Better Pain Free: Understanding Male Pelvic Pain

Better Man Clinics  

How common is pelvic pain amongst men?

Elizabeth Akincilar

What is published is somewhere between 8% and 12%.  I really think that it is so much higher to be honest with you. Because if you look at the rates of chronic prostatitis, whether it’s chronic nonbacterial prostatitis or actually bacterial prostatitis, that number is very high. I think a lot of those men are incorrectly diagnosed with bacterial prostatitis and they actually have chronic pelvic pain or non-bacterial prostatitis. So, I think that numbers are a lot higher. I mean, in women, it’s 20% to 25% of women. So, I would imagine it’s a little closer to 15 to 20% in men. But we don’t know.

Better Man Clinics 

Pelvic pain is a pretty generic term that can mean a lot of things to different people. For men, what are the common symptoms that men come to you with under the umbrella of pelvic pain?

Elizabeth Akincilar

Some of the most common symptoms are perineal pain, sitting pain, feeling like they’re sitting on a golf ball. Penile pain is also a pretty common thing or tip of penis pain even more specifically.  Post ejaculatory pain is probably the most common as far as sexual dysfunction goes that I find in men. Very often, men will also have urinary dysfunction and bowel dysfunction- things like constipation or incomplete bladder emptying or urinary frequency or urgency.  Often the symptoms go hand in hand.

Better Man Clinics  

Why is pelvic pain associated with sexual issues as well as urinary issues so often?

Elizabeth Akincilar

The pelvic floor has two components that we look at: the more superficial pelvic floor muscles (also known as the urogenital diaphragm) and the deeper pelvic floor muscles which are known collectively as the levator ani muscles. The urogenital diaphragm is, in part, responsible for urinary functioning, particularly when we want to not leak. When we laugh or cough, those muscles have to contract in order to prevent that leaking. In addition, those muscles are intimately involved in sexual functioning. They have to be able to contract and relax in order to get an erection and maintain an erection. And also, they have a role in ejaculation. Sometimes those muscles can be too tight. During sexual functioning, those muscles rapidly contract and relax during ejaculation to push the ejaculate out.  If those muscles are too tight, they can just tighten and tighten and tighten and you don’t get that relaxation after ejaculation. Therefore, after ejaculation, its almost like you have a cramp in those muscles and it produces pain post ejaculation. So, what we try to do is to relax those muscles so that when you enter a sexual situation, those muscles are at a normal resting tone and don’t tighten up too much during ejaculation.

Better Man Clinics  

Are those muscles primarily responsible for all the pelvic pain syndromes that we hear about?

Elizabeth Akincilar

Not necessarily. The muscles are one component. There’s also the fascia that surrounds our muscles and is superficial to the muscle that can play a part in in pelvic pain in that when there is dysfunction in underlying muscle, or nervous structures, or even viscera (organs) the superficial tissue responds by becoming less mobile. The tissue I am talking about is called connective tissue. It’s the tissue between the skin and the muscle. When that tissue becomes not mobile or hypo mobile, it doesn’t allow good blood flow in the tissue, which can cause a hypersensitivity in that tissue. If you think about it , if you put a rubber band around the tip of your finger, the tip of your finger becomes kind of hypersensitive as the blood is cut off. That’s somewhat what happens more globally in that situation. So that’s another contributor to pain. And then nervous or neuropathic pathology can absolutely contribute to male pelvic pain.  The nerve that we really consider is the pudendal nerve, which supplies the genitals, perineum, anus, rectum, and parts of the bladder. The other nerves that we consider are the ilioinguinal nerve genitofemoral nerve, and so on. A number of nerves can play a role in male pelvic pain.

Better Man Clinics  

So, it’s that combination of the nerves and the muscles, the structures all interacting? So, if somebody comes in with pain at the tip of their penis, and they think something’s wrong inside their penis, could it just be a nerve pain transmitted from somewhere else?

Elizabeth Akincilar

Indeed, indeed. One of the branches of the pudendal nerve, the penile branch, terminates at the tip of the penis. So yes, that’s absolutely one of the more common causes of penile pain, particularly if the description of pain is burning, searing, stabbing, electrical type pain.  Those are symptoms that are more consistent with neuropathic or nerve related pain versus pain that’s achy or sore and feels like a cramp- that tends to be more muscular in nature.

