Pelvic Myoneuropathy

Pelvic myoneuropathy is a new term given to the most common form of non-bacterial pelvic pain experienced by men. It is sometimes referred to as chronic nonbacterial prostatitis or male chronic pelvic pain syndrome (CP/CPPS or CPPS). The mechanisms of pelvic myoneuropathy may also underlie the etiology of IC (Interstitial cystitis).

Pelvic Myoneuropathy, in its most simplified and broadest terms, describes a process in which people of a particular genetic type and often with tense, anxious, and frequently atopic (allergy-prone) dispositions, develop a chronic process in the pelvis that involves muscles, nerves and mast cells. Such individuals tend to tense the muscles of their pelvic floors subconsciously and continuously. This clenching of deep muscles can be provoked either by the individual's tense disposition, or it can be the result of a "guarding" response to a preceding trauma to the pelvic or spinal area, pelvic surgery, bicycling, long periods of sitting and stress at work, and in some cases, urinary tract infections (prostatitis and cystitis). Other common events that lead to injury are:

1. chronic tense holding patterns that develop in childhood as a result of sexual abuse, traumatic toilet training, abnormal bowel patterns, guilt surrounding sexual feelings, dance training or stress
   
   
2. repetitive minor trauma or straining with constipation or urinary obstruction
   
   
3. other inflammations of pelvic organs such as urethritis, proctitis or anal fissures, or referred pain from other attaching muscle groups or viscera or nerves.
   The subsequent muscle spasm and hypertonicity of the pelvic muscles leads to a hyperirritability of the muscle fibers. The hyperirritable bundles of fibers within the muscles of the pelvic floor become "knotted", inelastic and unable to contract or relax. Trigger points are formed. The overstimulated nerves innervating these muscles, through a complex process involving central sensitization, intermingling of afferent (sensory) fibers, neural wind-up, intercommunication among nerve plexuses, neural cross-talk, viscerosomatic convergence, the nature of visceral afferentes, and individual variations of anatomy and neurophysiology, eventually set up a process in the tissues of the genitourinary tract that leads to pathology. This pathology results when the nerve endings overproduce chemicals called neuropeptides. Neuropeptides stimulate powerful immune defence cells called mast cells. Once stimulated, these cells produce a wide range of chemicals (histamine, TNF-alpha, inflammatory prostaglandins, leukotrienes) that cause pain, inflammation and the symptoms of sterile prostatitis, urethritis, orchalgia, epididymitis, and/or interstitial cystitis. Therapy is multimodal, involving intrapelvic deep muscle "trigger point" massage and release, specific stretching exercises, stress control and special forms of pelvic muscle relaxation training, nerve therapy (neurontin, elavil, botox), mast cell protectives and mast cell byproduct amelioratives (ProstaQ[1], Q-Urol, antihistamines, alpha-blockers, etc).
   

How do I know if I have Pelvic Myoneuropathy?
It is important to point out at this stage that there are many other factors which, whilst not common, could give rise to some of the symptoms of CPPS. It is therefore essential to see a urologist and be examined for any urological conditions such as strictures, UTI and bacterial prostatitis. Once these conditions have been either ruled out (most patients) or treated, it is then essential to have a full pelvic floor examination, which consists of two parts: a manual exam and a computerised EMG assessment of pelvic floor function.

Completing a pelvic floor examination:
The pelvic exam has two components: an internal exam and a computerized muscle assessment. The pelvic exam is focused on assessing the musculature and other pelvic tissues not the organs. The pelvic floor, also know as the levator ani, is evaluated with regards to its function. Can the patient locate the muscle and perform an isolated contraction? Or does she use other muscle groups to assist her in contracting the muscle? This is also known as substitution. Is there difference from the right side to the left? Are there trigger points in the muscles? Trigger points can be a source of pain as well as cause the muscle to not function properly. The therapist will also assess the ability of the pelvic floor to relax after a contraction. The ability of the patient to do a lengthening contraction from the resting position is also evaluated. This is also known as an eccentric contraction. An eccentric contraction is the motion that is required to initiate urination. During the internal exam the therapist will also be assessing the other tissues found within the pelvis - the connective tissue and the neural tissue specifically.

There are also other muscles inside the pelvis that are actually leg muscles. These are closely related to the pelvic floor muscle. So, if you traumatize a leg, you could set up a domino effect that could cause a pelvic floor problem. You need to monitor those muscles as well.

Besides the internal exam, there is also computer assessment. The computer assessment measures the force the pelvic floor muscle generates when it contracts and its range of motion. I utilize the computer to provide objective data to describe the pelvic floor changes as treatment progress.

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