Chronic pelvic pain syndrome (CPPS, formerly used the term “prostatodynia”) in men is a chronic, lasting more than three months, a feeling of pain, pressure or discomfort in the pelvic region, genitals or perineum, which cannot be explained because of the lack of any signs of infections, neoplasms or other pathological conditions. The prevalence of CPPS is 6% of the total number of men all over the world. The most often it is diagnosed in young people, including adolescents.
The US National Institute of Health classifies this condition as the third category of chronic prostatitis, otherwise called abacterial (non-bacterial) chronic prostatitis. It is this form that accounts for about 90% of all episodes of chronic prostatitis and has certain difficulties in establishing the causes of the observed manifestations, and, accordingly, with the treatment.
According to this classification, inflammatory, with an increased content of white blood cells in the secretion of the prostate, and non-inflammatory CPPS in men can be distinguished. Recently, such a division is questioned, since it is established that the number of white blood cells does not always correspond to the severity of the symptoms
Symptoms of Chronic Pelvic Pain Syndrome
The main symptoms include the following:
• permanent discomfort, pain in the perineum, suprapubic region, penis, testicles, anus, groin;
• pain during ejaculation (detected in 56% of patients suffering the syndrome and considered by some researchers as a distinctive feature of this condition, allowing to differentiate the latter from bacterial forms of prostatitis);
• inappropriate urination, such as frequent, sudden, difficult-to-manage desires, slow flow, intermittent flow, a feeling of incomplete emptying, etc. (such violations are more typical for the inflammatory variant of CPPS and are less pronounced in non-inflammatory form of the disease);
• sexual function disorder (erectile dysfunction is reported in 42%, premature ejaculation in 48%, and suppressed sexual excitement in 36% of all cases).
The general symptoms of the disease are the following:
• pain in the limbs, neck, and back.
In some cases, when pain in the bladder region and issues with urination prevail the syndrome of interstitial cystitis is meant.
The disease is characterized by periods of exacerbation of the signs, which continue several hours/days/weeks, and are followed by a decrease in symptoms. It is interesting that the cold can provoke exacerbations, while heat contributes to the relief of the condition. It has also been suggested that increased morbidity may be associated with food allergies, so that it is possible to reduce intensity of the manifestations by keeping a diet (no rigorous studies have been carried out yet, however, medical publications contain data that evidence feasibility of such treatment)
Intensity of pain varies from mild to debilitating, irradiation into the rectum possible hurting in sitting.
CPPS is often accompanied by violations such as depression, stress, anxiety disorders, irritable bowel syndrome (IBS), fibromyalgia (musculoskeletal pain), and chronic fatigue syndrome (CFS).
The reasons for the development of the condition have not been reliably ascertained yet. It is suggested that several factors influence the development of CPPS in men. Existing theories include exposure:
• nanobacteria (non-living structures - crystallized mineral and organic nanoparticles);
• increased intraprostatic pressure;
• intraprostatic reflux of urine due to inadequate relaxation of the urethral sphincter or the neck of the bladder;
• available interstitial cystitis;
• somatic disorders
• violations of local blood supply;
• emotional status of the disorder;
• fibromyalgia of the pelvic floor;
• low testosterone levels or disturbance of the mechanism of testosterone inhibition of prostate inflammation (it is known that testosterone protects the prostate gland against inflammatory processes).
Causative agents of the disease include the following:
• infectious diseases (including sexually transmitted disease);
• trauma, especially injury to the urethra, perineum;
• neurological disorders;
• non-infectious inflammatory reactions of an autoimmune or neurogenic nature;
• metabolic disorders (e.g., diabetes mellitus);
• functional disorders of urination;
• pelvic floor dysfunction (muscle spasm);
• impaired regulation of the local nervous system (due to past trauma, infection, etc., unconscious pelvic stress can provoke the release of nerve cells causing inflammation).
These factors can trigger the development of the syndrome in individuals who have an anatomical or genetic predisposition.
Diagnosis of CPPS is a “diagnosis of exclusion”, that is, to make the diagnosis, it is required to exclude other causes of pelvic pain (diseases of the organs of the urogenital tract, nervous system, intestine, etc.). First of all, bacterial prostatitis should be excluded, for example, by the method of “four-glass” or “two-glass” sample.
Diagnostic methods include the following:
• survey (identification of the past diseases, STIs, etc.) and examination of the patient (examination of genitals, perineum, inguinal area, digital rectal investigation);
• laboratory tests (urine, sperm and blood tests, determination of the level of the prostate-specific antigen, detection of infectious agents by PCR method);
• instrumental examination (urodynamic tests, cystoscopy, ultrasound of the pelvic organs and abdominal cavity).
Treatment of CPPS
Since the causes of pathology have been not accurately established to date, there are no options or quick and effective cure. Methods of treatment of CPPS are aimed at the improvement of quality of life of the patient and selected strictly individually in accordance with the body anatomy specific features and the course of the disease. The main goal of the therapy is to mitigate pain and restore sexual function. In some cases, spontaneous improvement or stabilization of the state was recorded.
The following conservative methods of treatment can be recommended:
• local thermal therapy (e.g., transurethral thermotherapy, transrectal hyperthermia);
• low-level exposure exercises (walking, swimming, stretching, yoga);
• lifestyle adjustment;
• healthy diet;
• physiotherapeutic treatment;
• intrarectal massage;
• psychotherapy (since 45% of patients with CPPS show psychological disorders, 65% have functional somatic syndromes, such as IBS, CFS).
The following medications can be prescribed:
• antibiotics (there is evidence of some efficacy of fluoroquinolones, tetracyclines and macrolides, which may be due to the presence of anti-inflammatory properties in these groups);
• alpha-blockers (to reduce the tone of the smooth muscles of the prostate, bladder neck, prostatic part of the urethra), such as Tamsulosin, Alfuzosin;
• non-steroidal anti-inflammatory drugs (ibuprofen, etc.);
• muscle relaxants (for example, based on botulinum toxin);
• drugs to reduce pain (including tricyclic antidepressants, gabapentinoids, in difficult cases – opioids);
• Injection anesthetics (with localization of pain in certain foci);
• inhibitors of estrogen reabsorption (mepartricin) to mitigate pain, reduce dysuric disorders.
If there are appropriate manifestations of interstitial cystitis, the bladder should be treated. Surgical methods are employed extremely rarely, for example, with obstruction of the urethra or bladder.
CPPS is a poorly understood disease that seriously violates the quality of life of a man. And since the exclusive role of inflammation of the prostate has been increasingly questioned recently, the maximum therapeutic effect can be achieved only by combining the efforts of specialists from several fields: urologists, neurologists, psychotherapists or psychologists, physiotherapists, etc.
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