Better Man Clinics 

And does that type of pain also translate into the testicles as well or not as much?

Elizabeth Akincilar

So, it depends. When men talk about pain in their scrotum or testicles, I really want them to differentiate between the two because, of course, they have different innervation. Different nerves supply the testicles versus the scrotum. But yes, scrotal or testicular pain could be due to nerve irritation. Testicular pain is usually more neuropathic in nature, or something more visceral, that I would refer back to my urology colleagues. Scrotal pain can be referred from muscular structures. That is something that we see- not as frequently as penile pain- but we definitely see.

Better Man Clinics 

Your point about penile pain is an important one. This is where a lot of frustration comes in. A man often comes in to see the doctor and says, “the tip of my penis hurts.” The doctor examines the penis and says, “There’s absolutely nothing wrong with your penis. We will send you to a urologist.” The urologist then looks at the penis and says, “there’s nothing wrong with your penis but, you know what, maybe there’s something wrong inside of your penis. We will put a camera in and we’ll check it out.” They are doing their due diligence. And you know what? Sometimes there is something wrong and you find it, but a lot of times there isn’t. And that’s where that frustration comes in.  The patient starts to think, “ Does the doctor think I’m crazy? Does my wife or my partner think I’m crazy? I’m feeling this pain, but you’re looking at my penis and saying that there is nothing wrong with it?” That lack of understanding that the pain is actually originating somewhere else and being transmitted to the penis- that’s kind of where the disconnect occurs. It is just so important that you point that out, because, you know, a lot of guys are questioning themselves like, “Am I really feeling this?” 

Elizabeth Akincilar

I think that it is a hard concept for the average person to understand that there is a possibility that pain can be referred from another structure. That is absolutely something that I have seen many, many times with men- they are just convinced that there must be something wrong with the with the organ itself versus having pain referred from another structure.

Better Man Clinics  

Is there anything that men are doing that might bring about pelvic pain? Any type of activities that they should avoid? 

Elizabeth Akincilar

I think a common denominator of all people that struggle with pelvic pain is constipation. We do a very bad job in Western countries talking about how to actually cope with it.  When was the last time your primary care provider asked you, “how exactly do you poop every day?” Most people have no idea how to do it correctly. I think that the Squatty Potty has recently brought some awareness. 

Better Man Clinics  

I am familiar with it from Shark Tank. Absolutely.

Elizabeth Akincilar

Right. I think that has brought some awareness. But prior to that, no one really talked about it. I think that people’s dysfunctional ways of evacuating stool, particularly straining to get stool out, is one of the big causes of pelvic floor dysfunction. Because, when we strain, even though we think we’re using our muscles to push that stool out, what we’re actually doing is tightening those muscles, and using our abdominal pressure to push through that tightening. If we do that on a day to day basis, those muscles just essentially become tight and they stay tight, because that’s now their more comfortable state. So that’s one habit that definitely contributes to pain.

Better Man Clinics  

How do you know if you’re straining too much to have a bowel movement? How do you know if you are constipated?

Elizabeth Akincilar

People often say, “Well, no, I poop every day. I’m not constipated.”  However, it’s how you poop that I’m interested in. So, if someone tells me they are not constipated, I usually ask a few follow up questions. First, I ask “have you ever had hemorrhoids?” That is a sign that you’re likely straining. “Have you had a history of fissures or little tears in the anus that cause a little bit of bright red blood when you clean yourself after having a bowel movement.” If you have a history of that, that likely means that you’re straining to have a bowel movement. I ask if the stool looks like pellets or corncob. The goal is smooth like a snake. That’s what we want. If it is anything harder than that, your stool is likely sitting in the colon too long and you’re not going frequently enough. Sometimes I’ll ask those questions which lead us to the conclusion that, indeed, you are straining to have a bowel movement.  

Better Man Clinics  

What other elements activities can trigger pelvic pain?

