• How a combination of Yog Asanas and Pranayam helped cure a patient of chronic pelvic pain syndrome. Details of a case study.

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Abstract

Pain in the pelvic region that lasts for 3–6 months or more is commonly referred to as chronic pelvic pain syndrome (CPPS). The pain may be incapacitating and episodic or it may be persistent. The patient’s life may be severely disrupted and greatly distressed by these symptoms. 

A 46-year-old male with CPPS came to the Yoga outpatient department for Yoga therapy (YT). Although he had taken medicines for a long time, the issue was not resolved. We started YT for 6 months.

At the end of the intervention, the National Institutes of Health Chronic Prostatitis Symptom Index score was reduced significantly from the baseline total score of 38–3, pain score of 18–2, voiding problem from 19 to 0, and a negative impact on the quality of life of 11–1. As a result, the patient had emotional well-being, reduced pain syndrome, and improved quality of life.

Introduction

Chronic pelvic pain syndrome (CPPS) is characterized by pain or discomfort in the pelvic area that persists for 3–6 months without any apparent reason and often comes with other symptoms related to urology or sexual dysfunction. Sometimes, it is termed “prostatitis,” although it is unclear the degree of involvement of the prostate as the source of symptoms.^[1] It is frequently linked to the symptoms related to the urinary tract and/or sexual dysfunction.^[2] 

CPPS is also termed as prostatodynia (painful prostate), chronic prostatitis, and abacterial prostatitis. According to the research guidelines, it may be “inflammatory” and “non-inflammatory,” but no separate symptoms and therapeutic approaches are described separately. Approximately 2%–10% of adult men complain of CPPS symptoms at any given time, and 15% of men experience the symptoms at some point in their live.^[3] Both pharmacotherapy and non-pharmacotherapy are available for the management of CPPS. However, no single therapy is accepted as an effective treatment. Monotherapy is considered as less effective than the combined therapy.^[4] 

As medicines such as alfa-1 adrenergic antagnists and phosphodiesterase type-5 inhibitors are not safe for the long-term treatment, some patients are treated with drugs initially and then prefer to shift to non-pharmacological interventions. Pelvic floor physical therapy and Yoga are non-pharmacological therapy and have the potential to minimize the symptoms of CPPS.

Here, the case of CPPS who did not improve after treatment of modern medicine was treated with Yoga therapy (YT) for 6 months is presented. This case report complies with the CARE guidelines.^[5]

Case Report

The patient is a 46-year-old married male, farmer by occupation living in the rural area visited Yoga outpatient department (OPD) at the Department of AYUSH, AIIMS, Bhubaneswar, on August 08, 2023 with complaints of burning micturition, pain in the lower abdomen, and sometimes feeling a sensation of incomplete urination from 1½ years. 

Previously, he consulted with an urologist and was diagnosed with CPPS and was taking one Tablet of Contiflo-T (0.4/5) at bed time from January 2023 to March 2023 for 2½ months and got symptomatic relief. The symptoms remitted after stopping of this medicine. He revisited the urology department and resumed the medicine for 1½ months but had no relief. He visited again to the urology department on August 2023 and was advised to continue same drug with practice of pelvic floor exercises, but he was preferred YT for better results.

Clinical Findings

On the first visit, his chief complaint was burning micturition, pain in the lower abdomen and sometimes feeling a sensation of incomplete urination. In addition, the patient reported persistent pain and discomfort in the hip joints and lower abdomen during ejaculation, which affected quality of life, and was unable to focus on regular business. He had no history of diabetes, hypertension, chronic constipation, urinary tract infection, trauma, or other systemic illnesses. On examination, his blood pressure, pulse rate, and body mass index were normal.

Diagnostic assessment

Per abdominal examination found no scar marks, abdomen was soft, mild tenderness at lower abdomen, and absence of organomegaly. There were no abnormalities found in the genitourinary examination. The ultrasonography of the whole abdomen and pelvis revealed the normal prostate size, bladder, and bladder wall thickness. The residual volume of urine was 228 mL and the volume of full bladder was 632 mL. There were no other abnormalities reported. The initial score of National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) is shown in Figure 1.

For Figure 1 - The improvement of self-evaluated National Institutes of Health-Chronic Prostatitis Symptom Index score. Max: Maximum, NIH-CPSI: National Institutes of Health Chronic Prostatitis Symptom Index, QOL: Quality of life. For Fig 1 table please click Here

Therapeutic interventions

As per the suggestion of his physician, he continued the drug for the 1^st month (August 8, 2023–September 8, 2023) along with Yogic intervention. After the completion of 1 month, he stopped the Tablet Contiflo-T (0.4/5) and continued YT for the next 5 months (up to February-2024). A Yoga Protocol (YP) was prepared with specific Asana and Praṇayama for the duration of 25 min, as mentioned in Table 1.

