Male Pelvic Pain
International Pelvic Pain Society
11th Scientific Meeting on Chronic Pelvic Pain
August 5-7, 2004
Marriott Oak Brook Hotel
Oak Brook, IL
At its meeting this August the International Pelvic Pain Society (IPPS) devoted one of the two postgraduate courses to male pelvic pain. The mission of the society, which was established in 1996, is to educate professionals how to diagnose and treat pelvic pain and improve the lives of women who suffer with it. But the society is recognizing that men with chronic pelvic pain face many of the same problems as women, such as the prejudice that they are “drug seekers” or “mental cases” and should seek psychologic help and that men also often live in frustration and hopelessness, as the IPPS mission statement notes women do. This course shows that IPPS is expanding its concern to men and is recognizing pelvic pain syndromes in men and women may have similar causes and may benefit from similar treatments. Following is a summary of the presentations made in this course. Many of the PowerPoint presentations these speakers used are available at http://www.pelvicpain.org
If Your Only Tool Is a Hammer, Everything Looks Like a Nail: A Nonurological Perspective on Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Jeanette Potts, MD
Cleveland Clinic Foundation
Dr. Potts is a general practicioner who acts as a gatekeeper for the urology institute at the Cleveland Clinic. She noted she sees about 300 to 400 men a year with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Like the other physicians making presentations at this course, she thinks that focusing on the prostate itself as a source of CP/CPPS may be a mistake and that many standard therapies just don’t work because of these mistaken assumptions. The strongest assumption is that “chronic nonbacterial prostatitis” (now called CPPS) is caused by an infection of the prostate gland that just cannot be identified. The presence of leukocytes (white blood cells, which are typically present in inflamed tissue) in prostatic secretions has sometimes been taken to indicate some hidden infection. But leukocytes don’t correlate with symptoms, and antibiotics, at least for longstanding disease, don’t work.
Unlike many of the pelvic pain specialists at this meeting, however, she was readier to attribute symptoms to psychologic sources, such as myofascial pain resulting from stress, somaticizing disorders (the current term for “hysteria”) and psychopathology, noting that stress alone can produce erratic electromyelograms (EMGs) and that relaxation therapy alone has produced good results. She offered the rationale that psychologic and physical disorders are no longer compartmentalized, citing as an example research showing serotonergic pathways are linked to physical syndromes such as irritable bowel and that the antidepressants that act on these pathways improve symptoms.
Nevertheless, she did caution that misdiagnosis, including psychopathology, can keep CP/CPPS from getting appropriate treatment. For example, a man whose “prostatitis” (without lower urinary tract symptoms) was treated with antibiotics, which helped, finally had an imaging study that showed he had chronic diverticulitis. Another “stressed out, high strung” patient, whom she had seen before, initially responded to physical therapy but came back with a recurrence that “felt different this time.” She nearly dismissed him as stressed, but got an imaging study that showed he had osteosarcoma (a bone cancer) of the acetabulum (where the top of the femur fits into the hip).
Like many of the other specialists at this meeting, she uses physical therapy, especially of the pelvic floor and pelvic region, as an important component of treatment. Other specialists, however, focus on nonpsychologic sources of pain, such as disease or damage of the pudendal nerve.
Dr. Potts thinks that, ultimately, many cases of chronic prostatitis may be regarded not just as myofascial or musculoskeletal but a urologic brand of a functional kinetic syndrome.
Prostatitis: Infection or Pain Syndrome?
Richard Berger, MD
University of Washington, Seattle
Chronic prostatitis has long been thought to be caused by infection, even when micro-organisms can’t be found. Dr. Berger himself was one of those researchers looking hard for the pathogens that might be responsible. But now he is looking elsewhere. “My journey,” he said, “has been from looking for infection in prostatitis to looking right now at anything but infection for prostatitis.”
Some 95 percent of chronic prostatitis is CPPS—the type with no evidence of bacterial infection. Dr. Berger doubts that everyone with a CPP diagnosis has the same thing because there are so many symptoms, including penile pain, perineal pain, frequency, double voiding, ejaculatory pain, urgency, suprapubic pain, rectal hesitancy, dysuria, and back pain—in the order of how often they occur. Most men have many sites of pain, with an average of four.
He emphasized that CPPS has a huge impact on individual lives and the economy. On average, CPPS patients suffer as much as patients with Crohn’s disease, and 10 percent of patients have a quality of life as poor as someone undergoing chronic dialysis. In addition, CPPS may account for more than $2 billion a year in the United States in direct medical costs.
Dr. Berger cautioned against the common therapy of antibiotics for patients with chronic symptoms because all that does is create resistant bacteria. How well antibiotics work for early symptoms needs study.