Elizabeth Akincilar

Particularly with men, some things that we commonly see relates to exercise. On such exercise is a really heavy squat. When we squat, especially like a deep squat, like a catcher’s squat, the pudendal nerve glides over a small bone in our pelvis, called the ischial spine. And if you do that repetitively, with a lot of weight, that nerve can become irritated, and then cause pelvic pain. We do see that sometimes with men who do lots of really heavy squatting in the gym. Another exercise that we think about is cycling.  Some people can spend six hours every weekend on a saddle cycling, and they’re just fine. Maybe they have a little bit of irritation or numbness, which isn’t that great, but it resolves. However, other people will really develop pelvic pain from cycling. Again, that’s often because the structures of the pelvic floor as well as the pudendal nerve are being compressed as you are sitting on that small, hard seat. When structures like that are compressed, they become ischemic (they don’t get enough oxygen) because the blood flow is somewhat compromised, and that can produce pain and dysfunction. Now, some people don’t develop pain and one of the hypotheses for this is that some people’s anatomy may be slightly different, where that nerve doesn’t have as much mobility because of a little variation in anatomy. That small difference in anatomy compromises it enough so that someone can develop pelvic pain while others do not. So that’s kind of it on exercise.  But other causes are just more sitting. You know, this last year and a half is a perfect example where people have been more sedentary, staying at home and working from home and sitting a lot.  Just that increase in sitting, like cycling, can compress those structures, compromise them and produce pain. The other thing that we see with men is around sexual functioning. Some men will either masturbate too often or too aggressively, literally causing too much tension on the penis or the penile shaft, and that repetitively or over a long period of time, can cause irritation to that pudendal nerve, particularly the penile branch, and can develop pelvic pain,  Also, any procedure or any techniques to try to lengthen the penis, like jelking, can also cause an injury or irritation to the penile branch or the pudendal nerve.

Better Man Clinics  

If I am participating in some of the activities you mentioned and I am getting chronic pelvic pain, will the pain go away if I simply stop that activity?

Elizabeth Akincilar

So, the answer is, hopefully.  I think the approach that makes the most sense is yes, you stop the activity and you see if the symptoms resolve.  If they do resolve, great.  In that case, maybe slowly get back on your bike and see if the symptoms return.  But if symptoms don’t resolve with stopping the activity, if the symptoms persist, then I think you always want to check with your physician to make sure that there is nothing wrong that can be identified by a urologist. If all those diagnostic tests come back negative, then it’s time to seek out an evaluation with a pelvic floor physical therapist.

Better Man Clinics  

A lot of guys will get very frustrated if they are told that they have to quit a favorite activity like bike riding to overcome chronic pelvic pain? Is there a path that men can take -precautions or therapy- through which they can potentially resume those favorite activities? Is there a path to get them back to doing what they really like to do?

Elizabeth Akincilar

Absolutely, absolutely. I think that’s an important point to make. You know, even if we take away activities for a temporary period of time, it doesn’t necessarily mean that it is permanent.  If your goal is to get back on the bike or get back in the gym and doing squats, then that’s my goal for you. And that’s what we will work towards. And there are often things that we can do to set you up for success. It is often not just the compression on the bike or on the seat that’s causing the pain.  There are other things that you may be doing in your daily life that are also contributing. For example, if you sit at a desk all day, creating a sit-stand workstation (so you’re not sitting all day) may help. If you are constipated, improving your bowel functioning may help. Incorporating exercises to actually relax your pelvic floor muscles before you get on the bike and after you get on the bike to try to combat some of that tightening that’s happening may also be beneficial. If there are other things that you’re doing in life that are compromising that pudendal nerve, identifying those behaviors or activities and modifying them can also help.   If you have severe pelvic pain and can’t sit at all because of the pelvic pain and you want to get back on your bike, that’s not going to happen in six weeks time. But it, indeed, could happen eventually.  If that is the goal, then that’s we work towards.

Better Man Clinics  

What are some red flags associated with pelvic pain.  What signs should men be aware of that could signal something serious is going on?

Elizabeth Akincilar

Numbness, true numbness is a red flag. Not altered sensation.  Not like, “oh, it feels like pins and needles”, but actually, when we take something sharp and touch the genitals or the perineum and you can’t feel it – that is a red flag.  Also motor loss.  Also, if all of a sudden you are starting to leak urine or leak stool or are unable to get an erection at all – those are red flags.

