Male Pelvic Pain

Original Editor - Stacy Schiurring based on the course by Pierre Roscher
Top Contributors - Stacy Schiurring, Kim Jackson, Lucinda hampton and Jess Bell

Introduction

Definition of pain:

QUOTE BOX: Pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” - Revised IASP Definition of Pain (2020)

Further notes on the new definition of pain:

• Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.*
• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a non-human animal experiences pain.

Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., ... & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976-1982.

Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., ... & Wang, S. J. (2019). Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain, 160(1), 19-27.

Classification models

Traditionally Prostate related

Chronic Prostatitis Related

• I-Acute bacterial prostatitis
• II-Chronic Bacterial prostatitis
• III-Chronic Prostatitis/Chronic pelvic pain syndrome (IIIa (inflammatory CPPS), IIIb Non-Inflammatory CPPS
• IV-Non-Asymptomatic Inflammatory prostatitis

• Bacterial Growth seen in Type I, II and Iv)
• No Bacterial Growth not seen in all presentation

UPOINTS (contemporary management system for men with chronic pelvic pain/Chronic Prostattitis)

Magistro, G., Wagenlehner, F. M., Grabe, M., Weidner, W., Stief, C. G., & Nickel, J. C. (2016). Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. European urology, 69(2), 286-297.

Bryk, D. J., & Shoskes, D. A. (2021). Using the UPOINT system to manage men with chronic pelvic pain syndrome. Arab Journal of Urology, 19(3), 387-393.

• U for Urinary (Storage/voiding symptoms/post void residual
• P for Psychological (Depression/catastrophizing)
• O for Organ Specific (Prostate tenderness, calcification, lower urinary obstruction)
• I for Infection (UTI/Prostate positive cultures)
• N for Neurologic/Systemic (Pain Beyond pelvis/IBS/Fibromyalgia/Chronic Fatigue syndrome
• Tenderness (Pelvic Floor spasm/Muscle trigger point)
• Sexual Dysfunction (Erectile dysfunction, ejaculatory dysfunction, orgasmic Dysfunction.

Anatomically Driven

• Prostate Pain Syndrome
• IBS
• Anal Pain Syndrome
• Neuromuscular Pain (PN/PFM)
• Bladder Pain Syndrome
• Scrotal Pain syndrome

• High % of chronic overlapping conditions & Therapy should extend far beyond the viscera

Clemens, J. Q., Mullins, C., Ackerman, A. L., Bavendam, T., van Bokhoven, A., Ellingson, B. M., ... & Landis, J. R. (2019). Urologic chronic pelvic pain syndrome: insights from the MAPP Research Network. Nature Reviews Urology, 16(3), 187-200.

Biospychosocial Framework

Aftab, A., & Nielsen, K. (2021). From Engel to Enactivism: Contextualizing the Biopsychosocial Model. This issue. European Journal of Analytic Philosophy, 17(2), M2.

• Bio- The body (pelvis and beyond)
• Psycho- The brain and nerves
• Social- the world we live in

• IS it Peripheral Mechanisms/Central Mechanisms
• Role of questionnaires
• Diagnosis Patterns
  • Bladder Pain Syndrome
  • Scrotal Pain syndrome
  • Pudendal Neuralgia/Pelvic Floor Dysfunction
• Differential Diagnosis
  • Prostate and bladder pain syndrome
  • Scrotal Pain syndrome

Assessment

Pena, V. N., Engel, N., Gabrielson, A. T., Rabinowitz, M. J., & Herati, A. S. (2021). Diagnostic and management strategies for patients with chronic prostatitis and chronic pelvic pain syndrome. Drugs & aging, 38(10), 845-886.

• Exclude dangerous underlying pathology
• Determine the diagnosis (taxonomic or phenotypic)
• Determine the emotional, cognitive, behavioural, sexual and functional consequences

Assessment History

• The Pain
  • Where is it?
  • What is it like?
  • When does it happen?
  • What makes it better/worse?
  • Do you have any other pain?

• Functional Symptoms
  • Bladder
  • Bowel
  • Sexual
  • Neurological

• Medical History
  • Previous Investigations
  • Previous Treatment
  • Medical and Surgical history
  • Medications

• Psychological Features
  • Anxiety about the pain
  • Impact of the pain

Assessment Red Flags

• Blood in Urine (Hamaturia)
• Blood in semen (Haematospermia)
• Smoking
• Occupational Petrochemicals
• Pelvic Radiation
• Ketamine abuse
• TB or schistosomal endemic areas
• NEW onset of UI or Faceal Incontinence

Physical Examination

• Addominal
• External Genitalia
• Perineum
• Digital Rectal Examination
• Lower Limb Neurological Examination

• Examination Red Flags
  • Palpable bladder
  • Penile/Tesiticula Mass
  • Excusitie tenderness/ Prostate/perineum
  • Reduced anal tone
  • Lower Limb Neurological Changes
  • Lower Limb Oedema

Management

Masterson, T. A., Masterson, J. M., Azzinaro, J., Manderson, L., Swain, S., & Ramasamy, R. (2017). Comprehensive pelvic floor physical therapy program for men with idiopathic chronic pelvic pain syndrome: a prospective study. Translational andrology and urology, 6(5), 910.

• A single intervention will rarely work
• Management is usually multidisciplinary
• Management should be individualised, and phenotype focused
• The strategy may include elements of self management

The Multidisciplinary Team

• GP
• Urologist/gastroenterologist/ colorectal surgeon
• Pain specialist
• Physiotherapist (pelvic floor down training, stretching, MFR/Education
• Psychologist/Psychiatrist
• Acupuncturist/Alternative medicine
• Dietery advice etc

Resources

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