Chronic Pelvic Pain in Men Treatment & Management
- Author: Richard A Watson, MD; Chief Editor: Edward David Kim, MD, FACS more...
Chronic pelvic pain syndrome (CPPS) is a well-established condition that is notorious for the pain and disability it causes. Treating CPPS challenges even the most compassionate physician; patients are often understandably tense, wary, and defensive, and most of them will have already encountered frustration and rejection under the care of several unsympathetic physicians. These patients often approach new physicians with an off-putting combination of unrealistic hopes for a cure and suspicion related to past diagnosis and treatment failures.
The patient and physician must agree on a workable relationship at the outset of treatment. The urologist and patient may wish to address several points, perhaps approaching treatment as a contractual agreement. Severely disabling CPPS has been treated with transurethral resection of the prostate (TURP) and even radical prostatectomy. (Radical prostatectomy is an extreme measure; consider this treatment only in the most desperate of cases, if at all. )
Initial points to address
As previously stated, CPPS is, despite its name, a condition, not a disease or syndrome. It is similar to other chronic conditions, such as arthritis, that, while treatable, are not curable. No known cure exists for CPPS, but treatments based on the cooperation of patient and physician makes this condition more bearable. Over time, this condition may improve or stabilize on its own.
Many medications and other forms of treatment can help to alleviate the symptoms of CPPS. However, being patient is important; try only 1 or 2 new treatments at a time, giving each enough time to take effect. Do not overwhelm the patient with an unreasonable number of simultaneous treatments, which causes only excessive inconvenience and expense. Simultaneous treatments might actually work against one another, and the adverse effects of these treatments might cause more, rather than fewer, problems for the patient.
Reassure the patient that CPPS is a real physical condition, not an imagined one. However, this devastating problem causes many psychological stresses for the patient; therefore, suggest medications to help calm the patient and offer consultation with a psychiatrist or psychologist. A mental health care professional who has a special interest in this area may prove beneficial. Urologists and other clinicians need to be attentive to the profound psychological impact of CP/CPPS, as research has suggested that newly diagnosed CP/CPPS patients may be more likely to develop a depressive disorder.
Reassure the patient that CPPS is not cancer, not a life-threatening condition, not a venereal disease, and not contagious. Explain that the patient did not acquire this condition from someone else, nor will he pass it on to anyone.
In addition, remind the patient that he is not alone, that many men experience this problem. Local and national support groups recommended by the physician can provide additional information and encouragement.
Agree on a schedule of planned follow-up visits performed as frequently as appropriate management of symptoms dictates. These scheduled appointments minimize the need for emergency visits and telephone calls while providing comfort and creating trust between doctor and patient.
The urologist institutes treatment through, and in close communication with, the patient's primary care physician, who remains the mainstay of care.
Remind the patient that he is free to seek the advice of other physicians and health care providers while he is under a urologist's care. However, the patient must keep the urologist informed of all other treatments and medications tried, including alternative medicines and home remedies.
Remind the patient that his problem is taken very seriously and that every effort will be made, with the patient's cooperation, to minimize the problems that this condition causes. The patient-physician relationship should be a partnership formed to gain control of this condition and allow the patient to more fully enjoy life.
Until the etiology of CPPS is known, no specific preventative strategy will be available. In some patients, this condition may be caused by the sequela of sexually transmitted disease. In such cases, more vigorous treatment of the sexually transmitted disease and/or more lengthy antibiotic treatment (>4 wk) for an initial bout of acute prostatitis may reduce the percentage of cases that progress to a chronic, incurable state.
The UPOINT system
Men with CPPS present with various symptoms. Moreover, the intensity of symptoms varies. Researchers have developed a categorization (the UPOINT classification) to separate patients into subgroups, according to which symptoms predominate. The hope is that by characterizing the set of symptoms that are specific for each given patient, treatment can be more accurately tailored. Furthermore, the categorization allows investigation into the success of various medications and treatments based on symptom subgroups.
The UPOINT classification has a 6-point system, as follows:
U - Urinary symptoms
P - Psychosocial symptoms
O - Organ-specific symptoms (such as the prostate)
I - Infection-related symptoms
N – Neurologic/systemic symptoms
T - Tenderness in the muscles and pelvic floor symptoms
In one clinical setting, 22% of patients with CPPS had symptoms limited to a single domain. The percentage of patients with symptoms in a given dominion ranged from as high as 52% of patients experiencing urinary symptoms to as low as 16% experiencing infection-related symptoms.
