do it by showing them how to relax their pelvic floor by looking at their air their pelvic floor area in a mirror to show that they get that sense of dropping. Then, so I suppose down training relaxation was my first line, neuromobility and desensitization. So pendal nerve glides using the hip and the lumbar spine, then direct internal glides on the nerve itself by strumming across it to try to get the nerve to be a bit more mobile. And then looking at the genitofemoral ilia inguinal nerve and the inguinal canal to do the same thing, either seeing if there's increased tension and muscle around that nerve, or do you just need to actually start getting it moving a little bit? And it's a little bit about graded desensitization. So, how much load can we put on that tissue to help desensitize it in a way? Because I think they're definitely with these guys, there's a degree of central sensitization happening, and you want to reduce their fear about moving and reduce the give them agency that they can actually move it themselves. Then the next thing is probably moving on quite quickly to more to control and strengthening, so contract, relax cycles, posterior pelvic floor activation, anterior pelvic floor activation. There's a bunch of signs behind cues that you could use. So things like if you ask a guy, for example, to contract your pelvic floor like you're doing a poo, it really works their posterior pelvic floor. But if you ask them to shorten their penis or lift their testicles or work the front part of their pelvic floor, it's been shown on ultrasound and MRI that it really works that the muscles at the front along the shaft of the penis, which are the ones that are really close to the dorsal branch of the pudendal nerve. So we get some of these muscles working, but we also get some of the mobility happening in the nerve itself actively. And then I think just applying my kind of background is really strength and conditioning. So I'm really interested in looking at applying specific strength and conditioning principles to these muscles to work on strength first, to then work on endurance, and then to work on power, just exactly the same way that you would do by working on muscles in the gym. And then the final thing is really like functional integration. So breathing and pelvic floor contraction and synergy and coordination, dynamic tasks like hip squat, hinging, rotation patterns with pelvic floor control, and then back to to kind of activity. So it's kind of that's kind of the overall plan, which is then kind of phased out, really, if you like, over maybe the first phase might be a zero. Because I think people say, How long does this take? Well, I think maybe phase one could be zero to four. We're looking at education, reassurance, relaxation. Phase two is maybe the nerve mobility work and then gentle contract relax. And then again at this point, maybe introduce sitting exposure because if sitting's an issue, you need to bring that back as a graded exposure. Phase week three, which could be eight to twelve weeks, you're again building strength and endurance, power, gym work. And then phase four is like 12 beyond three months. You're looking, we were looking at continue manual therapy, functional loading, and then getting them back on the bike and getting him over that fear of you know what did that look like for him? Because it's you know, because he was probably really anxious that if he went back on the bike, everything was gonna flare up.

SPEAKER_01 23:04

Bill, thank you so much for your time. We have covered tons, and there is still so much more to cover. I think listeners will be able to hear from the passion in your voice about how much there is that that we could unpick in this. So I would implore everyone to have a look at the case studies. And we definitely need to get you back on again. Bill, if you're happy to come back on, I think we need to talk more about this subject because it's not talked about enough and it's not. No, absolutely.

SPEAKER_00 23:28

I'll talk about it all day. That's fine.

SPEAKER_01 23:30

Well, we'll split it into 20 minute explain podcasts, maybe a series of them. Brilliant. Bill, right. Have a great rest of your evening. Thank you ever so much again. Thanks very much, James. Thank you. Take care.