Better Man Clinics  

On a high level, what are those red flags a sign of?

Elizabeth Akincilar

Those red flags are a sign that the pudendal nerve is being compressed to the point where it’s not conducting activity at all, and it could be entrapped.

Better Man Clinics  

Assuming we don’t have those red flags, what can guys try at home to manage run of the mill chronic pelvic pain? What resources are available to guys before they talk to a professional?

Elizabeth Akincilar

I think one easy thing to do is to start a mindfulness practice that encourages you to focus on decreasing, kind of turning the volume down, on your central nervous system.   Focusing on your breathing, particularly if you expand your diaphragm or really expand your rib cage, can make your pelvic floor relax automatically.  Practicing to breathe from the chest and not from the belly is important. Practicing that with a mindfulness practice can help relax the pelvic floor and sometimes really helps a lot.  Sometime, just that alone can reduce symptoms. Not straining to have a bowel movement, using a Squatty Potty, not bearing down when you have a bowel movement, improving your diet, increasing your activity- all those things can help. As far as self-treatment goes, with particular treatment of muscles or tissue, that’s a little bit harder to recommend without having some idea of what’s going on. We really need to assess the man and identify the issues before we can give them ideas on how to  treat at home. Whether that’s with a tennis ball or something called a Theracane or a foam roller, there’s a million tools out there that you can use.  However, we need to identify which would be best for them to use. There’s a couple of positions that are facilitators to relax the pelvic floor that I’ll often suggest. For those of you who are familiar with yoga positions, there’s a position called Happy Baby which is essentially on your back and you bring your knees kind of towards you with your legs, externally rotated and maintained in that position while focusing on your breathing- that helps to facilitate pelvic floor relaxation. Child’s Pose is another position that can help to facilitate pelvic floor relaxation. There are a couple of tools out there that can get people started.

Better Man Clinics  

With regards to the tools that you mentioned – the Theracane and foam roller – all that stuff is out there. You don’t need a prescription but, if I caught you correctly, you do need somebody to point you in the right direction. I saw some of these tools online and, you know, one of them looks like a weapon of mass destruction.  I’m sure if used it the correct way, it can be very valuable, but I just worry about guys using the tools incorrectly.  Could that potentially do more harm than good?

Elizabeth Akincilar

Yes, you really do need someone to point you in the right direction because pain is not always a good indicator of an intervention working.  “No pain, no gain” is really not true.  You really need to know where the dysfunction lies or where the muscle impairments are and then target them.  However, just using a foam roller and rolling over your legs and your butt every day and thinking to yourself, “this really hurts.  I’m going to really grind on”- that’s not necessarily a good thing to do. So, I caution people from just going online and looking at some foam rolling routine that someone put on, like a series of exercises for pelvic pain.  Just going through the series of exercises is not a great idea, particularly if there is any neuropathic involvement. Nerves are very stubborn and they’re somewhat vengeful structures. I think once you irritate them, it takes a while for that irritation to go down, so some of these stretches and exercises that are online can really compromise a nerve.  If it’s already irritated to begin with, you could just further irritate it. So, particularly if you have nerve symptoms like burning, shooting, stabbing, and lightning bolt pain, you really want to be particular about what exercises you do without the kind of guidance of a physical therapist.

Better Man Clinics  

There are a lot of support groups out there for chronic pain. What is your stance about diving into those groups without the help of a professional or some sort of guide?

Elizabeth Akincilar

Yeah, so this is a tough one. As providers, many of us have gotten into the social media world because we realize people want the information, they’re hungry to be to be educated, particularly with regards to pelvic pain.  They are not necessarily getting that education from their primary care provider. And that’s not found too often in the publications of primary care providers.  It is a very specific kind and poorly understood part of medicine. So, people are online- they’re Googling everything. Knowing that, we have, as many providers have, entered the social media world to try to educate people or, at least, give them the information. We want to provide them good information too, not just anecdotal information but actual data driven information that can hopefully get them on the right path. You don’t want to diagnose people online.  You just want to give people enough information to hopefully seek out a provider who can get them the rest of the way. And that’s really what we’re trying to do as well as trying to lessen some of the anxiety around some of these pain issues. Because, you know, having pain in your pelvis is quite anxiety provoking. Everyone will talk about their knee pain and their shoulder pain and their back pain, but you’re usually not sitting at dinner talking about your penile pain. So, I think it’s a way to educate and just bring awareness to it. 

