Chronic Pelvic Pain Syndrome. Shady Saikali Lebanese American University Moderator: Dr. Nazih Youssef 15/09/2016

Transcription

1 Chronic Pelvic Pain Syndrome Shady Saikali Lebanese American University Moderator: Dr. Nazih Youssef 15/09/2016

2 Outline DefiniKon EKology Clinical PresentaKon Non- surgical Treatment Surgical Treatment

3 Epidemiology ProstaKKs one of the most common diagnosis in urology clinic, increasing with age Significant prevalence of prostakks- like symptoms (2.2% to 16%) with a median prevalence rate approximakng 7% for chronic prostakks and CPPS

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5 DefiniKons Category IIIA / IIIB indisknguishable on presentakon Predominant symptom is pain (azer ejaculakon as well) Chronic > 3 months durakon Symptoms tend to wax and wane DrasKcally affects quality of life

6 EKology Microbiology E. Coli most common but not cultured in category III Uropathogenic E. Coli can form biofilms è chronic, treatment resistant prostakks Early vigorous treatment of first acute bout may prevent progression into chronic bacterial/ abacterial prostakks FasKdious organisms implicated in CPPS

7 EKology DysfuncKonal Voiding Anatomic or neurophysiologic obstruckon resulkng in high- pressure dysfunckonal flow Video- urodynamic studies, many pakents with prostakks syndromes show incomplete funneling of the bladder neck as well as vesicourethral dyssynergic pacerns (Kaplan et al, 1994, 1997; Hruz et al, 2003)

8 EKology IntraprostaKc Ductal Reflux One of the mechanisms in the pathogenesis of chronic bacterial and nonbacterial prostakc inflammakon in some individuals ProstaKc calculi are composed of substances found only in urine, not in prostakc secrekons (Sutor and Wooley, 1974; Ramiraz et al, 1980) It appears that prostakc calcificakon is common in pakents with nonbacterial CP

9 EKology Immunologic AlteraKons NoninfecKous inflammakon (nonbacterial prostakks or CPPS) è immunologically mediated inflammakon caused by some unknown ankgen or an autoimmune process IgA and IgM as well as similar ankbodies, fibrinogen and complement C3 idenkfied in prostate biopsies of pakents with CP CPPS can exist through persistent immunologic mechanisms long azer the bacteria have been eradicated (Galeone et al, 2013; Quick et al, 2013)

10 EKology Pelvic Floor Muscle AbnormaliKes Neural dysregulakon of the lower urinary tract may be a consequence of acquired abnormalikes in the central nervous system Researchers concluded that their findings reflect a funckonal disassociakon between the CNS and the peripheral target, the pelvic floor muscles Other pelvic structures source of pain and spread by proximity

11 EKology Psychosocial Important to be aware of it in clinic Recent studies demonstrate that psychological factors are involved in the disease, but it seems unjuskfied to label this group of pakents as neurokc or as having a psychopathologic condikon

12 Clinical PresentaKon NIH- CPSI: 9 queskons that address the three most important domains of the chronic prostakks experience: Pain (which is the primary symptom of CP/ CPPS) à 4 Qs (locakon, severity, and frequency). Urinary funckon: 2 queskons (irritakve, obstruckve). The quality of life or impact: 3 Qs

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14 Physical Exam Mandatory but usually not helpful in making definikve diagnosis DRE should be performed azer pakent produced pre- prostakc massage urine sample Degree of elicited pain during prostakc palpakon is variable and is unhelpful in differenkakng a prostakks syndrome.

15 Lower Urinary Tract Cytologic ExaminaKon and Culture Techniques In 1968, Meares and Stamey described classic four - glass urine colleckon technique Two- glass test, originally suggested by Weidner and Ebner (1985) and popularized by Nickel (1995, 1996, 1997a), is a simple, cost- effeckve screen to categorize pakents with chronic prostakks, quickly replacing four glass technique

16 Lower Urinary Tract Cytologic ExaminaKon and Culture Techniques Campbell Walsh Urology 11 th edikon

17 Lower Urinary Tract Cytologic ExaminaKon and Culture Techniques Campbell Walsh Urology 11 th edikon

18 Microbiologic Considera0ons Both the tradikonal and the NIH classificakon systems depend on culturing for standard uro- pathogens.