Many times, trials of medication have failed to show a successful outcome in terms of overall improvement. However, when researchers reassessed the results in terms of improvement in one particular domain or problem area, they occasionally uncovered a noticeable improvement. For instance, use of alpha-blockers, such as alfuzosin (Uroxatral) or tamsulosin (Flomax), did not seem to have a significant impact when the response in terms of overall symptoms was measured as the single endpoint. However, a hopeful response was detected when the researchers went back and looked at responses specifically within the urinary domain. Patients with predominantly neuropathic pain may benefit from pregabalin (Lyrica) and related mediations, whereas other patients may not.
Thus, although some medications have failed to achieve a measureable improvement in symptoms among all patients, they may actually be helpful for certain patients within a given domain or symptom subset. Medications that have been rejected in the past because most men experienced no improvement in terms of overall response may actually prove helpful for small subset of men who share a certain symptom.
The theory behind this classification of has been named the “snowflake hypothesis” because the 6 domains can be arrayed in a diagram like a snowflake. A Web site has been established to assist physicians in deriving a UPOINT score for their individual patients, available at UPOINTmd.com.
More recently, a seventh domain has been proposed for symptoms related to sexual function. Current validation studies confirm that the 6 UPOINT categories do remain internally consistent, with the exception of the organ-specific category, which seems to contain 2 separate subgroups: one for men predominantly with bladder symptoms and one for those with prostate symptoms.
Moreover, these 6 UPOINT domains seem to interrelate or cluster into 2 major divisions. Patients with symptoms in any one of the 3 categories that are specific to the pelvis (urinary, organ-specific, and tenderness) have more in common. Conversely, men with symptoms that are predominantly in one of the 3 systemic domains (neurologic, infection-related, and psychosocial) seem to have a common bond.
Research has shown that if patients are identified by their UPOINT phenotype and treated accordingly, the response rate is 84% response rate, with a CPSI score decrease of 12 points, from 25.2 to 13.2.
The UPOINT classification may help separate men with specific sets of symptoms who may be helped by a given medication targeted at relieving their particular symptom subset, even if other patients with different UPOINT classifications do not benefit.
Prostatic Massage (Therapeutic)
In therapeutic prostatic massage, the physician places a finger rectally over the back of the prostate gland (as is performed during a routine prostate examination) and presses firmly and methodically down upon the entire surface gland, working from the lateral edge centrally, with the goal of breaking open prostatic ducts that have become plugged with inspissated material and expressing the released secretions into the urethra.
The role of prostatic massage in providing symptomatic relief is controversial. With little evidence-based medicine to recommend it, regularly repeated prostatic massages have been recommended in the past, particularly for patients with a large, congested gland. Some patients find that massage provides temporary relief that is worth the awkwardness and discomfort of the maneuver itself.
In 1969, Winter recommended prostatic massage 1-3 times weekly for 3-4 weeks for chronic infection of the prostate. Although this maneuver has largely fallen out of favor with many contemporary urologists, some still revert to it, albeit on a less frequent schedule, to provide supplementary symptomatic relief for select patients.
The role of frequent ejaculation in either producing or reducing CPPS symptoms remains controversial. Patients with enlarged, symptomatically congested glands are often advised that regular sexual intercourse may alleviate their symptoms. While little objective evidence substantiates this claim, most patients find this recommendation more attractive than serial prostate massages by their local urologist.
Whether frequent sexual intercourse relieves or actually exacerbates the condition seems to vary idiosyncratically from patient to patient.
The primary author's anecdotal observation is that patients tend to be most adversely affected by sudden, dramatic changes in the frequency of intercourse, either increase or decrease. For example, a patient who remains sexually abstinent while on prolonged business trips is apt to experience a flare-up of CPPS when he leaves home and again when he returns.
Whether masturbation produces an effect comparable to that of intercourse remains as unproven as it is widely advised. Ironically, similar prostatic maladies were attributed in 19th-century medicine to an excess of masturbation; what was condemned as a cause of prostatitis in the 1800s is being promoted as a cure in the 20th century. Before recommending masturbation, bear in mind that this is a sensitive subject; this activity is objectionable to some patients' moral and religious standards.
Transurethral Resection of the Prostate
A widely held opinion among urologists is that TURP should be a rarely used approach of last resort, offered only by experienced resectionists to patients who have experienced extreme, persistent symptoms over a protracted period, with no relief from nonoperative interventions. Candidates for TURP must understand clearly that symptomatic relief is not guaranteed. Indeed, symptoms may even worsen and could be compounded by the added burdens of erectile dysfunction and urinary incontinence.
