Imagine experiencing pain in the most intimate of areas. The narrow variety of treatment options available are not only invasive, but yield increasingly frustrating results or perhaps they aren’t successful. Now imagine being stigmatized for trying to seek health care for those concerns. This is an all too familiar trend in practice from the men seeking help for their pelvic pain.
Topics in this article may challenge perspectives massage therapists hold. It is encouraged that the profession honours its capacity as individual clinicians with this information, while also challenging its comfort levels. It is important health care providers grow in their understanding and reasoning.
Men have pelvises, and by extension, a pelvic floor too. They may need to discuss their concerns about bladder, bowel and sexual health with a health care provider. Incontinence, overactive bladder/bladder pain syndrome, erectile difficulties, premature or changes in ejaculation, chronic constipation, testicular or anal/rectal pain and prostatitis (or chronic pelvic pain syndrome) are a few examples of conditions men may need to speak to their health care provider about. Unfortunately, bringing it to the attention of a health care provider can be stressful and embarrassing. Men often will wait to see if symptoms will resolve on their own. (Kannan & Veazie, 2014, Aschka, C., et .al., 2001)
Persistent pelvic pain can wear a lot of disguises, particularly, prostatitis. Simply defined, prostatitis is an inflammation of the prostate gland.
For those who are not familiar, prostatitis has four categories: (Nickel J. C, 2000)
- Acute Bacterial prostatitis
- Chronic Bacterial prostatitis
- Chronic non-bacterial prostatitis (NBP) or Chronic Pelvic Pain Syndrome (CPPS)
- Inflammatory
- Non inflammatory
- Asymptomatic inflammatory prostatitis
Although its definition is simple, prostatitis is complicated in its treatment and management. One may assume management is straight forward if a bacterial infection is present. Perhaps a cycle of antibiotics and the problem will resolve. Unfortunately, bacterial-related prostatitis cases only make up 5-10% of all prostatitis diagnosis. 90-95% of all prostatitis cases are type 3 prostatitis; the non-bacterial type, also referred to as chronic pelvic pain syndrome (CPPS). (Anothaisintawee T, et. al., 2011, Doiron, R.C. et. al., 2019). Currently antibiotic therapy is recommended for initial treatment intervention. (Bowen, D. K. et. al., 2015) The role of antibiotics in the management of non-bacterial prostatitis has been questioned in research. (Rees, J. et. al., 2015) Although it has been reported that even in the absence of a bacterial infection, antibiotics provided symptomatic relief (Rees, J. et. al., 2015).
Little is known about what causes chronic pelvic pain syndrome (NBP) and even less about how to manage it. (Rees, J. et. al., 2015). Some studies suggest that age, surgeries, stress and lifestyle can be contributors, but risk factors remain unclear. (Wang, Y., et. al. 2016)
Symptoms are not localized to the prostate, which can be embarrassing information to share. (Kannan & Veazie, 2014) Symptoms can present as pain in the perineum, penis, anorectal region, lower back, abdominal, hip and groin. It can also present with erectile difficulties, pain with ejaculation and/or urination and IBS symptoms. (Rees, J. et. al., 2015) With multiple symptoms comes a large amount of testing, imaging and interventions. This has been described in my practice by men as a chaotic process that leaves them anxious about receiving a scary diagnosis like cancer or an untreatable sexually transmitted infection. Then they endure a wait time of up to six weeks only to discover all tests come back negative. One study reported the more interventions someone has for their pelvic pain, the worse their reported outcomes on pain and quality of life were. (Schaeffer, et. al., 2002) Prostatitis as a collective does not discriminate as it effects 34-50% of men in their life time. (Rees, J. et. al., 2015).
Prostatitis is not only biological or tissue driven. Anxiety, depression, insomnia and relationship strain are a few of the psychological and social consequences of persistent pelvic pain in men. (Brünahl, C., et. al. 2017) In one study, 95.2% of men living with persistent pelvic pain fulfilled diagnostic criteria for at least one mental health disorder. The highest scored categories were somatization, depressive and anxiety disorders. (Brünahl, C., et. al. 2017) It is crucial clinicians take a wide lens or biopsychosocial approach with this population as pelvic pain is multifaceted. (Brandt C. 2021)
Relevance to Massage Therapists
In a recent social media post of mine, I shared some observational statistics made over the last three years of treating men with pelvic pain. Out of 302 men seen for their pelvic pain, 184 had seen or regularly see a massage therapist for treatment related to their pelvic health concerns, without disclosing them to their massage therapist. This is very relevant to massage practice because the chances are very likely that at some point in their career, they have treated someone with an underlying pelvic health concern and not been aware.