Better Man Clinics  

It is definitely a challenge. I jumped on a few of these pain support groups just to check them out. I think they are extremely beneficial in the sense that you’re going on there and you see that you’re not alone. You see that there are people who can not only empathize, but sympathize, with the pain you’re having. They are validating that pain. Some of them can even share their stories of their journey and potentially send you to the right person, or at least refer you. But what always worries me is that mixed with that is a contingent of charlatans and snake oil salesmen . Desperation leads people to say, “well, I’ll just try anything.” That’s what worries me about the social media part.

Elizabeth Akincilar

Absolutely, I couldn’t agree with you more.  When patients tell me that they’re on various support groups, whether it’s Facebook or whatever it is, I always caution them.  I always encourage them, “if you want information about whatever it is, come to me and I will find that information for you.”  I will find really evidence-based medicine or evidence-based information as much as I can. Because in these groups, like you said, there are people that will say, “I have similar symptoms and I tried this and that worked well.”  As we know, everyone is so unique and no two patients are the same and no two histories are the same. So, you really can’t compare yourself to someone else online. And the other thing about these online groups is that folks that tend to really frequent some of these support groups are often folks who are still struggling and still looking for solutions. And so, I think it paints a picture that no one gets better, that no one improves, because many patients who do improve and return to their previous lives of having sex three times a week and bike riding when they want are not on those groups anymore. They’re getting on with their lives. So, for those patients that do have success – please, if you were on one of those groups before, go post your success story.  There is another side to this- that not everybody with this problem is doomed to be in pain for the rest of their lives. So, that’s one of my real struggles with some of those groups. I’m grateful that they’re there because they do allow people to know they’re not alone. I do appreciate that.

Better Man Clinics  

For a man who develops pelvic pain and has tried the stuff at home and nothing’s really working, who do they see first? Who do they see next? How do they potentially eventually get to a therapist like yourself?  What is the optimal path?

Elizabeth Akincilar

Men usually go to a urologist first to make sure that all the plumbing is okay. Assuming everything comes back normal, the next step is to see a pelvic floor physical therapist and get an assessment.  Then, depending on what the physical therapist finds, you go from there.  If there is a strong neuropathic component, I want them to see a pain specialist to talk about different medications that may help them control the pain and allow them to be more functional. If there’s a strong anxiety component, I may refer them to some sort of mental health specialist to try to control that component of it. In this world, physical therapists see themselves like the captain of the ship.  Patients will come see us and we are going to assess everything and get them to other people that will help in this process.  We see people on a weekly basis, so we really get to see how their symptoms are changing or progressing.  We really get to know the patient and modify different behaviors and activities in their life. 

Better Man Clinics

What should I expect when seeing a physical therapist like yourself for the first time for pelvic pain?

Elizabeth Akincilar

During the first visit, I want to know your whole history.  I want to know how this started, when this started, what activities you do, and what other health issues you have.  I want to know everything about your urinary symptoms and sexual functioning. So, I get that whole history and really have a good understanding of how this all happened, and also what you’ve maybe tried in the past – other treatments or medications – and what’s worked and what hasn’t worked.  Then I do a physical assessment. That starts with an external exam during which I’m looking and palpating (or examining) the tissues from the belly button to the knees, front and back. I’m examining the soft tissue below the skin and the muscular tissue, and I’m looking for restrictions and muscle mobility. I am looking for what we call myofascial trigger points, which are points within muscles that are taught and don’t move well and can cause pain. We do that exam. And then I also do an internal exam, which involves placing one finger through the anus during which we palpate the pelvic floor musculature. And again, we’re looking for muscles that are tender to touch, muscles that don’t move well or are too tight. We also do palpate the pudendal nerve to see if there is any nerve sensitivity. There shouldn’t be severe sensitivity. If there is sensitivity or if the palpation recreates some symptoms, those are significant findings, and will help us to determine what the best treatment is.

