Chronic pelvic pain syndrome in men (CPPS) is a persistent or recurrent local pain in the pelvis that persists for 3 months over the past six months, not associated with an infectious process. Along with pain, symptoms are represented by discomfort in the perineum, sluggishness of the urine stream, frequent urge to urinate, sexual dysfunction. Clinical examination includes TRU, ultrasound scanning of the bladder, secret analysis, STI tests, culture seeding, determination of PSA level. Treatment depends on the pathogenetic factor: pharmacotherapy, psychotherapy, physiotherapy, minimally invasive surgery are used.
Chronic pelvic pain syndrome is mainly found in abacterial chronic prostatitis, patients aged 45-50 years are most susceptible to it. However, during prostate biopsy, histological signs of inflammation are found only in a third of patients, which indicates a possible extraprostatic etiology of the syndrome. The negative impact of CPPS on the quality of life is compared with that of acute myocardial infarction, angina pectoris and Crohn’s disease. 92% of men develop erectile dysfunction, 56% of them have dyspareunia, 31% have ejaculatory disorders, 66% have decreased libido. Patients with hypochondria face pathology more often.
The pathophysiological mechanisms associated with the possible etiology of CPPS remain unknown. Scientists believe that the clinical manifestations of the syndrome arise due to the interaction of psychological stimuli with dysfunction of the immune, nervous and endocrine systems. The main reasons are considered:
- Undiagnosed inflammation. Some cases of abacterial prostatitis are not actually such, as they are associated with latent chronic urogenital infection. In 47-75% of patients, a deeper examination reveals chlamydia, genital mycoplasmas, gonococci, anaerobes, trichomonas, candida, viruses that have developed resistance to therapy, i.e. are in a state of parabiosis.
- Ischemia and congestia. The absence of regular ejaculation, frequent constipation, varicose veins of the pelvis lead to a violation of the blood supply to the prostate. With ischemia, abacterial inflammation develops, the outcome of which is fibrosis of the prostate with atrophy of its glands. Chronic hypoxia – a companion of ischemia – disrupts the functions of the gland: secretory, endocrine, evacuation and is accompanied by chronic pain syndrome.
- Other reasons. Operations on the prostate gland, rectum, bladder, injuries, urological manipulations can lead to damage to the nerve fibers innervating the pelvic organs. Neurological pathology (compression-ischemic neuropathy, degenerative changes in intervertebral discs, diabetic polyneuropathy, pubic osteitis, nerve changes after radiation therapy) cause pain typical of CSTB.
Contributing factors include irrational nutrition: the use of alcohol, spices, coffee, an overabundance of fatty foods in the diet, leading to obesity. Overwork and stress increase the local production of cytokines that support the inflammatory process in the prostate gland. Lack of physical activity increases the risk of developing chronic pelvic pain syndrome in men by 28%.
There are about 50 aspects of pathogenesis that somehow explain the development of this pathology in men. A certain role in the development of CPPS is played by special signaling molecules called cytokines, which are produced mainly by leukocytes. Under the influence of certain conditions (for example, circulatory disorders, immunosuppression), cytokines stimulate the development of the inflammatory process. Tissue necrosis factors, interleukins, interferons, neutrophil-activating factors are only some representatives of cytokines. An imbalance of proinflammatory cytokines and endogenous inhibitors is associated with the development of inflammation with concomitant pain in patients with this syndrome. Genetic predisposition – disorders in DNA sequences on chromosomal sites responsible for regulating the production and action of various cytokines, contributes to the appearance of persistent pain manifestations.
Some researchers believe that one’s own immunity is important in the development of chronic pelvic pain. The immune system, in addition to bacteria and toxins, begins to reject the body’s own healthy tissues, in this case, the prostate gland. Testosterone has been proven to protect the prostate from the inflammatory process. Perhaps its low level or a violation of the mechanism in which testosterone inhibits inflammation in the prostate gland, in some men leads to this syndrome. Dysfunctions of the nervous system at the local and/or central level can also provoke the appearance of pain. A protein known as nerve growth factor leads to an increase in their number and hypersensitivity, which makes the syndrome more pronounced. The above pathogenesis factors can be combined with each other.
Taking into account the variety of manifestations and the change in the degree of their intensity in CST, a classification was developed to divide patients into subgroups, taking into account the prevailing symptoms. This measure helps to determine the most effective management tactics in each specific case. The UPOINT classification includes 6 aspects:
- U – symptoms from the urinary tract: dysuric disorders (feeling of incomplete emptying, frequent urination), residual urine after urination (measured by ultrasound).
- P – psychosocial manifestations: depressive state, depressed mood, insomnia, feeling of inferiority, fear, refusal of habitual activities.
- O – organ-specific symptoms associated with the prostate gland: reduction of pain after urination, pain during prostate palpation.
- I – symptoms associated with infection: discharge from the urethra, itching, burning, painful sensations during ejaculation.
- N – neurological/systemic manifestations: pain localized outside the pelvis.
- T – muscle symptoms: tension of pelvic skeletal muscles during palpation, determination of trigger points.
Symptoms are similar to clinical manifestations in men with chronic bacterial and non-bacterial prostatitis. Typical complaints of discomfort during urination, frequent urge, difficulty urinating. Symptoms of obstruction of the lower urinary tract are accompanied by moderate or severe pain in the pelvis, lower back, perineum or genitals. Pain can be present constantly or appear in a certain period, the intensity of pain is variable: from debilitating aching to pronounced. The pain may increase with movement or manifest itself at rest.