How many men with pain in their low back, pelvic girdle, groin or abdomen have received treatment from an RMT? Treating lower back pain is a frequent occurrence in practice. (Smith et. al., 2011) Pelvic pain can wear other, orthopedic-type disguises. A reason for this is because “Pelvic organs’ afferent innervations converge at spinal segments with neurons from somatic structures such as the skin and muscles of the back and buttocks, abdomen, thighs and perineum. Thus there is a huge potential for referred pain, secondary muscular and viscero-visceral hyperalgesia.”(Curran N., 2008). In less scientific terms, there’s similar spots in the spinal segments that the pelvic organs and somatic structures communicate to the spinal cord/ central nervous system and because of this, there’s potential for other structures to get involved and sensitized.
A common analogy for this occurrence might be having one think of police action in their neighbourhood. One may be on high alert for threatening or potentially threatening activity in the area. When there’s a threat or even perceived threat, all the neighbours in the area (muscles, other connective tissue and even other organs) might become over active or hypervigilant in order to prevent harm or further harm. This may lead to over activity of the pelvic floor musculature (PFM), over active bladder, IBS symptoms and sexual dysfunction. (Curran N., 2008) These are the peripheral or bottom up influences. Also consider the top down or centralized pain influences such as anxiety, depression, stress and social contexts. This offers another layer of potential pain system sensitization, and may even contribute to the chronicity of pelvic pain. (Brünahl, C., et. al., 2017 & Dybowski., et. al., 2018)
Would the massage therapy profession feel equipped to navigate a treatment with someone who disclosed their pelvic health concerns? Would massage therapists feel comfortable talking about bladder, bowel and sexual health concerns? How would you feel talking about pelvic health with a male client? There is gap in the massage therapy education when it comes to this topic. Even the basics such as erections, sexual health, therapeutic alliance and clinician safety were not taught competently in school. Moreover, men need another entry point to receive care for their pelvic health concerns. Massage therapists have plenty to offer this population from pain relief, help with sleep, anxiety and depression (Moyer, Christopher A., et. al., 2004) and creating save spaces to talk about their pelvic concerns. The current way these sensitive topics are taught or not taught in school leaves the profession ignorant which does not serve the profession or, more importantly, the public.
I stated earlier in my practice, 184 men actively seek care from an RMT for treatment related to their pelvic health concerns without disclosing to the RMT they have pelvic health concerns. Of the 184, 76% of this group reported the biggest barrier to disclosing a pelvic health concern was their RMT would stop treating them. Most men valued their relationship with their RMT over wanting to disclose a pelvic health concern and risk making the RMT feel uncomfortable.
In my practice, it is very common that men report their fear of disclosing a pelvic health concern to an RMT they receive regular treatment from. The fear being the RMT perceives them as sexualizing the treatment environment. In the case of 13 men who did feel comfortable enough to disclose a pelvic health concern to their RMT, they reported the RMT:
- Suddenly became too busy to treat them anymore
- Abruptly cut them off and strongly suggested talking to their doctor
- Ended the treatment because the RMT didn’t feel comfortable treating them anymore.
When I first started documenting all these occurrences, the immediate concern for these men came to mind. The way they had been treated by their RMT continues the cycle of stigmatization these men face, and may further solidify their beliefs to suffer in silence. However, it also presented a unique opportunity. Massage Therapists may be the first point of contact to educate, dismantle the stigma and make a meaningful referral if management is out of that individual massage therapist’s scope of practice. My observations would suggest men heavily value their therapeutic relationship with their massage therapist. If massage therapists are striving towards being recognized as health care professionals, they must embrace navigating uncertainty in their practices.