Better Man Clinics 

Let’s say a man comes directly to you before they see anybody else. Are there other medical conditions that you’re potentially at least evaluating for or trying to rule out, aside from the actual muscle and nerve problems that you’re going to be treating? Are there other medical conditions that you’re thinking about.

Elizabeth Akincilar

If they are really having symptoms of prostatitis – urinary dysfunction, perineal pain- and they haven’t seen a urologist, I’m absolutely going to recommend that they go see a urologist to make sure that we rule out infection- not just a prostate infection, but also sexually transmitted infections or urinary tract infection. If I’m expecting something more neurological- if they have real motor dysfunction, or motor loss- I may utilize my neurology colleagues to make sure we’re not dealing with something more serious. So, absolutely, I always want that collaboration with medical doctors, whether that’s a urologist or a neurologist or gynecologist (because there are some gynecologists that treat male pelvic pain). I absolutely want them on board.

Better Man Clinics  

What kind of treatment options could you offer a man with pelvic pain?

Elizabeth Akincilar

We do manual treatments in the office.  Those are hands-on treatments that normalize the soft tissue muscle restrictions or lack of mobility. Also, to regain normal neural mobility, we give our patients things to do at home to facilitate that treatment process. We suggest things like a mindfulness practice. We talked a lot before about behavior modification. I mentioned before about incorporating a sit-stand desk that gives you the option of sitting or standing at your desk so that you’re not sitting for eight to 10 hours a day. There are various cushions that we recommend that provide some relief to some of those structures. Some of them have a doughnut like structure to them. There are a bunch of different options out there. Some are just more gel like that help distribute your weight a little bit more evenly on the cushion. We want to also talk about your exercise routine and see if we need to make modifications. For example, if you’re someone who goes to the gym and you really like to do deep squats, we may modify them or take them out of your exercise routine for a bit until we can really get the pain under control and then reincorporate them. So, it’s really a combination of the hands-on treatment, your home program, and then modifying your behavior and activities. 

Better Man Clinics  

You mentioned the hands-on treatment.   What is that? Is that like a massage? Is that like stretching? What is actually involved with the hands-on treatment?

Elizabeth Akincilar

There are different manual techniques that we utilize that will manipulate the superficial or connective tissue as well as muscular tissue. There are a bunch of different techniques that we use, but they involve using my hands on you to try to normalize these restrictions that we find in the in the soft tissues and in the muscle. We do that externally, as well as internally. Does it hurt internally as with one finger? Does it hurt? If the tissue is dysfunctional, then yes, it can be uncomfortable.  But the feeling changes fairly quickly. Once we start to treat those muscular impairments, or muscular dysfunction, we’re also changing the behavior that is contributing to whatever caused that in the first place.  As a result, it really starts to resolve fairly quickly. I tend to tell my patients that you should start to see improvement or change after four to six treatments.  Now, it’s not like a light switch and all of a sudden your symptoms are all gone. It’s more like a dimmer.  If your pain was, say, a six out of 10, when you walked into the office, within four to six treatments, maybe it’s more like a four or five out of 10. It is a real gradual change. Or maybe if you were getting up six times at night to go to the bathroom, maybe it’s down to four.

Better Man Clinics 

With more and more treatment, do the symptoms get better and better? Or are you just reaching kind of steady state somewhere between zero and where you were?

Elizabeth Akincilar

That’s a good question. I think the point is to return the patient to his desired activities, you know, with as little discomfort as possible. I think it really depends on the chronicity of the pain. If you have someone that has had chronic pain for 15-20 years, getting to zero pain may not be a realistic goal.  In that situation, you want to reach a functional level of discomfort.  For example, you get the patient to the point where they can get on their bike and ride 10 miles with a pain level of two or three out of ten but, in a day or so, the pain resolves and he can get on the bike again. That might be very acceptable to some people. For other people it’s not acceptable. It really depends on someone’s particular goals- that’s what we work towards.

Better Man Clinics  

So, you approach treatment with a goal in mind rather than an open ended process of “lets see how good we can get?”

