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1999 Selected Abstracts from American Urological Association annual meeting

The New Theory That Prostatitis is a Tension Disorder:

Anyone With Prostatitis Should Be Aware Of The Disagreement Among Professionals About the Cause of Prostatitis

Anyone with prostatitis should be aware of the disagreement among professionals about the cause of prostatitis. This is especially true if he currently has pain or discomfort:
  • in the penis
  • in the testicles
  • above the pubic bone
  • in the low back, down the leg, in the groin or perineum
  • during or after ejaculation
  • while sitting
This condition often involves:
  • having a sense that there is a golf ball in the rectum that can't be dislodged
  • urinary frequency and urgency
  • dysuria or burning during or after urination
  • a need to urinate even after one has just urinated
  • some sense of pelvic discomfort
  • no evidence of infection in the urine or prostatic fluid
  • no evidence of disease in the prostate or elsewhere in the pelvic floor
The reason that understanding this lack of agreement about the cause of prostatitis is important, especially for sufferers of the problem, is that the definition of a problem determines what you do about it. If you have chest pain caused by indigestion, you don't elect to have open heart surgery to correct the pain. Indigestion tells you what to do about your chest pain..
Similarly, if prostatitis is caused by chronic tension in the pelvic muscles where there is no evidence of infection, you might take pause before you elect to have your prostate removed or take another course of antibiotics or have your prostate gland painfully squeezed and massaged.
There is a genuine controversy about what prostatitis is among urologists and professionals treating this problem. There are three basic views outlined below:
  • Prostatitis is a condition caused by chronic squeezing of the pelvic muscles that, after a while, causes a self perpetuating and chronic irritation of the contents of the pelvic floor, including irritation of the nerves and other delicate structures involved in urination, ejaculation and defecation.
  • Prostatitis is caused by a bacteria or unknown microorganism in the prostate gland.
  • Prostatitis is an autoimmune problem.
The majority of urologists tend to propound the second and third theories. Because of this, their treatments tend to focus on the use of antibiotics or pain medications. Sometimes urologists will tell their patients that there may be a microbe responsible for the problem that still has not been identified..
Below I want to discuss the first that prostatitis as a condition of chronic tension in the pelvic floor. In this view, everyone deals with the stresses of life by focusing their tensions in different parts of the body. For instance some people tense in their necks and heads and get headaches. Some tense in their gastrointestinal tracts and get irritable bowel syndrome or constipation. Some clench their jaws and get a condition called TMJ syndrome. Some subset of these people develop pain and dysfunction in their heads, gastrointestinal tracts, jaws etc. as a result of this chronic focus of tension.
Similarly, prostatitis as a tension disorder sees abacterial prostatitis/prostatodynia essentially as a 'headache in the pelvis" or "TMJ of the pelvis". In this view it is a condition usually manifesting itself after years of tensing the pelvic muscles. It usually tends to occurs in men who hold their tension and aggression inside. They squeeze themselves rather than lashing out at others. Often they have work in which they sit for long periods of time and the only way they have found to express their frustration is to tense their pelvic muscles. This tension has become a habit with them. Often they do not know they tense themselves in the pelvic floor.
If in fact abacterial prostatitis/prostatodynia (which happens to make up about 95% of all cases of chronic prostatitis) is a condition of chronic tension in the pelvic floor, one would have to question whether drugs or surgery are a correct treatment. In fact there is no effective drug regimen or surgical procedure for this condition although at Stanford we have had men consult with us who, in moments of desperation, have had their prostates resectioned or removed and who have taken heroic doses of antibiotics and other drugs. None of these treatments have helped them. Not infrequently, these treatments have made the problem worse or created other problems.
In a pilot study, men with abacterial prostatitis/prostatodynia, often are often found to have trigger points or "knots" of contracted muscle fiber that are very painful when pressed and refer pain to different places in the pelvic floor. Not infrequently, men will report that pressing on these trigger points recreates the pain that they usually have. From the view of prostatitis as a tension disorder, trigger points and tender points in the pelvic floor come about because of chronically contracted muscles there. To deactivate the trigger points is a method borrowed from physical therapy called "myofascial release" or "soft tissue mobilization". This is done inside the pelvis where the therapist pushes against the trigger points, stretching the tender contracted tissue.
After a number of sessions there is often a significant reduction of symptoms. Frequently, with an extensive course of these treatments, symptoms tend to continue to diminish or disappear but only if the patient learns to stop chronically tensing the pelvic muscles.
Learning to profoundly relax the pelvic muscles is not an easy thing. Chronic pelvic tension has usually been a long standing habit for many men who have pelvic pain. Learning to relax the pelvic muscles requires a major commitment of time. It involves learning a relaxation method we have developed aimed at stopping this chronic squeezing of the pelvic floor muscles.
Seen this way, prostatitis is a secret language that the body is using to tell the man that he needs to handle his stress in his life differently. In offering a treatment based on the view that abacterial prostatitis is a tension disorder, there has been a difficulty with reimbursement from insurance companies. This makes it very difficult for a patient to follow a minimal protocol of intrapelvic myofascial release and progressive relaxation of the pelvic floor.
Because we who see prostatitis from this viewpoint want to get patients off of drugs, we get no financial support for research from drug companies who are often the major source of research funding. Furthermore, because no surgery is involved and urologists are not extensively trained in looking at conditions which result from the direct interaction between mind and body, there has not been much interest in learning and using this treatment among our colleagues in urology.
I hope that this discussion is useful to the many men who suffer from prostatitis and offers the hope we see in its treatment.
David Wise, Ph.D.
Clinical Psychologist
Visiting Scholar
Stanford Healthcare Services
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