When TURP is undertaken, completing a thorough resection of all tissues, down to the capsule, is essential. The concern is that residual tissue, partially coagulated, with obstruction of the ductal drainage from prostatic acini, might exacerbate the patient's symptoms.
Myofascial Release Therapy and Paradoxical Relaxation
Myofascial release therapy is a combination of internal and external trigger-point release therapy. It has proven more effective than standard external massage therapy alone.
Paradoxical relaxation is a methodology used to train autonomic self-regulation and pelvic muscle tension release. This psychotherapeutic treatment technique is used to help the patient decrease anxiety and nervous system arousal while counteracting the habit of tensing the pelvic muscles under stress. It is termed "paradoxical" because patients are directed to accept their pain and tension as a way of relaxing or releasing it. This approach incorporates group therapy, breathing techniques, and behavioral therapy, among other elements, to help reduce CPPS symptoms.
Anderson et al have developed a protocol that employs a team composed of a urologist, psychologist, and physiotherapist to provide a multifaceted approach to treating patients with CPPS and educating them on how to effectively alleviate their symptoms. This "Stanford protocol" incorporates myofascial trigger point assessment and release therapy, as well as paradoxical relaxation therapy.
Urologic evaluation is completed by the urologist, while myofascial trigger point assessment and release therapy is performed by the physical therapist, and techniques of paradoxical relaxation are taught by the psychologist. This novel approach capitalizes on the patient's own involvement in the treatment of CPPS.
Patients are taught the anatomy of the pelvic floor and lower abdomen and instructed on how to effectively manipulate their trigger points. Patients are also taught methods of relaxation in order to relieve autonomic dysfunction. A study showed an improvement in pain and urinary symptoms in 72% of patients with refractory CPPS following intensive Stanford protocol therapy.
The widespread acceptance of this approach among practicing urologists awaits further demonstration of its reproducibility and efficacy in multiple medical centers with larger numbers of patients and a greater variety of practitioners.
A readable text that describes this approach to the evaluation and management of CP/CPPS and that might prove helpful to clinicians and patients alike is A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndrome by Wise and Anderson (2003).
The influence of diet on chronic pelvic pain syndrome (CPPS) varies. Traditionally, patients have been warned to avoid excessive intake of prostate irritants, such as tobacco (smoking), coffee, tea, soda (cola drinks and diet drinks may be especially irritating), caffeine, spicy foods, and alcohol.
Inform the patient that none of these items is known to cause actual physical damage or to worsen the long-term prognosis. Nevertheless, responsible limitation of these items may help to control the day-to-day symptoms. A glass or two of wine or sherry may lessen nocturia symptoms.
Alkalinization of the urine seems to help some patients. A teaspoonful of baking soda (sodium bicarbonate) in a tall glass of warm water taken at bedtime may help to reduce nighttime symptoms. However, caution patients regarding the risk of an excessive sodium load with higher oral intakes, especially in patients receiving treatment for hypertension, fluid retention, or congestive heart failure. A potassium-based alkalinizer, such as potassium citrate (Urocit K), may prove more efficacious under these circumstances. Conversely, Stephen W. Leslie, MD, has found that some of his patients have very alkaline urine, which can also be irritating and result in discomfort and dysuria.
Sitz baths may provide partial relief from acute exacerbations. Rather than a shallow perineal dip, a deep tub bath in water as hot as can be comfortably tolerated seems to provide better overall temporary relief and relaxation.
Ultimately, a cure for chronic pelvic pain syndrome (CPPS) will be found by researchers who make distinctions among cases rather than by those who place all cases into a single category. Clinical investigators who are able to recognize within the conglomeration of conditions classified as CPPS a discrete subset of patients whose symptoms and findings can be proven to relate to a single, common etiologic factor will achieve meaningful success in treatment. In this way, multiple, individualized cures (as opposed to one cure) for CPPS will be progressively achieved, one subset of patients at a time.
The key to enabling this painstaking, multidirectional journey to success lies in wider encouragement and more effective funding of well-designed clinical, bench-top, and translational research projects.
Public awareness of the prevalence of CPPS, its devastating effects in terms of personal suffering, and its remarkable financial impact in terms of work-loss, hospitalizations, polypharmacy, and seemingly endless office visits needs far greater promotion. Funding for research from private and public sectors needs to be increased.
The patients who experience this condition and the physicians who care for them must have the courage to be more vocal in demanding higher priority in terms of immediate care and long-term research.
Pain management specialist
Anesthesiologists and other experts in pain management may be able to assist in providing significant symptomatic relief. No analgesics are specifically appropriate in the treatment of prostatitis. Standard mild analgesics such as acetaminophen, aspirin, and ibuprofen are well within the purview of the urologist's (and indeed, the primary care physician's) domain of management.