More recently Dr. Berger has been looking at CPPS as a chronic pain syndrome, looking to see whether patients develop allodynia (perception of nonpainful sensation as painful) or hyperalgesia (when normally mildly painful stimuli produce high levels of pain) and tender points, like those seen in fibromyalgia.
Typical tender point locations on the body help diagnose fibromyalgia, and Dr. Berger has expanded these points to include points that are typical in men with CPPS, including external points on the pubic bone, the inguinal canals, the perineum, and the penis and internal points over the levators ani and beside the prostate. He has found that CPPS patients have higher fibromyalgia point scores as well as higher internal and external pelvic point scores than healthy men. Twenty-five percent of men with CPPS, he pointed out, have no prostate tenderness. Although this is lower than in healthy men (50 percent), if physicians focus on the prostate only, they may fail to find significant pain.
Dr. Berger has also looked at surface EMGs and has found that CPPS patients have more variability in electrical activity than healthy men, giving a sensitivity of 80 percent and a specificity of 90 percent for diagnosing CPPS. A physical therapist at the course noted, however, that superficial sensors don’t always reflect the high tone of the pelvic floor in men. Often, when perirectal readings are normal in a man with CPP, internal rectal sensors show strong abnormality, she noted.
Men with CPPS also show differences in sensing heat. Dr. Berger has found. they felt heat earlier and have more pain from heat than healthy men on the perineum, which is supplied with nerves from sacral roots, but these differences don’t show up with heat on the anterior thigh, which is supplied by different nerves that originate in the lumbar region.
Like many of the experts here, Dr. Berger treats many of his CPPS patients with physical therapy and noted that these men have more pelvic floor spasm, pain with palpation, and more difficulty with quick contractions—relaxing and contracting pelvic floor—than healthy men.
Whether CPPS and IC are the same is still an open question, said Dr. Berger. They share many symptoms, and quality of life is just as poor. Also, many men with CPPS show glomerulations on their bladder linings, as many IC patients do. On the other hand, men who had been diagnosed with IC showed evidence of the recently discovered antiproliferative factor (APF) in their urine, whereas men with CPPS did not. (In the study cited, however, some of the men with IC had been diagnosed with CPPS first but were then found to meet the NIH study criteria for IC.) Also, a study of the potassium sensitivity test, often used in IC, did not help diagnose CPPS in men. (The test, however, is not highly sensitive or specific for IC either, and recently, a group of IC experts reporting to NIH said the test could not be recommended as a diagnostic tool for IC.)
Dr. Berger recommended that physicians who treat and research CPPS look at the syndrome in a more global and biopsychosocial context, because it’s well known in pain syndromes that if you address only pain sensation, you won’t succeed. Social, psychologic, possibly genetic, and many other factors need to be addressed for patients in a multimodal, pain-clinic type of process, he said.
The Role of Interstim in Treating Pelvic Pain Syndromes
Craig Smith, MD
Glen Ellyn, IL
Neuromodulation is changing urology, said Dr. Smith. The sacral nerve stimulator, Interstim, has already been approved for treatment of urgency and frequency, urge incontinence, and nonobstructive urinary retention, and studies are going on to find what other problems nerve stimulation might be useful for, including CPPS. Dr. Smith thinks neuromodulation may eventually become first-line therapy before surgeons consider major reconstructive procedures, such as for incontinence.
Most clinical studies have been done with Interstim, which stimulates the sacral nerve roots. Other neuromodulators, however, are also being tested, such a stimulator of the pudendal nerve (which arises from sacral nerve roots and supplies the anal area, perineum, and penis or clitoris) and the posterior tibial nerve (running to the heel and also coming from sacral roots). Neuromodulators are considered minimally invasive because open surgery isn’t required; the leads that stimulate the nerves are placed through the skin.
Interstim to treat CPPS or orchalgia (testicular pain) has been tried in 21 published studies. It has also been studied in IC. In general, studies show that neuromodulation reduces pain, but does not always resolve it completely. About 60 percent of patients tend to respond. One thing he does to help avoid complications and get better results is to ask patients, who are under sedation during the implant procedure, about whether his placement of the leads causes pain. If it does, he moves the lead. Many patients are able to reduce or stop their narcotic use. Dr. Smith thinks that neuromodulation is likely to be one component in multimodal therapy for CPPS.
Dr. Smith suggested possible sources of nerve abnormalities and damage, including pelvic trauma from surgery, neuroinflammation, and psychologic stress leading to spasm. All these events have local effects on the musculoskeletal system, producing spasm and ischemia. He also reviewed what is known about neurologic control of urinary function
His approach to treatment is to treat the whole patient, including managing behavioral and psychological stress, using medications to reduce pain and anxiety, and using physical therapy, which includes biofeedback to help train men to relax the pelvic floor and myofascial release.
