Dr. Jeannette Potts wrote:You have to look. The other thing that I do is examine the torso in great detail starting with the abdominal wall. It's not just about tenderness on palpation in the left lower quadrant. It's like, well, what's on the surface, and are there trigger points that could be referring pain? There are certain patterns of pain referral that are well-known and well-recognized. As I explained to my patients many times, it's like I'm looking for the fuse box, and I'm looking for the fuse that may be affecting something far off.
That's a really important concept too, is to educate patients about the way that referred pain occurs. I reassure them it's not phantom pain or it's not something that's in their head, but that it is something that may not be in the organ in which they're perceiving it. It's important to educate and validate at the same time, but then that brings me to something that's extremely common. In 2000, I was the first person to put prostatitis, and I put that in quotation marks, in the realm of a functional somatic syndrome. 65% of just randomly selected charts that I looked at retrospectively showed that these men who were sent to me in second opinion for prostatitis met the criteria for functional somatic syndrome. Today, we call that a central sensitization syndrome.
These are folks who have a predisposition to have overlapping syndromes for which there is no true physical finding, but the symptoms are real. It's the person with irritable bowel syndrome, the person with TMJ syndrome, with chronic fatigue, non-ulcer dyspepsia, the 38-year-old patient who said, "Well, yeah, last year, I did go to the emergency room. My wife and I thought I was having a heart attack, and it turned out I was just having this pain," non-cardiac chest pain, these types of things.
It's important to take a history to assess for all of those things. Oftentimes, it's not in the chart. Oftentimes, the patient did not receive an official diagnosis, but that type of history, "Oh, yeah, I did go to the emergency room for this." Then, you'll see things in the life span. "Yeah, when I was in law school, I had this terrific migraine problem that just kept coming and going." Maybe they weren't migraines. Maybe they were another type of headache like muscle tension. "Then, I suffered this type of issue and when I got this new job, this happened, and this happened."
Full interview here:Dr. Jeannette Potts wrote:If it's the rare infectious disease, and again, that's less than 5%, and we have to remind ourselves we live in an era now where gonorrhea does not go unchecked and untreated. There's fewer stricture disease in this era. We have antibiotics that can kill just about everything and now, we have to deal with resistance. Men, for the most part, are not having tonsillar abscesses and rotten teeth and then becoming bacteremic in seeding their prostates. I mean prostatitis is extremely rare, and what is so sad is that the classification system uses prostatitis as the umbrella and then places pelvic pain in the bottom as one of the categories. That's 95% of the cases. That would be like one of the slides that I use is I invented an NIH encephalitis classification system, and within the realm of all the encephalitis and these life threatening infections, you put a headache. It's the same kind of thinking, so I reversed the approach. I rule out the infection. It's pretty easy. If I have a doubt, I will do a localization culture. As we know, physicians who tend to do localization cultures are very few, but they do tend instead to use other treatments outside of antibiotics.
https://www.urotoday.com/video-lectures ... 53-44.html
My issue with this last comment is that yes, some men are not improved after weeks of therapy, but then you need to look at how Clair Davies recommended trigger points be treated, and that was multiple times a day for several consecutive days. Treating trigger points once a week does not work. My own experience bears this out. I suffer trigger points in my shoulders and neck, and once they flare up I have to treat them numerous times per day for a few days to get them to subside. A weekly or monthly treatment would be completely useless. I think this explains a lot of the so-called physical therapy treatment "failures".Dr. Jeannette Potts wrote:I do want to make another comment about therapy. As you know, Diane, even at the risk of my medical reputation, I was promoting physical therapy for this since the mid-'90s. I'm really delighted that it's become mainstream therapy rather than alternative therapy. Sadly, however, I think that physical therapy has become the new ciprofloxacin.
I'm now seeing patients who have spent thousands of dollars, have seen five or six physical therapists, and they have a urological problem. Not everything is myofascial pain. If a physician does not make the diagnosis either by a history that corroborates a myofascial disorder or a physical exam, it's not that hard to do the physical exam to not only make the diagnosis and then make an appropriate consultation with physical therapy, not only is that important. It's also important to get the patient to buy in, that they realize, "Oh, this is why I'm doing it." It should not be the physical therapist being the first person going in that territory. It's very off-putting especially to men.
The other thing is if they're not getting better in six weeks, they need to be referred back to that urologist or preferably to someone who really wants to make the diagnosis. Central sensitization syndrome is extremely common. Sometimes, you need tandem therapy with the physical therapy. Some patients may have myofascial disorders but need pharmacological assistance to get over the hump, but some don't need physical therapy.