Elizabeth Akincilar

Yes, we absolutely set goals on day one. Those are questions that we ask – what are your goals?  Is your goal to get back on your bike, to be able to engage in sexual activity without pain, or to only get up once at night to urinate.  That becomes our goal.  We set goals over a number of weeks.  Usually, within four to six weeks we have a set of goals and then eight to 12 weeks another set of goals.  About every 8 to 10 weeks, we reassess and see if we are meeting or making progress towards those goals. We modify the goals accordingly because, sometimes, people make progress very quickly and faster than we anticipated while, at other times, it takes a little bit longer. There are a lot of things that are contributing to and affecting the speed of progress or lack thereof.

Better Man Clinics  

How long does a typical treatment take?

Elizabeth Akincilar

Treatments are an hour in length.  Usually, we see folks once a week. I usually tell patients that it is very hard to say on day one how long I’m going to need to see them.  Usually, I need to see somebody for a few appointments to get an idea how they’re responding to the treatment and how committed they are to the recommendations that I’m making. Once I know that (usually within four treatments or so), I can usually make a fairly good prediction.  All that said, I usually tell folks to count on seeing me for at least three months, sometimes it is less and sometimes it is more.  If you come in with six months of pain, three months may be sufficient.  If you come in with five years of pain, it’s likely not going to be longer.

Better Man Clinics  

Pain is always considered a chronic problem.  You can treat it with a massage and you feel better, but it can come back tomorrow.  Are you providing them longer term solutions that they can execute themselves, so they don’t necessarily need to come back to you indefinitely for the hands-on treatments?

Elizabeth Akincilar

Absolutely. We want to foster independence.  We want to educate them and teach them how they can manage mild symptoms or prevent them from escalating.  I usually tell people, “if you have a recurrence of your symptoms after you’ve gotten off of your routine, get back on the routine for a few weeks and see if you can get the symptoms to reduce and, often, they do.  People often just need to refocus.  If not, they come in and sometimes just need a few tune up appointments.  It is really about creating independence. It is the same thing with any orthopedic injury, whether it’s your knee or your back. These are things that sometimes flare up and requires you to get back to stretching or strengthening. The pelvis is really no different. It’s just that we don’t talk about this as much

Better Man Clinics  

Are there any significant risks to the manual treatments?

Elizabeth Akincilar

No.  If you have an active fissure or hemorrhoid that’s actively bleeding, we’re going to avoid internal work at that point. But no, it’s very safe and conservative.  That is one of the nice things about physical therapy. It is very safe.  That’s not to say that we can’t create some symptoms, temporarily, if we’re trying to push a little too much. 

Better Man Clinics  

To what extent do you see success with physical therapy for pelvic pain in men? How would you define success? And how successful do you think you are in terms of treating pelvic pain?

Elizabeth Akincilar

In general, we are quite successful. Now, we do not keep statistics. We don’t keep that data. So, I really can’t say very confidently. The majority of our patients absolutely see success. Are all of them pain free? No, I wouldn’t say that necessarily. But have the majority of them reached their functional goals, like getting back to whatever their desired sexual functioning is or their desired exercise plan or being able to go back to work, take care of their kids?  Yes, I would say the majority of them have. Absolutely.

Better Man Clinics  

How can someone find someone like you to help them? How can they find a physical therapist who specializes in pelvic pain?

Elizabeth Akincilar

Yeah, it’s a great question. There are a few directories out there by different organizations. The American Physical Therapy Association has a directory. Unfortunately, it’s considered women’s health, but there are also providers listed that treat men. Herman and Wallace is an organization that is a continuing education organization, but they also have a directory that lists providers. And, in these directories, physical therapists will often list what and who they treat- if they treat men and women, if they have certain specializations to treat pudendal neuralgia, or if they treat something like pediatrics. However, even if you find someone in your area with one of these directories, for men in particular, it’s a good idea to call and ask if that particular physical therapist has experience treating male pelvic pain, because it is different treating men and women. It is also different treating a man post prostatectomy (or when they have their prostate removed), versus treating men with pain. It’s a very different treatment approach. So, I always recommend that men ask specific questions like whether the physical therapist, commonly (not just once a year), treats men with pelvic pain.