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

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

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

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.

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 (CPPS).FOLLOW UP ON NEW PP PAGE LINK.

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, CPPS, or asymptomatic prostatitis.

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

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

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

Anatomically Driven Classification

Male pelvic pain can also be grouped based on the symptoms into an anatomical classification. It should be noted that these chronic overlapping pain conditions commonly occur in the same patients simultaneously. Such classification categories can include:

• Prostate Pain Syndrome
• IBS
• Anal Pain Syndrome
• Neuromuscular Pain
• Bladder Pain Syndrome
• Scrotal Pain syndrome

Biospychosocial Framework

Please read this article for an in-depth review of the biopsychosocial model. Due to the complex nature of pain, a holistic whole-person approach to assessment, treatment, and interventions are required to fully understand the root cause of a person's pain. This is true to male patients with pelvic pain as well, especially given the often intimate and potentially embarrassing nature of pelvic pain diagnoses. Please read this article for an in-depth review of the complexities of treating men's health conditions.

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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