Keep in mind that the patient's analgesic needs are likely to fluctuate. Often, encouraging the patient to maintain a long-term, low-level intake of a minor analgesic such as acetylsalicylic acid or acetaminophen three times daily diminishes his need for more potent analgesics. Patient and physician fear of analgesic abuse or addiction often lead to undermedication, causing unnecessary pain and suffering.
Be quick to invite consultation from specialists at an established pain management center. Clinicians at Washington University have documented the beneficial impact that a coordinated, multidisciplinary approach between the urologist and the pain management team can have on improving the quality of life for many of these patients. These patients are often dismissed too easily, and their complaints are trivialized. Symptomatic patients can be encumbered by pain as devastating as that caused by cancer, neurologic diseases, and other conditions that merit a vigorous approach to effective pain management.
Frequently, if only anecdotally, patients with CPPS have been categorized as being tense, high-strung, hypochondriacal, and even neurotic. Experiencing the daily torment of uncontrolled pelvic pain, urinary dysfunction, and social embarrassment can understandably lead to profound psychological sequelae. Many patients encounter frustrated, dismissive, and unhelpful physicians in the course of treatment, compounding their frustration, depression, and despair. A sympathetic, constructive attitude by the physician can do much to alleviate this strain.
Moreover, a mild relaxant such as diazepam (Valium), prescribed judiciously, may help the patient adjust to his condition and, at the same time, relax the spasm of the pelvic floor muscles, providing objective relief.
Prescribe psychiatric medications with caution and rarely without consultation with a psychiatrist. A psychiatrist who is particularly interested in helping patients with CPPS can be a valuable member of the treatment team that includes the primary care physician, the urologist, and the pain management experts.
Researchers in Taiwan followed 3051 adults, who had been newly diagnosed with CP/CPPS over a 3-year period. These patients were more likely to subsequently develop a depressive disorder in that time frame than were a control group without CP/CPPS who were followed for the same amount of time (hazard ratio, 1.63). The risk was particularly high for men younger than 30 years (hazard ratio, 2.50).
This study serves to remind of the importance of “whole-man” evaluation and follow-up for patients with this condition. Urologists and other clinicians need to be attentive to the profound psychological impact of CP/CPPS. Coping mechanisms and medications that address the patient’s mental condition may also assist importantly in ameliorating his physical symptoms.
Avoiding a misunderstanding when recommending psychiatric counseling is important because the patient may perceive that his physician thinks that he is insane, hysterical, or delusional. Reassure the patient that his condition is real and that his suffering is not imaginary. Psychological support is appropriate in helping the patient cope more effectively with his serious, real-life problem.
An andrology specialist should be consulted for management of erectile dysfunction, if present. Specialists at Stanford University found that 92% of men with refractory CPPS reported related erectile dysfunction, including problems with decreased libido (66%), pain upon ejaculation (56%), and ejaculatory dysfunction (31%). In a cross-sectional study of 8,261 Korean men, a significant correlation was found between scores on the Premature Ejaculation Diagnostic Tool and NIH-CPSI scores, which persisted after adjustment for age, metabolic syndrome status, testosterone level, and International Index of Erectile Function-5 score.
Sexual dysfunction is a potentially devastating effect of CPPS, and managing it can greatly improve the patient's attitude and quality of life. An excellent review of this topic by Sadeghi-Nejad and Seftel brings attention to reports that link CPPS to sexual dysfunction.
Many remedies and treatments are available, including phosphodiesterase-5 enzyme inhibitors (eg, sildenafil), vacuum devices, injection and intraurethral therapies, and penile implants; a physician would be profoundly remiss to not broach the topic and its treatment possibilities. The patient’s partner should be strongly encouraged to be involved early in the counseling and treatment process.
Physical medicine therapist and physiotherapist
Clinical researchers at Columbia University found that an important subset of patients who had been treated unsuccessfully for symptoms of chronic abacterial prostatitis for between 1.5 and more than 10 years and who were unresponsive to long-term antibiotic and alpha-blocker therapies were actually experiencing pseudodyssynergia (a contraction of the external sphincter during voiding). This condition was documented based on electromyographic and fluoroscopic findings. Patients thus identified responded to treatment with biofeedback and behavior modification in 83% of cases.