Massage culture perpetuates that treatments are most appropriate if this is a female pelvis, or someone who owns a pelvis with a uterus, vulva and cervix, and/or if this is a pregnant or postpartum pelvis. The women I’ve served in my practice have disclosed to me never being asked about their sexual health concerns, even when reason for treatment directly indicated a sexual health screen. The definition of sexual health by the World Health Organization is as follows: (WHO, 2006)
“Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; …[It’s] fundamental to the overall health and well-being of individuals, couples and families…Sexual health, when viewed affirmatively, requires positive and respectful approach to sexuality…as well as the possibility of having pleasurable and safe sexual experiences”
Notice how this definition not only states how it’s fundamental, but sexual health is not defined only by its absence of disease or dysfunction. Massage therapists need to stop viewing the pelvis as a dystopia of dysfunction or potential dysfunction. Pelvises are very robust and are capable of a coordinating a large range of complex functions. From pregnancy and delivery, erections, orgasms, urination and bowel elimination. It’s a storage center, that’s also equipped for pleasure and allows people to experience physical intimacy with themselves or one another. Anatomically speaking, the urogenital system is very intimately connected in the male pelvis. The prostate and bladder share the urethra (and penis) for urination and ejaculation. It’s almost impossible to compartmentalize the urination functions from the sexual functions because of shared structures. The biases and views massage culture hold are creating barriers to care, especially in men’s pelvic health. I understand I am standing on the shoulders of giants. The profession in Canada, especially in British Columbia, has come a long way from being viewed as a part of the sex industry to now being recognized as health care. I thank those voices who came before me in their avocation to desexualize massage therapy as I would not be able to practice the way I am today. With that said, the profession will always progress onward, and now it’s time to carve out a novel path for the profession.
Chronic pelvic pain is a multifaceted condition and massage therapy has the potential to serve a role in its management. Massage Therapy provides a safe space for people to discuss and receive care for their concerns. As a population that is often stigmatized for their pelvic health concerns, men would severely benefit from this. Massage therapy is non-invasive, provides pain relief and has an effect on anxiety and depression. All of these are effects men living with persistent pelvic pain would benefit from. However, the profession needs to conquer their apprehension and hesitation around managing the entirety of pelvic health, including sexual health and men’s health. Further education for RMTs is needed around navigating uncertainty in their practices. Finally, if massage therapists can provide care that suspends judgement and allows for greater inclusiveness and collaboration with people, they’ll be recognized for the important role they contribute. Massage therapy is set up for serving men living with persistent pelvic pain, but it is now up to the profession to enact it’s potential.
Erections: Guilty unless proven innocent.
The topic of erections only came up in first term massage therapy college and was introduced as such: “Erections are a normal part of massage therapy.” Then well-intended instructors contrast that statement by sharing stories of times clients sexualized the treatment environment. This immediately left a poor impression of treating men. From then onward, I was on alert when a male would come in for treatment. I would question every shift they made on the table, every deep breath during the treatment and if there was an erection present, I just ignored it and would be on even higher alert, anticipating something sexual to happen. Sound familiar?
A clinician’s experiences and biases towards erections can sexualize the treatment environment when someone with a penis comes in for treatment. I wasn’t made aware of this until I took a course on sexual biases in health care. My experience with erections up until massage college was only in an intimate sexual setting with a partner. No wonder I would get annoyed or upset that someone had an erection during a treatment. This is a time I’m not implying or offering a sexual encounter and this isn’t someone who is my partner. The layer of potential threat becomes thicker with the stories those instructors shared or a personal experience of a client sexualizing the treatment environment. The alarms start going off and I would become anxious or uncomfortable. Anxiety is contagious. When anxious vibes get sent into the treatment environment, our clients can pick up on them. Perhaps they shift on the table, adjust their erection or change their breathing to hide or dissipate it. However, being on high alert, those actions may appear to massage therapists like they are potentially sexualizing the treatment environment. This is why communication is so important in these instances. If massage therapists aren’t comfortable talking about erections, it’s likely they won’t follow up on client’s actions or behaviors if the therapist is perceiving them as sexual. In reality, the client might just be trying to dissipate their erection to ease the therapist’s obvious anxiety. This is why communication is key.
Erections are a normal part of receiving massage, but no one tells massage therapists or massage therapy students why beyond “It’s a normal neurophysiological process.” Massage therapy is largely known to effect the nervous system in helping facilitate the parasympathetic nervous system (PNS) to take over. When the PNS takes over, this is a good time for rest, digest and sex. Have you ever had a client’s stomach growl during a massage? Of course. Does this mean this person is going to whip out a sandwich and chow down mid treatment? No, because context matters. Their nervous system is getting their digestive system primed for food because the massage has facilitated PNS firing. Same with erections. The massage and the safe environment all play a role in the nervous system priming erectile tissues to get ready for sex. This doesn’t mean someone has sexualized the treatment environment. Their background processes are getting them ready just in case the opportunity presents itself. However, like the the digestion example, it’s the decisions and behavior of the person with the erection that determine if they have sexualized the treatment environment. This is a part of something called sexual intelligence; having the ability to understand when sexual advances or communication about sex is appropriate or warranted and when it’s not. Therefore, we shouldn’t be making judgement calls or condemning a population of people with penises for sexualizing the treatment environment, based solely on the fact an erection is present.
