Pelvic floor rehabilitation in chronic pelvic pain syndrome

Carlo Curatolo1, Giuseppe Masiello1, Tommaso Turtur1, Vincenzo Verriello1, Mauro Altomare1
  • 1 Ospedale Civile di Molfetta, U.O.C. Urologia (Molfetta)


Chronic pelvic pain syndrome (CPPS) is used to designate unexplained chronic pelvic pain in men. The management of patients with chronic pelvic and perineal pain requires preliminary clinical analysis designed to identify correlated urological and abdominal dysfunction. Physical evaluation is required to identify trigger points responsible for myofascial pain, pelvic floor muscle tension, and lumbar-pelvic-hip instability. Physiotherapy is one of the first step therapy suggested in and must be initiated early in the course of the disease by therapists trained in these techniques. These techniques can be supported by use of several drugs. Palmitoylethanolamide (PEA) is an endogenous fatty acid amide, belonging to the class of nuclear factor agonists. PEA has been demonstrated to bind to a receptor in the cell-nucleus (a nuclear receptor) and exerts a great variety of biological functions related to chronic pain and inflammation. Aim of this study is to describe muscle examination in patients with chronic pelvic and perineal pain and to determine the results that can be expected from physiotherapy and use of palmitoylethanolamide.

Materials and Methods

In the study from January 2014 to April 2015 22 men (average age 37,8 – range 26-62) with Chronic Pelvic Pain Syndrome (CP/CPPS) were selected and enrolled in this study. The pain was associated to irritative voiding symptoms in 12. Preliminary clinical and instrumental evaluation was performed to exclude other pathologies. Physical evaluation was performed to identify trigger points responsible for myofascial pain, pelvic floor muscle tension, and lumbar-pelvic-hip instability. In all patients we administered palmitoylethanolamide, 1200 mg for 15 days and 600 mg for 75 days. Pelvic floor rehabilitation was performed after 15 days of therapy and comprised repeated muscle contractions of the pelvic floor and biofeedback, twice a week for 6 weeks.


All patients were evaluated with Vas pain score and SF 12 score for quality of life before and after therapy. Vas and SF 12 were administrated at three and six months after therapy. We observed a significant decrease of Vas score and increase of SF 12 in 18 of 22 patients ( 81,8%). In 8 of the 12 patients with irritative voiding symptoms we observed significant improvements (66% ). These evaluations were confirmed by the dates at three and six months after therapy ( 16 and 14 of 22 patients). No adverse reactions were recognized during administration of the drug.


Pelvic pain is pain in the area of the pelvis. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both women and men. Chronic pelvic pain in men is often referred to as Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP/CPPS). This pain is associated with irritative voiding symptoms and/or pain located in the groin, genitalia, or perineum in the absence of pyuria and bacteriuria. The use of the term prostatodynia is not encouraged in current practice. This term carries the negative historical connotation of being a "wastebasket" designation for a melange of psychosomatic symptoms and suggests that the source of the patient's symptoms invariably lies within the prostate gland itself. Current research has provided evidence of numerous extraprostatic considerations, including neuropathic and other systemic pathologies.
There are no standard diagnostic tests; diagnosis is by exclusion of other disease entities. Multimodal therapy is the most successful treatment option, and includes blockers, phytotherapy, and protocols aimed at quieting the pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control. Recently some protocols have used Palmitoylethanolamide (PEA). It is an endogenous fatty acid amide, belonging to the class of nuclear factor agonists. PEA, as an N-acylethanolamine, has physico-chemical properties comparable to anandamide, and while it is not strictly an endocannabinoid, it is often studied in conjunction with anandamide because of their overlapping synthetic and metabolic pathways. The signaling lipid PEA is known to activate intracellular, nuclear and membrane-associated receptors and regulate many physiological functions related to the inflammatory cascade and chronic pain states. PEA's mechanism of action sometimes is described as Autacoid Local Injury Antagonism (acronym ALIA),and PEA under this nomenclature is an ALIAmide. Since 1993, many papers have been published on the various effects of PEA on the mast cell. Mast cells are often found in proximity to sensory nerve endings and their degranulation can enhance the nociceptive signal, the reason why peripheral mast cells are considered to be pro-inflammatory and pro-nociceptive and in this work has been used successfully in association with pelvic rehabilitation, in order to emphasize the role of the drug with the use of relaxing exercises understood through biofeedback.


PEA's activity is currently seen as a new inroad in the treatment of neuropathic pain and related disorders. PEA has been explored in various clinical trials in a variety of pain states, for inflammatory and pain syndrome. From a clinical perspective the most important and promising indications for PEA are linked to neuropathic and chronic pain states, such as diabetic neuropathic pain, sciatic pain, CRPS, pelvic pain and entrapment neuropathic pain states.
Although the limited number of treated patients in this work Palmitoylethanolamide, in association with pelvic floor rehabilitation, seems to be a useful alternative in the first step of treatment of chronic pelvic pain in men with or without voiding symptoms.


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