Chronic Prostatitis/Chronic Pelvic Pain Syndrome in 2004: Classification, Clinical Characteristics, and Treatment Options
J. Quentin Clemens, MD
Dr. Clemens presentation was an overview of prostatitis etiology, diagnosis, and treatment. He believes that prostatitis is very common, with a prevalence in the male population from 2 to 10 percent. A study of medical care visit data gathered by the US government showed that prostatitis accounted for 2 million office from 1990 to 1994—eight percent of urology office visits and one percent of primary care office visits. Another study by Kaiser Permanente indicated the prevalence is about three percent, with that figure going up with age. Most chronic prostatitis is nonbacterial (CPPS). Chronic bacterial prostatitis does exist, he said, but it is rare.
He reviewed the traditional four-glass test for culture and microscopic examination. Although finding leukocytes in prostatic secretions is not considered diagnostic, he did note that recent preliminary research has shown that inflammatory markers found in those secretions may help diagnosis.
Treatment of acute bacterial prostatitis includes therapy with antimicrobials that get into the prostate. He emphasized that the prostate should not be massaged in this situation. Chronic bacterial prostatitis requires low-dose, suppressive antimicrobial therapy.
Generally, nonbacterial prostatitis is considered to be chronic (CPPS) if a man has had pain for at least three months along with a variable degree of voiding dysfunction and sexual symptoms. Although a score as high as 12 or 15 on the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) suggests CPPS, he said, the questionnaire is intended to judge how patients are doing, not for diagnosis per se.
For evaluation, Dr. Smith uses the lower urinary tract localization test, the NIH-CPSI, flow rate, residual urine determination, and urine cytology. Some tests he considers optional are semen analysis and culture, videourodynamics, cystoscopy, and pelvic imaging.
His approach to treatment may include antimicrobial agents and alpha blockers, although these have been shown not to be effective for longstanding CPPS that has already been treated unsuccessfully with these agents. In addition, he may use tricyclic antidepressants, nonsteroidal anti-inflammatory agents, physical therapy—including biofeedback and pelvic floor work, gabapentin (Neurontin), phytotherapy, neuromodulation, transurethral microwave thermotherapy (TUMT), anticytokine therapy, and more.
Dr. Clemens sees IC and CPPS as similar, but he said, in his experience, men with IC predominantly feel bladder pressure and do not call that pain and urinate frequently because of the constant urge. Patients with overactive bladder may have accidents, whereas IC patients do not. He believes IC is not common in men but does occur and probably more commonly than has been reported. He noted that occasionally, postejaculatory pain may have seminal vesicle obstruction as a cause, so careful evaluation is needed.
The NIH Chronic Prostatitis Collaborative Research Network, which recently met and also collaborated with the Interstitial Cystitis Collaborative Research Network, is planning new clinical trials. They will be looked at the usefulness of alpha blockers for men with newly diagnosed nonbacterial prostatitis and will be looking at new oral agents and procedures, such as botulinum toxin (Botox) injection, acupuncture, and pelvic floor therapy for CPPS. Many of the same treatments will be investigated for both CPPS and IC.
Divining Pelvic Pain: Anesthesia, Anatomy, and Anecdotes
Stanley Antolak, Jr, MD
Center for Urologic and Pelvic Pain
Lake Elmo, MN
Dr. Antolak’s practice is focused mainly on treating pelvic pain in men and women that is caused by damage to the pudendal nerve. He and the two other experts who spoke at the conference about pudendal neuropathy noted that it is a “master masquerader.” Patients have symptoms typical of CPPS and IC and sometimes other gynecologic, urologic, and proctologic problems that aren’t relieved by common treatments for these conditions. The real source of their symptoms is, in fact, damage to the pudendal nerve, and the problem is cured or greatly improved with treatments aimed at releasing pressure on the nerve or reducing nerve inflammation. Those treatments range from simple self care, such as sitting on a pad that takes pressure off the perineum, to surgery to release of the nerve.
Gerard Amarenco in France first recognized the problem in competitive
cyclists in 1987. Roget Robert, French anatomist and surgeon, developed a treatment protocol, which he described in an article published in 1997. He regards it as a kind of tunnel syndrome, in which the nerve is trapped, similar to carpal tunnel syndrome Common causes of the nerve damage are rigorous athletic training, especially for cycling, and hard falls on the buttocks. Other sources of damage include pelvic or rectal surgery; radiation therapy, such as for prostate cancer; and cancer metastases that impinge on the nerve. How common pudendal neuropathy is isn’t clear, but the opinion of experts here ranged from rare to a common cause of chronic pelvic pain. Nevertheless, they all emphasized that it is not recognized enough.