It’s important to normalize erections and talk about them before a treatment as part of the informed consent process. The “ignore it” method doesn’t serve the safety of clients and therapists very well. What if the client is really uncomfortable with their erection during a treatment? Or having a difficult time understanding nervous system arousal and sexualization are two different occurrences that walk really close together. Think about my example above. My experience with erections prior to massage school was only in an intimate sexual encounter. What if that is the same for the individual in front of us? What if this person feels guilty for having an erection during a massage because of their views on sex and relationships? Perhaps they feel during the treatment that massage offers a level of intimacy only reserved for them and their partner. Do they know they can stop the massage if they need to? These are all topics men have brought to my attention that I wasn’t aware of. I never thought about the emotional consequences of someone having an erection they perceive as a result of someone other than their partner eliciting.
This is why talking about erections with clients is very important for everyone’s safety and comfortability. I’ve treated men who disclosed to me their long history of erectile difficulties, only to get an erection during the massage. It can be very confusing and make them appear like they were lying about their struggles and case history. Remember, massage has a positive effect on anxiety and depression. (Moyer, Christopher A., et. al., 2004) Anxiety and depression in men contribute to erectile difficulties. (Velurajah, R., et. al., 2021) This is why discussing the physiology of an erection during the initial conversational part of the treatment process is vital in promoting safe spaces for everyone receiving care. Guilt, shame and embarrassment can play into pelvic health problems. The last thing health care providers need to do is make someone feel guilty about a bodily function that is completely normal. Especially during an intervention that literally sets up someone’s nervous system to have that response. Here is my little blurb about erections during the informed consent process to clients:
“Erections are a normal physiological response to receiving massage therapy. This occurs because massage therapy helps facilitate your nervous system responsible for rest, digest and sexual functions. However, just because this response happens doesn’t mean I’m interpreting that as sexual in nature, but I will be checking in to see if you feel safe to continue treatment. If you don’t feel comfortable continuing treatment, let me know you would like to stop the massage at any point in time. I’ll then re-drape and leave the room.” Make communicating a withdrawal of consent to treatment easy by giving them the phrasing or wording to opt out. The only time I don’t address an erection during treatment is if they are asleep during the massage, which I’ll clarify with them during the consent process.
Communicating that you will be inquiring about their erection during the treatment also sets you up for safety. If someone has sexualized the treatment environment, don’t wait to be in a position where someone has to behave inappropriately before you stop the treatment. In practice, when there is a visible erection, I ask “I noticed you have an erection. Do you feel safe to continue the massage or would you like to stop?” Their response is going to tell me if I need to stop treatment or not. If they get flustered and apologetic, I typically respond with, “ No need to apologize. We discussed at the beginning how erections are a normal neurological response to massage therapy. I want to make sure you feel safe continuing the treatment and if you need a moment to adjust or if you would like to stop the massage.” If they have sexualized the treatment environment they’ll usually make a lewd comment of some kind, and then I end the treatment and discharge them in a follow up email. No guessing and no analyzing. Clear and confident communicate puts me in a better position to advocate for my client’s safety, and my own.
Erections are a topic in massage therapy requiring more clarity in how to navigate. Normalizing them with education on why they occur during a massage, communicating with client’s that erections are a normal part of receiving massage, erection check ins during treatment and the ability to recognize when a client has sexualized the treatment environment, are areas massage therapists need more confidence in. Clear communication around erections is the best way to promote safety within the treatment setting for our clients and for ourselves. Erections are a normal occurrence during massage interventions and need to be taught in a positive and productive manner.
BIO:
Jocelyn Kirton has been an RMT since 2013. She has taken a special interest in treating patients with persistent pain, specifically in the abdominal and pelvic regions. Her treatment foundations are built around a neurocentric patient centred clinical reasoning framework. Her educational and practical experiences have given her the unique opportunity to incorporate her knowledge base allowing for a modern and evidence-based approach to persistent abdominal and pelvic pain. Outside of her practice, Jocelyn wants to impact the Massage Therapy profession by educating RMTs on the positive impact the profession can have for people dealing with abdominal and pelvic pain. She is motivated for other health care professionals to recognize the benefit patients with pelvic pain would receive from seeing an RMT. In her opinion, it’s time RMTs get comfortable as a profession in managing patients with abdominal and pelvic pain that is evidence based and safe.