Lately, authorities have appreciated that, in many cases, symptoms formerly attributed to CPPS may actually reflect pelvic floor spasm and chronic pelvic pain that is not prostatic in origin. In light of this, physiotherapists may provide an important role in helping to diagnostically distinguish and therapeutically ameliorate neuromuscular-based symptoms. For example, patients with palpable myofascial tenderness in the rectal area often chronically unable to relax their pelvic floor musculature. This dysfunction of the pelvic floor muscles (ie, levator syndrome) is objectively documentable. Moreover, significant symptomatic relief has been achieved through modulation-based therapies such as biofeedback, alpha blockers, and sacral nerve stimulation.
Six weeks of electroacupuncture therapy has been shown to produce significant pain relief. In this technique, electroacupuncture is applied at six different sites via an electrical pulse generator in order to release spasm in the pyriformis muscle while stimulating the sacral nerve. A prospective, randomized, nonblinded clinical trial in 54 men with class IIIB CP-CPPS found that electroacupuncture, given twice a week for 7 weeks, was more effective than levofloxacin plus ibuprofen for improving pain, urinary symptoms, quality of life, and total NIH-CPSI scores.
Growing clinical experience strongly suggests that pain syndromes labeled prostatitis may in fact reflect tension in the pelvic musculature and its associated tendons—myofascial pain. It is postulated that, in these cases, CPPS is not isolated to the prostate but is rather a neuro-inflammatory condition that releases endogenous pain-producing substances.
A study by Anderson et al suggested that pain in at least a subset of patients with chronic prostatitis (CP)/CPPS may result from a variant of fibromyalgia rather than from prostatic inflammation. Spasm in these muscles causes referred pain to the penis, prostate, or neighboring pelvic structures. For example, pressing on a trigger point in the muscles of the pelvic floor (puborectalis/pubococcygeus muscles) was found in the study to cause patients to experience penile pain.
A trigger point is a hyperirritable, sensitive, or tender spot within a taut, palpable band of skeletal muscle or fascia. Ten different myofascial trigger points were identified within the pelvic region. In the Anderson study, pressing firmly on one or more of these pressure points caused the patient to experience referred pain in one or more of seven different sites: the penis, perineum, rectum, suprapubic area, testicles, groin, and/or buttocks.
It is speculated that, at least in some cases, the tenderness experienced by individuals with CP/CPPS during digital prostate examination may be due less to tenderness caused by an inflamed prostate and more to inadvertent stimulation of myofascial trigger points in the pelvic floor musculature on which the prostate is resting. Significant pain reduction was achieved with myofascial release therapy.
Patients should keep a CPPS diary that has a page for each date, divided into two columns for a voiding diary and an environmental impact record.
In the voiding diary, (1) the time and approximate amount of each void and (2) the time and amount of each fluid intake are recorded. This record helps to distinguish between urinary frequency (voiding normal amounts of urine over a 24-h period but in small, frequent voids) and polyuria (voiding excessive amounts of urine each day overall).
In this light, objectively monitoring the patient's response to the advice to drink large quantities of water each day is often valuable. The general agreement is that dehydration should be avoided because good hydration contributes to overall well-being and may dilute the concentration of the urinary irritants that exacerbate symptoms of chronic pelvic pain syndrome (CPPS) type III.
On the other hand, advising a patient already seriously affected by excessive daytime and nocturnal frequency and urgency to maximally increase his intake of fluid seems counterintuitive.
While advice to drink large quantities of water might be interpreted by one patient as meaning 1-2 quarts of fluid each day, another might take it to mean 1-2 gallons. Information from a voiding diary can help to guide the patient safely between the hazards of too much and too little daily fluid intake.
Environmental impact record
In the environmental impact record, every possible incident of living, on days when symptoms flare up markedly and on days when symptoms are unusually quiescent, is detailed. All incidents of daily living are recorded, including those on the following list:
The type, time, and amount of food and beverage intake
Exercise performed or lack of activity, including bike riding, long car rides, and prolonged sitting or standing
Incidents of sexual stimulation and whether or not they resulted in ejaculation
They should also include a lack of sexual stimulation
Any unusual physical or emotional stress
Exposure to allergens, such as animals, dust, and pollen
Each day, when either a marked flare-up or an unusual abatement of symptoms occurs, the patient is encouraged to complete both columns of the diary in fullest possible detail.
Evaluation of the diary
After a series of good days and bad days have been recorded, the patient can review these recordings with the physician, looking for patterns in diet, exposure, or activity that characterize either type of day. The idea is to reduce factors associated with flare-ups and to maximize factors associated with relief.
This exercise should not be undertaken with the expectation of a cure for CPPS, but rather with the hope that clearer insight will be gained into some of the factors influencing the condition, which may provide the patient with better control over it.
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