The temperature reaction is normal, otherwise it indicates a bacterial infection. Concomitant paresthesia (numbness of the glans penis, feeling of cold) are typical for neuropathic disorders. Erectile dysfunction in CPPS (weakening of erection, painful ejaculation, premature ejaculation or difficulty in reaching climax, erasure of orgasm) is the main reason for contacting a urologist or andrologist.
Since chronic pelvic pain syndrome in men is a diagnosis of exclusion, based on the assessment of complaints and examination data, the examination algorithm is set for each patient individually. Initially, the urologist excludes potentially life-threatening conditions (prostate and bladder cancer, obstructive uropathy), which can occur independently or together with prostatodynia. Consultations of a neurologist, oncologist, psychotherapist and other specialists may be useful. Clinical and laboratory examination is based on:
- Visualization methods. TRU, ultrasound of the bladder with the control of residual urine, Dopplerography, MRI of the pelvic organs help to clarify the condition of the prostate gland, the presence of obstruction, features of blood supply. These studies are aimed at excluding other treatable diseases, but none of them is universal.
- Laboratory diagnostics. The main task is the elimination of STIs. The secret of the prostate, ejaculate, urine are sown on nutrient media in order to identify the pathogen and determine its sensitivity to drugs, evaluated using microscopy. There is no reliable correlation between the number of leukocytes and bacteria with the severity of symptoms. Their increased number in secret indicates an infectious genesis. PCR diagnostics is preferable for the identification of infectious agents. PSA is studied in men over 45 years of age.
- Video hydrodynamic examination. Evaluation of urodynamics shows signs of spastic dysfunction of the bladder and prostatic part of the urethra. The main purpose of the study is to identify hidden neuropathies and select the right treatment regimen that will ease the condition. The pathology is indicated by incomplete relaxation of the cervix and narrowing of the prostatic urethra due to compression of the prostate.
- Cystoscopy. Cystoscopy is performed to obtain data on inflammation in the bladder, the tumor process. Sedation during the examination contributes to better filling, which makes it possible to diagnose interstitial cystitis. In addition, according to the indications, it is possible to take a tissue sample for biopsy and perform small interventions – removal of a polyp, treatment of ring stricture of the urethra.
Differential diagnosis is carried out with proctological diseases: chronic rectal fissure, irritable bowel syndrome. From the side of urology, similar manifestations may occur in bladder stones, bacterial prostatitis, urogenital tuberculosis, tumor processes of the urogenital sphere, prostate fibrosis.
Treatment of chronic pelvic pain syndrome in men is based on a pathogenetic factor. Initially, the least invasive methods are used, in case of their ineffectiveness, surgical intervention may be performed. The tactics of conducting are mostly conservative, extremely rarely operational:
- Drug therapy. Antibiotics, antiviral or antifungal drugs are prescribed if a connection with an infectious agent is established. In the non-infectious form of inflammation, NSAIDs, antioxidants, hormone therapy (testosterone), alpha-blockers are indicated. For congestive and ischemic causes of CPPS, angioprotectors and disaggregants, PDE-5 inhibitors, androgens, and antioxidants are prescribed. In the neuropathic form, antioxidants, vitamins B, D, neuroprotectors are used. In the myogenic form of chronic pain, the main drugs are muscle relaxants.
- Physical therapy. Physiotherapeutic effects can help eliminate various factors of CPPS. Electroacupuncture and percutaneous nerve stimulation reduces pain by relieving muscle spasm. Electrophoresis, magnetotherapy, laser and thermal effects, vibration, water and mud treatment, enhance the effect of drugs, increase the concentration of the active substance directly in the focus of inflammation, improve microcirculation, which allows the use of physiotherapy techniques for treatment and prevention.
- Psychotherapy. Working with a psychologist or psychotherapist (depending on the mental status of the patient), taking appropriate medications (antidepressants, anxiolytics) helps to improve the psychoemotional component of pelvic pain syndrome. Relaxing techniques, image management techniques, self-hypnosis, biofeedback, cognitive behavioral therapy are used.
- Surgical treatment. Surgical methods include dissection of the bladder neck, prostate TUR, radical prostatectomy, which is used extremely rarely due to high invasiveness and the risk of complications. Surgery for CPPS in men plays a very limited role and requires further study. The introduction of botulinum toxin A through the urethra into the lateral lobes of the prostate reduces pain in 80% of men after 6 months of follow-up.
Prevention and prognosis
The prognosis depends on the establishment of the underlying cause and the possibility of its correction. There are no pathognomonic preventive measures. The patient is recommended to adhere to a healthy lifestyle, exclude alcohol, spices and coffee from the diet, if necessary, reduce body weight, exercise (swimming pool, yoga, walking), avoid stressful situations. Considering that the pathogens of sexually transmitted infections are important in the development of chronic prostatitis, casual sex should only be with the use of a condom. It is important for a man to monitor the regularity of ejaculation, as this ensures drainage of the prostate gland, prevents stagnation of the pelvis. With all the symptoms of trouble on the part of the urogenital sphere, it is necessary to sign up for a consultation with a urologist.