19 Cytologic Considera0ons DifferenKaKon of the two subtypes of category III CP/CPPS depend on cytologic examinakon of the urine or EPS or both. No validated cutoff point for level of WBCs per HPF that is required to differenkate an inflammatory from noninflammatory CP/CPPS. Wide range in literature for normal value

20 Urodynamics Chronic LUTS in young men are ozen misdiagnosed as chronic nonbacterial prostakks when in fact they indicate a cohort of men with undiagnosed chronic voiding dysfunckon

21 Endoscopy Clinical experience (rather than controlled clinical studies) suggests that lower urinary tract endoscopy (i.e., cystoscopy) is not indicated in the majority of men presenkng with CP/CPPS unless: Hematuria lower urinary tract evaluakon (e.g., VB1 urinalysis) addikonal studies (e.g., urodynamics) indicate the possibility of a diagnosis other than CP/CPPS.

22 Transrectal Ultrasonography The diagnoskc value of US in differenkakng benign from malignant prostate disease is controversial TRUS can be valuable in: diagnosing medial prostakc cysts in pakents with prostakks like symptoms (Dik et al, 1996), diagnosing and draining prostakc abscesses (Granados et al, 1992) diagnosing and draining obstructed seminal vesicles

23 Prostate Biopsy At this Kme, histologic, culture, and molecular biologic evaluakons of prostate biopsy specimens in pakents with CP/CPPS remain research tools only.

24 Other Possible Markers Monocyte chemoacractant protein- 1 Macrophage inflammatory protein- 1α detected in EPS. Both of these chemokines are elevated in category IIIA and IIIB CP/CPPS Macrophage inflammatory protein- 1α may be a further marker for clinical pain in these pakents (Desireddi et al, 2008)

25 EvaluaKon Mandatory evaluakon includes history- taking, physical examinakon, urinalysis, and urine culture. Recommended evaluakon includes lower urinary tract localizakon test (culture), NIH- CPSI, flow rate, residual urine determinakon, and urine cytology.

26 UPOINT Classifies CP/CPPS pakents into six domains: urinary (U) psychosocial (P) organ- specific (O) infeckon (I) neurologic/systemic (N) tenderness of pelvic floor skeletal muscles (T) Directs individualized and mulkmodal therapeukc approaches to CP/CPPS

27 Campbell Walsh Urology 11 th edikon

28 Treatment (Nonsurgical) An0microbial Most commonly prescribed treatment for chronic prostakks syndromes In acutely inflamed prostate gland, pharmacokinekcs do not play significant role in ankbiokc penetrakon 1970s to 1990s most commonly used ankmicrobial agent in treatment of chronic prostakks was TMP- SMX (Moon, 1997; Nickel et al, 1998a) TMP- SMX less effeckve both in bacterial eradicakon and costefficacy (Kurzer and Kaplan, 2002)

29 Treatment (Nonsurgical) Alpha adrenergic Hypothesized è α- adrenergic blockade may improve ourlow obstruckonè diminishing intraprostakc ductal reflux A number of meta- analyses and comprehensive reviews of these data recommended that α- adrenergic blockers provided significant symptom ameliorakon only azer more than 6 weeks of therapy (Mishra et al, 2007; Yang et al, 2006; Nickel, 2008a).

30 Treatment (Nonsurgical) An0inflammatories AnK- inflammatory drugs (NSAIDS, steroids etc.) theorekcally improve inflammation within prostate and possibly result symptoms reduckon (Pontari, 2002) PotenKal of various ank- inflammatory agents, immune modulators, and cytokine inhibitors makes these classes of drugs potenkally useful as adjunckve therapy for the chronic prostakks syndromes, but clinical trials suggest that they are not a useful monotherapy

31 Treatment (Nonsurgical) Muscle Relaxants Use of α- blockers to relax smooth muscle and skeletal muscle relaxants combined with adjuvant medical and physical therapies has been advocated and promoted (Anderson, 1999; Zerman and Schmidt, 1999) Hormone Therapy TheoreKcally, ankandrogens could result in regression of prostakc glandular Kssue, improved voiding parameters, and reduced intraprostakc ductal reflux (Nickel, 1999c) Neuromodulator therapy One proposed mechanism is that CP/CPPS, parkcularly in chronic cases of long standing, represents neurogenic pain syndrome (Pontari and Ruggieri, 2004).

