Male Pelvic Pain: Difference between revisions

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== Pain Classification Models ==
== Pain Classification Models ==


Classifying pain is a way for clinicians to better understand and design a plan of care to address a patient's pain.  Over the years, classification systems have been developed to define, classify, or stratify different presentations or symptoms of pelvic pain. Traditionally, male pelvic pain classification has been based on chronic prostatitis e.g. chronic pelvic pain syndrome.<ref name=":1">Roscher, P, Male Pelvic Pain. Men's Health. Physioplus. March 2022.  </ref>'''FOLLOW UP ON NEW PP PAGE LINK.'''
Classifying pain is a way for clinicians to better understand and design a plan of care to address a patient's pain.  Over the years, classification systems have been developed to define, classify, or stratify different presentations or symptoms of pelvic pain. Traditionally, male pelvic pain classification has been based on chronic prostatitis e.g. chronic pelvic pain syndrome (CPPS).<ref name=":1">Roscher, P, Male Pelvic Pain. Men's Health. Physioplus. March 2022.  </ref>'''FOLLOW UP ON NEW PP PAGE LINK.'''


=== Chronic Prostatitis Related ===
=== Chronic Prostatitis Related ===
The chronic prostatic related classification system was created by the US National Institutes of Health (NIH), which divides chronic prostatitis into different categories: a combination of chronic bacterial prostatitis, chronic pelvic pain syndrome, or asymptomatic prostatitis.<ref name=":2">Pirola GM, Verdacchi T, Rosadi S, Annino F, De Angelis M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556531/ Chronic prostatitis: current treatment options.] Research and reports in urology. 2019;11:165.</ref>
The chronic prostatic related classification system was created by the US National Institutes of Health (NIH), which divides chronic prostatitis into different categories: a combination of chronic bacterial prostatitis, CPPS, or asymptomatic prostatitis.<ref name=":2">Pirola GM, Verdacchi T, Rosadi S, Annino F, De Angelis M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556531/ Chronic prostatitis: current treatment options.] Research and reports in urology. 2019;11:165.</ref>
{| class="wikitable"
{| class="wikitable"
|+<ref name=":1" /><ref name=":2" />
|+<ref name=":1" /><ref name=":2" />
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|-
|-
|'''Category IV:''' Asymptomatic inflammatory prostatitis
|'''Category IV:''' Asymptomatic inflammatory prostatitis
|Due to prostate inflammation in the absence of genitourinary tract symptoms, always associated with chronic pelvic pain syndrome.
|Due to prostate inflammation in the absence of genitourinary tract symptoms, always associated with CPPS.
!
!Yes
|}
|}


=== UPOINTS (contemporary management system for men with chronic pelvic pain/Chronic Prostattitis) ===
=== UPOINTS ===
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.
This tool was proposed in 2009<ref>Shoskes DA, Nickel JC, Dolinga R, Prots D. [https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.384.4216&rep=rep1&type=pdf Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity.] Urology. 2009 Mar 1;73(3):538-42.</ref> to separately identify the different possible reported symptoms of CPPS.
 
{| class="wikitable"
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.
|+
 
!'''Reported Symptoms'''
* U for Urinary (Storage/voiding symptoms/post void residual
!'''Descriptors'''
* P for Psychological (Depression/catastrophizing)
|-
* O for Organ Specific (Prostate tenderness, calcification, lower urinary obstruction)
|'''U'''rinary symptoms<ref name=":1" /><ref name=":2" />
* I for Infection (UTI/Prostate positive cultures)
|
* N for Neurologic/Systemic (Pain Beyond pelvis/IBS/Fibromyalgia/Chronic Fatigue syndrome
* storage phase 
* Tenderness (Pelvic Floor spasm/Muscle trigger point)
* voiding phase
* Sexual Dysfunction (Erectile dysfunction, ejaculatory dysfunction, orgasmic Dysfunction.
* Post-void residual
|-
|'''P'''sychosocial dysfunction<ref name=":1" /><ref name=":2" />
|
* depression
* catastrophizing thoughts
|-
|'''O'''rgan-specific findings<ref name=":1" /><ref name=":2" />
|
* prostate tenderness or swelling,
* leukocytosis in prostatic fluid
* hematospermia
* prostatic calcifications
* lower urinary obstruction
|-
|'''I'''nfection<ref name=":1" /><ref name=":2" />
|
* exclusion of infective etiology or bowel contamination
* UTI
* prostate positive cultures
|-
|'''N'''eurological/systemic <ref name=":1" /><ref name=":2" />
|
* presence of abdominal and/or pelvic pain
* Irritatable Bowel Syndrome (IBS)
* Fibromyalgia (FM)
* Chronic Fatigue Syndrome (CFS)
|-
|'''T'''enderness of muscles<ref name=":1" /><ref name=":2" />
|
* presence of palpable muscle spasm in abdomen and pelvic floor
* presence of trigger points in abdomen and pelvic floor
|-
|'''S'''exual Dysfunction<ref name=":1" />
|
* erectile dysfunction
* ejaculatory dysfunction  
* orgasmic dysfunction
|}


