Pelvic Pain in Men

BACKGROUND

Pelvic pain, often associated with urinary urgency and burning, can come from a number of causes. Unfortunately, though very treatable, physicians are very poorly trained in treating it. If it does not go away with antibiotics, they will sometimes even presume you're crazy (standard medical presumption: "If the doctor can't figure out what's wrong with you, then you must be crazy." Sadly, this abusive approach is all too common in medicine — though fortunately decreasing).

Diagnosing

Because of the diffuse nature of pelvic pain, a knowledgeable physical exam is critical to defining its source. Basically, you want to see what area triggers the pain by conducting the following tests.

Pain by external touch

Does touching/squeezing the testicles reproduce the pain? If yes, is it localized to one testicle or both? Is the pain reproduced by touching the scrotal sac alone? Is the pain decreased by lifting the testes so they are not hanging down and are supported? If the answer to any of these is yes, then it suggests that area is the source of the pain and can be addressed based on which is positive. If not, then a scrotal and testicular pain cause for the pain is less likely.

Pain by internal touch

Is the pain reproduced by a rectal exam with a finger in the rectum? If yes, the critical question is which area reproduces it. If it is worsened by massaging the prostate (the area toward the front of the body which feels like a firm plum), then the prostate is the likely source (especially if there is a boggy, softer area which is tender — suggesting infection). If the pain is reproduced by deep massage of other tissues besides the prostate during the rectal exam, then it is likely coming from pain in the muscles making up the pelvic floor (which often occurs along with the prostadynia if the prostate is tender). This is called "Pelvic Floor Pain."

Discharge

If there is a penis discharge, one should look for sexually transmitted infections (which physicians are good at checking for), or prostatitis (which is what physicians will often diagnose).

If none of the above

If there is no tenderness in any of the above areas which reproduces the pain pattern, I recommend doing a pelvic CAT scan (including the lower spine).

TREATMENT

Treatment depends on the cause of the pelvic pain. The causes can be:

•	Torsion of the testes
•	Epididymitis
•	Prostadynia
•	Pelvic floor pain
•	Interstitial Cystitis

IF YOU HAVE TORSION OF TESTES:

If you've had a testes exam and it reproduces pain, the urologists will usually have looked for torsion (twisting) and looked at surgery. This is more likely a cause with sudden severe pain, than chronic pain.

IF YOU HAVE EPIDIDYMITIS:

Medications

Antibiotics

If epididymitis (inflammation of the long, tightly coiled tube behind each testicle, called the "epididymis" — it carries sperm from the testicle to the spermatic duct) is present, antibiotics usually will eliminate it.

If Caused by Chronic Inflammation

Epididymitis can sometimes occur from chronic inflammation and pain caused by reflux of sterile urine, and nerve blocks may be warranted. However, try the following first.

Herbal pain relief

Begin with a general herbal pain relief (take for 6 weeks).

Fish oil

Take fish oil daily.

Motrin

Consider Motrin family meds.

Physical comfort

Use cool packs and wear underwear that support the testes (e.g., Jockey briefs) without being too tight.

IF YOU HAVE PROSTADYNIA:

If reproduced on palpation of the prostate, it is likely infectious prostatitis or prostadynia (prostate pain without a clear infection or other known cause). Prostadynia is usually related to a mix of triggers, including chronic candida fungal infections, pelvic floor muscle pain and spasm, and associated fibromyalgia.

Medications

Antibiotics

Diflucan

Most important is the use of 3-12 months of treatment with the prescription antifungal Diflucan 200 mg a day (use the cheap generic form). This medication tends to be used more by holistic doctors (who recognize fungal infections in the body), so some physicians will try to scare you away from using it saying it can cause liver inflammation. In truth though, it is less likely to do this than acetaminophen (e.g., Tylenol), and is much safer than ibuprofen (e.g., Motrin) family medications.

Recommended Supplements

Herbal pain relief

Add an herbal pain relief supplement to the treatment regimen. It can take 3-6 months to see symptomatic relief, but it is usually quicker.

Quercitin

For prostadynia, if antibiotics do not offer even transient relief, then adding the bioflavonoid vitamin Quercitin 500 mg 1-2x a day can help (give it 6 weeks).

IF YOU HAVE PELVIC FLOOR PAIN:

Pelvic floor pain comes from the muscles in the pelvic floor being in spasm and constantly putting pressure on the prostate and nerves going to the pelvis. The pain then causes people to tighten the pelvic muscles in response, causing an ongoing cycle of pain. This often accompanies prostadynia.

Therapies & Advice

Rectal muscles

When you are on the commode, see how far you can relax your anal/rectal and urination muscles without anything coming out. You will probably be amazed at how much extra tension is kept in these muscles. It is good to get in the habit, throughout the day, of releasing the muscles as much as you can (of course while staying continent).

Sitz baths

Symptoms can also be helped by sitting in a sitz bath. This can be made by filling your tub several inches high with comfortably warm to hot water and squatting in the water so that the warm water circulates on the anal area and soothes it and helps it to heal.

SHINE

Also, use the SHINE Protocol described in this application (see SHINE under the "More" tab) and at my website (though it focuses on fibromyalgia muscle pain, it applies to pelvic muscle pain as well) and in my book Pain Free 1-2-3 (which also has a section on pelvic pain). This mix of treatments can be very helpful for pelvic muscle pain.

Neurontin and Elavil

In addition, ask your doctor for a trial of the medications Neurontin (300-900 mg) and/or Elavil (10-25 mg) at bedtime to see if they help (start with a lower dose if next day sedation is a problem) and give them 6 weeks to work.

Rectal pain

If you have anal or rectal pain, see the section on Rectal Pain

IF YOU HAVE INTERSTITIAL CYSTITIS:

If the pain is mostly localized to urinary urgency and burning on urination, and not reproduced on rectal exam, see the section on Interstitial Cystitis.