Dr Jeannette Potts
Formerly at the Cleveland Clinic
and Case Western Reserve
Specializing In:
Men's Health
Urological Pelvic Pain Syndromes
Chronic Pain in men and women

UCPPS - A New Perspective

© Cleveland Clinic
Designed by Dr. Jeannette Potts and Mark Sabo

A man with UCPPS is more than just another patient with an inflamed prostate gland. As acclaimed business leader, Peter Drucker , described the knowledge age worker - a four-dimensional being ,deserving of compassion and respect- all patients should be approached similarly by their care-giver. Unfortunately, given today's climate in healthcare, this perspective is rare, especially when it comes to those with chronic pain.

The symptoms of UCPPS, historically attributed to an inflamed prostate gland or prostatitis, may arise from unbalanced, weak or abnormally tense muscles in the back, abdomen, thighs or pelvic floor. Symmetry of the pelvis and sacroiliac joints, as well as posture and other aspects of body mechanics influence these symptoms either by predisposing the patient to this condition or by perpetuating the syndrome by habitual misuse or abuse of the musculoskeletal system.

Note the potentially culpable muscle group, highlighted in yellow, and one of its most characteristic referred pain patterns in blue. The iliopsoas muscles, which can be assessed via deep palpation in the lateral aspects of the abdominal wall, may cause referred pain in the pelvis, lower back and buttocks.

The Sacroiliac joint is assessed for symmetry and stability. Dr. Potts checks for SI obliquity while the patient is in a standing position.

The levator ani muscle group provides most of the pelvic floor support. Abnormally contracted muscles may cause referred pain in the buttock, perineum and rectum. Many patients complain of discomfort described as "sitting on a golf ball." While the sensation may perpetuate the erroneous belief of an enlarged inflamed prostate, one must bear in mind that habitual contraction of these muscles has been shown to create this sensation, as documented in the colorectal literature, and that most patients with this complaint, who are seen by colorectal specialists, are women. There is now growing evidence to support a neuromuscular approach to alleviate this discomfort. Trigger points of the anterior levators has also been associated with penile pain.

The obturator internus is responsible for internal rotation or adduction of the hip. Trigger points or shortening of this muscle may cause referred pain to the perineum and ipsilateral testicle. If abnormally contracted, leg length discrepancy is magnified, further aggravating hip and pelvic imbalances.

The obturators are assessed during the pelvic floor exam, best carried out in the lithotomy position. In addition to palpation of all the pelvic floor muslces and bony structures, provocative testing of the obturator internus muscle is also carried out.

Thorough examination of the pelvis is essential when evaluating men and women with this condition. Sadly, most patients, especially men, are not thoroughly evaluated in this manner. As Dr Potts has said during her many lectures, " if a man with this condition is simply bent over to check his prostate gland, I call that an half-assed exam."

The adductors comprise a large muscle group, predominantly in the medial thigh. Their insertions on the lower bony structures of the pelvis are relatively small and are therefore quite vulnerable. Frequently, knots or tightening of the muscle fibers are palpable and cause genital pain or pelvic discomfort.

These very specific physical factors influencing pain, voiding and sexual function are likewise influenced by men's lifestyles and stress. Work or recreational activity may influence these dynamics and should be seen as modifiable factors. Career satisfaction, marital relationship, family dynamics, spiritual solace, likewise contribute to amelioration or exacerbation of the condition. There is no better illustration for the need to evaluate and treat our patients as 4-D beings than in patients suffering from chronic pain. Appropriate care of the patient requires engagement of an empathic physician, which begins with the initial interview and assessment of the patients. Dr. Potts believes that the process of formulating the diagnosis is indeed the beginning of therapy.

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