Chronic Pelvic Pain in Men Workup

Because chronic pelvic pain syndrome (CPPS) is a diagnosis of exclusion, review the patient's records and perform a thorough physical examination to eliminate the possibility that another, more treatable disease is causing these symptoms. Assure the patient that only diagnostic tests that hold a reasonable chance of producing a significant result will be recommended. The patient should not rule out the possibility that these examinations may reveal an alternate diagnosis, but he should also know that he will not be burdened by excessive testing.

Excluding potentially fatal conditions (eg, prostate cancer, obstructive uropathy, pyonephrosis, bladder cancer, carcinoma in situ of the bladder) to any reasonably possible extent is imperative. Further, remember that patients with a documented, long-standing diagnosis of prostatodynia are not exempt from the development of any of these and other serious conditions.

Periodically, particularly in the setting of a flare-up of symptoms, a streamlined repetition of basic screening investigations, eg, thorough physical examination with digital rectal examination of the prostate, prostate-specific antigen (PSA) measurement, urine culture and cytology, renal and/or bladder ultrasonography, or intravenous pyelography, should be judiciously undertaken.

Imaging studies

Because no diagnostic finding for CPPS has proven definitive, all imaging studies (eg, kidney, ureter, and bladder radiography; intravenous pyelography; videocystourethrography; computed tomography [CT] scanning; magnetic resonance imaging [MRI]; ultrasonography of the scrotum; transrectal ultrasonography of the prostate) are aimed at excluding the presence of other, more definable and treatable causes of the patient's symptoms. None of these studies warrants universal application.

A cost-effective diagnostic algorithm should be individualized for each patient suspected of having CPPS, incorporating only laboratory tests and imaging procedures that are appropriate to that specific patient's problem.

Flow rate

A formal flow rate study often shows intermittency of flow and weakening of the urinary stream with a diminished peak urinary flow rate. The urethral pressure profile typically shows a high maximum urethral closing pressure.

No tests exist for which the results unequivocally indicate the diagnosis of chronic pelvic pain syndrome (CPPS). The presence of pyuria, bacteriuria, or both supports a diagnosis of bacterial prostatitis.

The presence of an inordinate number of WBCs in the EPS and/or bacteria on Gram stain and/or a heavy, nearly pure growth of a known bacterial pathogen on culture indicate a diagnosis of bacterial prostatitis. However, contamination from the urethra, an external site, or a source of infection in the upper urinary tract can lead to a false-positive result, while errors in collection or processing can lead to a false-negative result.

The NIH Chronic Prostatitis Cohort Study, in reviewing the screening results from 488 men with chronic prostatitis (CP), CPPS, or both, found (discouragingly) no reliable correlation between the leukocyte counts or the bacterial counts and the degree of symptomatology, whether the analysis was performed on the EPS, the postmassage voided urine (ie, the third midstream bladder specimen [VB₃]), or the ejaculate. The authors concluded that factors other than leukocytes and bacteria must contribute to symptom development in men with CPPS.^[13]

Stamey recommended the 3-glass urinalysis method, and, while this approach is widely taught, it is much less widely practiced by clinical urologists today. Nickel suggested that a simplified premassage and postmassage test may prove more efficacious.^[14]

Prostatic massage (diagnostic) and 3-glass urinalysis

Massaging the prostate produces EPS. The finding of high colony counts of bacterial pathogens and/or a significant excess of WBCs suggest the presence of a treatable infectious agent, particularly if these findings can be reproduced after a second massage. However, because eliminating urethral contaminants from these specimens is impractical, the clinical reliability of these findings is subject to challenge.

Most men find this process distinctly unpleasant, and many patients find the procedure greatly difficult or impossible to tolerate.

In many cases, no prostatic secretion flows from the meatus after massage. In these cases, Stamey recommends obtaining the first 10 mL of voided urine immediately following massage, a VB₃, and submitting that specimen for Gram stain and culture as a substitute for the EPS.

The PSA level is often elevated in men with acute bacterial prostatitis and may also be modestly elevated in those with chronic prostatitis (CP)/chronic pelvic pain syndrome (CPPS).

PSA testing in men with CPPS symptoms may be helpful in distinguishing between chronic bacterial prostatitis (ie, an elevated PSA value) and prostatodynia (ie, a PSA value within the reference range).^[15] However, this theory has yet to be tested in a well-controlled clinical trial. Moreover, testing the theory presents problems because researchers would have to counsel large numbers of men who are younger than age 40 years and who have an elevated PSA value secondary to benign prostatic inflammation that their elevated PSA test result is not an indication of prostate cancer.

Voided urine cytologies, while not routine, should be readily considered whenever the index of suspicion is at all elevated, as it would be, for instance, in patients who have had a long history of smoking, who have had occupational exposure to known toxins, or who exhibit persistent microhematuria. When such a patient is undergoing cystoscopy, bladder-wash cytology should be obtained.

Carcinoma in situ, at times, presents as a velvety patch of mucosa, but often it may be indistinguishable from normal urothelium.

Videourodynamic evaluation often reveals evidence of a spastic dysfunction of the bladder neck and prostatic urethra. Beyond helping to detect occult neuropathies, urodynamic evaluation of patients with chronic pelvic pain syndrome (CPPS) type III may lead to a better understanding of the underlying voiding dysfunctions peculiar to select subsets of patients with this condition. Nickel contends that dysfunctional voiding and intraprostatic reflux of urine may be initiating factors in the onset of CPPS type III.^[14]

Additionally, by subcategorizing patients with CPPS type III based on the presence and the nature of abnormal urodynamic findings, an improved rationale for case-specific therapies may be forthcoming.^[16]

Incomplete relaxation of the bladder neck and abnormal narrowing of the prostatic urethra occur on voiding views.

These findings alone might not clearly justify the expense and discomfort associated with the procedure. The main role of urodynamic studies is to rule out another underlying, unsuspected, but well-defined neuropathy amenable to treatment.

Although the study results may be entirely normal, cystoscopy, at most, reveals only nonspecific findings of minimal to mild inflammation and congestion in the area of the trigone and prostatic urethra. The main purpose of this intervention is, as with uroradiography, to help rule out the presence of other causes of the patient's symptoms.

Cystoscopy can be performed in an outpatient setting after urethral injection of lidocaine (Xylocaine) jelly. However, cystoscopy under general or regional anesthesia or under conscious sedation offers a couple of advantages. As a rule, patients with chronic pelvic pain syndrome (CPPS) tend to be hypersensitive with a low pain tolerance. When the patient is unable to cooperate fully, endoscopic inspection is compromised.

In addition, general or regional anesthesia allows for more comfortable performance of cold-mucosal cup biopsies to rule out carcinoma in situ and for hydrodistention of the bladder to rule out interstitial cystitis. Also, minor pathology, such as an annular stricture of the urethra or a prostatic polyp, can be treated at the same time.

With anal sphincter electromyography (EMG) and/or sphincter function profiles (microtip catheter), the reflex reactivity during cystometrography is recorded, and findings indicate the presence of hypertonicity and failure of the pelvic floor musculature to relax. These are signs of an underlying myofascial pain syndrome. Overall pelvic floor activity during cystometrography can also be monitored via an intra-anal surface electrode.

While such experimental evaluations are not yet part of the standard urological armamentarium, they are available at select centers.^[6]