For more information and course listings: https://pelvicrmt.com or @jocelynkirtonrmt on IG
References:
Anothaisintawee, T. (2011). Management of Chronic Prostatitis/ Chronic Pelvic Pain Syndrome. JAMA, 305(1), 78. https://doi.org/10.1001/jama.2010.1913
Aschka, C., Himmel, W., Ittner, E., & Kochen, M. M. (2001). Sexual Problems of Male Patients in Family Practice. Journal of Family Practice, 50(9), 773.
Bowen, D. K., Dielubanza, E., & Schaeffer, A. J. (2015). Chronic bacterial prostatitis and chronic pelvic pain syndrome. BMJ clinical evidence, 2015, 1802.
Brandt, C. (2021). Physiotherapy and pelvic floor health within a contemporary biopsychosocial model of care: From research to education and clinical practice. South African Journal of Physiotherapy, 77(1). https://doi.org/10.4102/sajp.v77i1.1538
Brünahl, C., Dybowski, C., Albrecht, R., Riegel, B., Höink, J., Fisch, M., & Löwe, B. (2017). Mental disorders in patients with chronic pelvic pain syndrome (CPPS). Journal of Psychosomatic Research, 98, 19–26. https://doi.org/10.1016/j.jpsychores.2017.04.011
Curran, N. (2008). Chronic Urogenital Pain in Men. Reviews in Pain, 2(2), 25–28. https://doi.org/10.1177/204946370800200207
Doiron, R. C., Shoskes, D. A., & Nickel, J. C. (2019). Male CP/CPPS: where do we stand? World Journal of Urology, 37(6), 1015–1022. https://doi.org/10.1007/s00345-019-02718-6
Dybowski, C., Löwe, B., & Brünahl, C. (2018). Predictors of pain, urinary symptoms and quality of life in patients with chronic pelvic pain syndrome (CPPS): A prospective 12-month follow-up study. Journal of Psychosomatic Research, 112, 99–106. https://doi.org/10.1016/j.jpsychores.2018.06.013
Kannan, V. D., & Veazie, P. J. (2014). Predictors of Avoiding Medical Care and Reasons for Avoidance Behavior. Medical Care, 52(4), 336–345. https://doi.org/10.1097/mlr.0000000000000100
Moyer, C. A., Rounds, J., & Hannum, J. W. (2004). A Meta-Analysis of Massage Therapy Research. Psychological Bulletin, 130(1), 3–18. https://doi.org/10.1037/0033-2909.130.1.3
Nickel J. C. (2000). A new era in prostatitis research begins. Reviews in urology, 2(1), 16–18.
Rees, J., Abrahams, M., Doble, A., & Cooper, A. (2015). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU International, 116(4), 509–525. https://doi.org/10.1111/bju.13101
Schaeffer, A. J., Landis, J. R., Knauss, J. S., Propert, K. J., Alexander, R. B., Litwin, M. S., Nickel, J. C., O’leary, M. P., Nadler, R. B., Pontari, M. A., Shoskes, D. A., Zeitlin, S. I., Fowler, J. E., Mazurick, C. A., Kishel, L., Kusek, J. W., & Nyberg, L. M. (2002). Demographic And Clinical Characteristics Of Men With Chronic Prostatitis: The National Institutes Of Health Chronic Prostatitis Cohort Study. Journal of Urology, 168(2), 593–598. https://doi.org/10.1016/s0022-5347(05)64686-1
Smith, PhD, J. M., Sullivan, PhD, S. J., & Baxter, DPhil, G. D. (2011). A Descriptive Study of the Practice Patterns of Massage New Zealand Massage Therapists. International Journal of Therapeutic Massage & Bodywork: Research, Education, & Practice, 4(1). https://doi.org/10.3822/ijtmb.v4i1.97
Velurajah, R., Brunckhorst, O., Waqar, M., McMullen, I., & Ahmed, K. (2021). Erectile dysfunction in patients with anxiety disorders: a systematic review. International Journal of Impotence Research. Published. https://doi.org/10.1038/s41443-020-00405-4
Wang, Y., Chen, C., Zhu, C., Chen, L., Han, Q., & Ye, H. (2016). Social Determinants of Chronic Prostatitis/Chronic Pelvic Pain Syndrome Related Lifestyle and Behaviors among Urban Men in China: A Case-Control Study. BioMed Research International, 2016, 1–7. https://doi.org/10.1155/2016/1687623