32 Treatment (Surgical) Minimally Invasive Surgery (Ballooon dilakon, TUNA, ESWT, Microwave Hypertherapy, Botulinum Toxin InjecKon) at best show modest symptomakc relief TURP not been advocated for category III CP/ CPPS, but open radical prostatectomy shown to benefit few pakents with sx of nonbacterial prostakks or prostatodynia or both (Davis and Weigel, 1990; Frazier et al, 1992)

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34 References Campbell Walsh Urology 11 th edikon Medscape Chronic Pelvic Pain in Men Treatment & Management Author: Richard A Watson, MD; Chief Editor: Edward David Kim, MD, FACS Chronic prosta--s: management strategies Murphy, Macejko A, Taylor A, Nadler RB Drugs. 2009;69(1): doi: /

35 QuesKon 1 What is the percentage of acute prostakks that could develop into chronic prostakks? a) 2% b) 5% c) 7% d) 10%

36 QuesKon 2 When do you consider prostakks a chronic syndrome? a) > 3 weeks b) > 6 weeks c) > 12 weeks d) > 24 weeks

37 QuesKon 3 What is considered the best management to avoid chronic prostakks? a) Early alpha blockade therapy b) Appropriate treatment of the acute bout c) Avoid foley catheter inserkon d) AnK- androgen therapy

38 QuesKon 4 Intra- prostakc calculi are closely associated with: a) Higher risk of prostate cancer b) Recurrent acute episodes of prostakks c) Prolonged durakon of symptoms d) Increased prostate volume

39 QuesKon 5 What is the least recommended test used to diagnose CPPS? a) 2 glass test b) Uroflowmetry c) Residual urine volume d) Urethrocystoscopy

40 QuesKon 6 Improvement on alpha blockade therapy is considered successful azer how many weeks of therapy? a) > 3 weeks b) > 6 weeks c) > 12 weeks d) > 24 weeks

41 QuesKon 7 The most prescribed agent in treatment of CP/ CPPS is: a) AnKbioKcs b) NSAID s c) Alpha - blockers d) Skeletal muscle relaxants

42 QuesKon 8 What is considered the last resort in the treatment of CP/CPPS? a) TUNA b) TUMT c) TURP d) Open prostatectomy

43 QuesKon 9 Which of the following categories is the least asked about in NIH- CPSI? a) Pain b) Urinary symptoms c) Quality of life d) Frequency of acute infeckons

44 QuesKon 10 How can you differenkate category II from category III chronic prostakks upon presentakon? a) DRE b) Suprapubic Tenderness c) It is NOT possible to differenkate d) Perineal pain e) General appearance

45 QuesKon 1 What is the percentage of acute prostakks that could develop into chronic prostakks? a) 2% b) 5% c) 7% d) 10%

46 QuesKon 2 When do you consider prostakks a chronic syndrome? a) > 3 weeks b) > 6 weeks c) > 12 weeks d) > 24 weeks

47 QuesKon 3 What is considered the best management to avoid chronic prostakks? a) Early alpha blockade therapy b) Appropriate treatment of the acute bout c) Avoid Foley catheter inserkon d) AnK- androgen therapy

48 QuesKon 4 Intra- prostakc calculi are closely associated with: a) Higher risk of prostate cancer b) Recurrent acute episodes of prostakks c) Prolonged durakon of symptoms d) Increased prostate volume

49 QuesKon 5 What is the least recommended test used to diagnose CPPS? a) 2 glass test b) Uroflowmetry c) Residual urine volume d) Urethrocystoscopy

50 QuesKon 6 Improvement on alpha blockade therapy is considered successful azer how many weeks of therapy? a) > 3 weeks b) > 6 weeks c) > 12 weeks d) > 24 weeks

51 QuesKon 7 The most prescribed agent in treatment of CP/ CPPS is: a) AnKbioKcs b) NSAID s c) Alpha - blockers d) Skeletal muscle relaxants

52 QuesKon 8 What is considered the last resort in the treatment of CP/CPPS? a) TUNA b) TUMT c) TURP d) Open prostatectomy

53 QuesKon 9 Which of the following categories is the least asked about in NIH- CPSI? a) Pain b) Urinary symptoms c) Quality of life d) Frequency of acute infeckons

54 QuesKon 10 How can you differenkate category II from category III chronic prostakks upon presentakon? a) DRE b) Suprapubic Tenderness c) It is NOT possible to differenkate d) Perineal pain e) General appearance