He was trained for the first 5 days under the supervision of a trained Yoga instructor for the accuracy of Yogasana and Praṇayama and was advised to practice every morning on an empty stomach. He was provided the handouts for YP for regular home-based practice. Further he was advised to avoid oily, spicy, and deep fried food and to take high-fiber diet to prevent constipation which exacerbate the CPPS symptoms. The detail timeline of treatment is mentioned in Table 2.

Table 1 Yoga protocol for everyday practice

Table 2 Timelime of the Treatment

To see tables click Here

Follow-up and outcomes

He was instructed to report at yoga OPD for 1 day within the 1^st week of every month for evaluation and to record the NIH-CPSI score. After 6 months (September 2023–February 2024) of intervention, the pain syndrome decreased greatly, and his quality of life improved dramatically, allowing him to return to his normal life. The total NIH-CPSI score was lowered from 38 to 3, with a pain score of 18–2, a voiding problem from 19 to 0, and a negative impact on quality of life of 11 to 1. [Figure 1]

Discussion

The pathophysiology of CPPS is extremely complex, comprising the central nervous system, peripheral nervous system, muscular system, and psychological component. The unknown etiology of CPPS leads to a diversified therapeutic approach, there is no universal consensus on the therapeutic approach for CPPS. Mostly, antibiotics and alpha-blockers are prescribed suspecting bladder and prostate infection. In addition to that, symptom-relieving drugs are used to get relief from the symptoms to some extent.^[6] However, expensive treatment and potential side effects has limited the use of these drugs for an extended period of time.

The patient was treated with YT for CPPS for 6 months in this case. Pelvic floor hypertonicity and hypotonicity are the two most common pelvic floor dysfunctions associated with a variety of urological diseases. Pelvic floor hypotonicity causes urine incontinence and can be treated with Asanas that strengthen both muscle layers of the pelvic floor (deep layer or levator ani and superficial layer of the urethral and anal sphincters). Asanas can relax both layers of the pelvic floor, addressing hypertonia.^[7]Yoga decreases anxiety and stress-induced sympathetic hyperactivity and activates the parasympathetic nervous system.

A cross-sectional comparison research revealed that regular practice of Yoga reduced sympathetic activity and increased parasympathetic activity.^[8]Yoga can reduce pain intensity and enhance the quality of life for persons experiencing chronic pelvic discomfort. The Asanas such as Poorna Titali and Shroni Chakra are helpful to reduce the muscle tension of inner thighs, Tiryak Tadasana and Trikonasana are helpful to strengthen the pelvic area, tones the reproductive organs, and alleviate the nervous depression. Ardha Ushtrasana and Supta Vajrasana and Supta Vajrasana give a good stretch to the pelvic region; Padottanasana and Supta Pawanmuktasana give a good massaging effect to the pelvic muscles and reproductive organs. 

Pranayamas such as Nadishodhana and Bhramari help to induces tranquility, improve concentration, and relieves stress and anxiety.^[9] A randomized case–control study found that after 8 weeks of Yoga practice, reduced pain and improved quality of life significantly in a group of 30 female patients suffering from chronic pelvic pain.^[10] Further, another study revealed that 6 weeks of yoga practice improved the daily activity, emotional well-being, and sexual health of women suffering from chronic pelvic pain.^[11]

Yoga practitioners should never push themselves beyond their physical capacity. Those suffering from lower back pain should avoid practicing this YP. Diet could be taken after 15–20 min of Yoga practice.

Conclusion

The practice of Yoga for 6 months reduced pelvic pain, along with other irritating and obstructive symptoms, and also had a positive impact on the quality of life in patients of chronic pelvic syndrome. The relaxation mechanism and synchronizing activity between muscles and nerves of Asanas and Praṇayamas lessen pelvic pain significantly.

Therefore, the Yoga program employed in our study can be used as an alternative nonmedicinal treatment option for CPPS. Further blinded randomized trials are needed to gather more evidence about the effectiveness of YT in cases of chronic pelvic syndrome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support

Nil.

Conflicts of interest

There are no conflicts of interest

Names of authors and about authors

Santosh Kumar Sahu, Ajit Kumar Pradhan, Prasanta Kumar Sahoo, Bibekananda Muduli1 Department of Ayush, All India Institute of Medical Sciences, Bhubaneswar, 1Department of Yoga and Naturopathy, Maharaja Sriram Chandra Bhanjdeo University, Baripada, Odisha, India.

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Article available online/offline on: AYU, Vol. 45, Issue 4, October December 2024, Page no 184-187, for more details please visit: www.ayujournal.org

Address for correspondence:

Dr. Santosh Kumar Sahu, Department of Ayush, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar ‑ 751 019, Odisha, India. E‑mail: yoga_santosh@aiimsbhubaneswar.edu.in

 
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