No objective tests are available yet to diagnose it. A test of how well the nerve conducts impulses, called the Pudenal Nerve Motor Latency Test (PNMLT) and anesthetic blocks of the nerve don’t always demonstrate the problem. Dr. Antolak is researching a thermal sensory testing method that may aid diagnosis. At the moment, the best way to diagnose it, he said, is to exclude the other problems and to recognize the hallmarks of pudendal neuropathy that nearly all patients have—pain when they sit that is relieved by standing up, lying down, or sitting on the toilet, which they nearly always call “the best seat in the house.” Taking a careful history is extremely important, he emphasized. He asks careful questions about the location of the pain, how it occurs, when it occurs, and what patients think started it.
Dr. Antolak also compresses the nerve at the two points where it most commonly becomes trapped or damaged to see if that reproduces pain in the areas the nerve serves. The nerve arises from lower sacral roots (usually from S2, 3, and 4), runs under the piriformis muscle (which goes from the sacrum to the top of the femur under the gluteus), and crosses the over the sacrospinal ligament, where it attaches to the ischial spine—a sharp protrusion on the pelvic bone—and under the sacrotuberous ligament. Dr. Antolak thinks of these ligaments at the ischial spine as a lobster claw that can pinch the nerve, which he can feel at the ischial spine through the rectum. The nerve then enters the pelvic region and passes through the Alcock or pudendal canal, which Dr. Antolak palpates externally. The nerve splits into three branches, usually after going through that canal, to serve the rectum and anal area, the perineum or vulva, and the penis or clitoris.
He pointed out that the nerve roots that contribute fibers to the pudendal nerve and the way the pudendal nerve branches are not the same in everyone. Usually, only sacral nerve roots contribute to this nerve, but even roots from as high as the lowest lumbar vertebra can contribute fibers. In 50 percent of patients, the inferior anal nerve branches off before the Alcock canal, so they may not have rectal symptoms, and occasionally the branch never even joins the pudendal nerve but goes through the sacrospinus ligament on its own. In addition, the main trunk of the pudendal nerve can vary away from the ischial spine by as much as an inch. Anatomic variations are the reason why, sometimes, injections to the nerve area may not ease pain, and surgery must be done very carefully.
Nerves traveling back to the same roots in the spine as the pudendal nerve, such as from the bladder or from as far away as the foot, can also produce pain in the areas the pudendal nerve serves or even the bladder. This is called referred pain. Similarly, the areas these other nerves serve can become painful because of the pudendal neuropathy. For example, some patients with pudendal neuropathy feel pain in on the posterior thigh and inner upper thigh, the area served by the posterior femoral cutaneous nerve that can arise from the same sacral roots as the pudendal nerve. Treatment can take advantage of these relationships. For example, a stimulator of the posterior tibial nerve at the ankle or even ice on the soles of the feet can sometimes ease urinary or genital symptoms.
Dr. Antolak noted that about 50 percent fibers in the pudendal nerve are sensory, only 20 percent are motor, and 30 percent are autonomic—probably the highest of any peripheral nerve in the body. This is why autonomic effects such as cold skin or peau d’orange can be seen. Peau d’orange is an orange and dimpled appearance of the skin caused by leakage of interstitial fluid.
Unless pain scores are high, treatment should start with less invasive therapy, including physical therapy and self care, said Dr. Antolak. The major feature of his self-care regimen is using a seating pad that suspends the perineum.
The next step is perineural injections. He uses a combination of fluoroscopy and computed tomography (CT) imaging to guide him in placing the injection needle because relief can depend on how accurately the injections are placed. He does two injections into the interligamentary space (near the ischial spine) and one into the Alcock canal. The injections include both an anesthetic, which dulls nerve pain in the short term, and a corticosteroid, which reduces inflammation. Dr. Antolak pointed out that Jerome Weiss, MD, one of the other experts here who spoke about pudendal neuropathy, also uses heparin in the injection, which may help break down scar tissue.
The anesthetic can take from minutes to one to four days to take effect. The corticosteroids have their effect after 7 to 10 days. Pain relief lasts from one to three weeks, but there are also cumulative effects, and a series of injections can sometimes produce permanent relief, said Dr. Antolak.
Results can be dramatic. The injections can relieve neuritic pain, sphincter obstruction, irritable bladder symptoms, and erectile and ejaculatory function or female sexual dysfunction. Many of the patients he spoke about had relief of longstanding pain, which they had suffered for as long as 44 years.
Complications can include increased pain after the injection, no response because of poor needle placement, and sciatic anesthesia.
Many questions about the etiology, diagnosis, and treatment of pudendal neuropathy remain to be researched, said Dr. Antolak. How much of CPPS is attributable to pudendal neuropathy is one of the most important.
Dr. Antolak’s website:
International websites with information on pudendal neuropathy:
http://www.tipna.org/index.htm (The International Pudendal Neuropathy Association)
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