=== Anatomically Driven ===
=== Anatomically Driven ===

Revision as of 06:16, 8 March 2022

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

Introduction[edit | edit source]

Pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” - International Association for the Study of Pain[1]

The International Association for the Study of Pain (IASP) created the new definition for pain, stated above, in 2020. The description of pain continues with the following notes:

  • Pain is always a personal experience to that individual, that can be influenced by biological, psychological, and social factors
  • Pain and nociception are different phenomena, meaning pain cannot be solely explained by sensory neurons
  • The concept of pain is a lifelong experience
  • An individual's report of a pain experience should be respected
  • Although pain usually serves an adaptive role, it may also adverse effects on function and well-being
  • Verbalisation is only one way to express pain; inability to communicate does not remove the possibility of a pain experience

[1]

Pain is subjective and unique to the individual experiencing it. Pain can be physical, mentally, and or psychologically debilitating. The IASP points out that pain is one of the main causes people seek out medical care, and chronic pain is a leading source of human suffering and disability.[2]

Pain Classification Models[edit | edit source]

Classifying pain is a way for clinicians to better understand and design a plan of care to address a patient's pain. Over the years, classification systems have been developed to define, classify, or stratify different presentations or symptoms of pelvic pain. Traditionally, male pelvic pain classification has been based on chronic prostatitis e.g. chronic pelvic pain syndrome (CPPS).[3]FOLLOW UP ON NEW PP PAGE LINK.

Chronic Prostatitis Related[edit | edit source]

The chronic prostatic related classification system was created by the US National Institutes of Health (NIH), which divides chronic prostatitis into different categories: a combination of chronic bacterial prostatitis, CPPS, or asymptomatic prostatitis.[4]

[3][4]
Category Description Bacterial Growth?
Category I:

Acute bacterial prostatitis

Due to acute bacterial infection determining prostatitis symptoms, systemic infection, and acute bacterial UTI. Yes
Category II: Chronic bacterial prostatitis Due to chronic bacterial prostatic infection with or without prostatitis symptoms. Yes
Category III: Chronic prostatitis/chronic pelvic pain syndrome
  • Used when an infective agent is absent and the disease is led by chronic pelvic pain symptoms and voiding symptoms in the absence of UTI.
  • Patients present with urological pain or discomfort in the pelvic region, associated with urinary symptoms and/or sexual dysfunction, lasting for at least 3 of the previous 6 months.
  • This category is further divided into IIIA (inflammatory) and IIIB (non-inflammatory)
 No
Category IV: Asymptomatic inflammatory prostatitis Due to prostate inflammation in the absence of genitourinary tract symptoms, always associated with CPPS. Yes

UPOINTS[edit | edit source]

This tool was proposed in 2009[5] to separately identify the different possible reported symptoms of CPPS.

Reported Symptoms Descriptors
Urinary symptoms[3][4]
  • storage phase
  • voiding phase
  • Post-void residual
Psychosocial dysfunction[3][4]
  • depression
  • catastrophizing thoughts
Organ-specific findings[3][4]
  • prostate tenderness or swelling,
  • leukocytosis in prostatic fluid
  • hematospermia
  • prostatic calcifications
  • lower urinary obstruction
Infection[3][4]
  • exclusion of infective etiology or bowel contamination
  • UTI
  • prostate positive cultures
Neurological/systemic [3][4]
  • presence of abdominal and/or pelvic pain
  • Irritatable Bowel Syndrome (IBS)
  • Fibromyalgia (FM)
  • Chronic Fatigue Syndrome (CFS)
Tenderness of muscles[3][4]
  • presence of palpable muscle spasm in abdomen and pelvic floor
  • presence of trigger points in abdomen and pelvic floor
Sexual Dysfunction[3]
  • erectile dysfunction
  • ejaculatory dysfunction
  • orgasmic dysfunction

Anatomically Driven[edit | edit source]

  • 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[edit | edit source]

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[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

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[edit | edit source]

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

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ 1.0 1.1 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.
  2. ↑ Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). pain. 2019 Jan 1;160(1):19-27.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Roscher, P, Male Pelvic Pain. Men's Health. Physioplus. March 2022.  
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Pirola GM, Verdacchi T, Rosadi S, Annino F, De Angelis M. Chronic prostatitis: current treatment options. Research and reports in urology. 2019;11:165.
  5. ↑ Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009 Mar 1;73(3):538-42.
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