Dr. Krithika Doshi. Chronic Pelvic Pain: Headache in the Pelvis Pelvic Pain in Men- Are they all Noncyclical?

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2 Chronic Pelvic Pain: Headache in the Pelvis Pelvic Pain in Men- Are they all Noncyclical? Dr Kritika Doshi Introduction: Chronic pelvic and urogenital pain syndromes have recently been recognized as a clinical entity i. There is no generally accepted definition of chronic pelvic pain. Definitions: The International Continence Society (ICS) has defined the urogenital pain syndromes as ii : Genitourinarypain syndromes are all chronic. Pain is the major complaint, but there may be concomitant complaints related to the lower urinary tract or bowel, or of a sexual or gynecological nature. The American College of Obstetricians and Gynecologists iii has proposed the following definition, limited to females: chronic pelvic pain is noncyclic pelvic pain of at least 6 months duration that localizes to the anatomical pelvis, the anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care. Previously, Chronic pelvic pain (CPP) was defined as a noncyclical pain that had a duration of at least 6 months and can lead to decreased quality of life and physical performance. The pain can be attributed to problems in the pelvic organs and/or problems in related systems, and possible psycho social attributes may contribute to the manifestation. Initially, thought to be common in females, males also report urogenital/pelvic pain. The pain is localized to the lower abdomen and the pelvic and perineal region; is chronic and causes significant emotional trauma and distress to the person as the distribution of pain complaints is localized to areas that are related to sexual function, defecation and urination; are often considered taboo and are complicated by psychological and unique physiological issues. Classification: A] The domains of chronic pelvic pain (CPP) syndromes iv : include: 1) Related to the pelvic organs: Lower urinary tract domain Female genital domain Male genital domain Gastrointestinal domain 2) Other sources of pain which may be perceived in the pelvis, even though the actual site of the problem may not be within the pelvis: Musculoskeletal domain Neurological domain 3) Related to general factors that influence the response to the pain or its impact on the individual: Psychological domain Sexual domain

3 Comorbidities B] The International Continence Society (ICS) introduced 7 pain conditions: painful bladder syndrome urethral pain syndrome vulvar pain syndrome vaginal pain syndrome scrotal pain syndrome perineal pain syndrome pelvic pain syndrome (occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel, or gynecological dysfunction in the absence of proven infection or other obvious pathology) Incidence: Male chronic pelvic pain syndrome: 8.2% (range %) Increases with age(men aged have a 3.1-fold greater risk than those aged v ) Scrotal pain syndrome: Not known After vasectomy surgery 2 20% 2 6% have a visual analogue score > 5 /10 Pathophysiology: Pathophysiology of urological chronic pelvic pain syndrome (UCPPS) is still poorly understood. The term pelvic pain is an enigma as it does not give a clear indication of the mechanism of the pain and does not take into account that many of the symptoms and signs may be outside of the anatomical pelvis vi, vii. Assessment: Till date, diagnosis was based on exclusion of other conditions as often, examination and investigational workup remain unrevealing, and no specific cause of the pain can be identified. But, for a patient presenting with pelvic pain, thorough history is crucial, including establishing that the pain has been present for at least 6 months, identification of any potential inciting event and/or triggers, character, radiation, and severity. Careful clinical history and examination show that patients with pelvic and urogenital pain often suffer from more than one pain. An indication of the source of pain is vital, yet it can be obscured in individual cases by the range of possible primary sources and secondary consequences, and the varied responses. To ensure a systematic approach, the ICS set out a series of domains which serves as a checklist to facilitate consideration of possible issues. The assessment of CPP in males includes questioning to assess onset, duration, inciting factors, laterality and any effect on urination and sexual function. A rectal examination is needed and thorough evaluation of the genitalia, which may be performed in the supine and standing positions to identify any lesions, masses, and discharge. Patients affected in the gastrointestinal domain commonly report constipation, diarrhea, defecatory pain, obstructive defecation, abdominal cramping, or rectal pain/pressure/burning. The main components are:

4 i) The Anorectum: Anorectal problems may result from hemorrhoids, abscesses, fissures, ulcers, levator ani syndrome, or chronic proctalgia ii) The Colorectum:. Colorectal problems may give rise to abdominal tenderness, watery/bloody diarrhea, or rectal bleeding and systemic features (weight loss and fever). Inflammatory bowel disease and malignancy must be excluded. iii) Functional disorders should be ruled out, including irritable bowel syndrome viii. There is a growing body of literature relating depression and catastrophizing to the experience of pain and pain-related sequelae in CP/CPPS ix (chronic prostatitis/chronic pelvic pain syndrome ). There is evidence that the response to noxious stimuli may be influenced by the gonadal hormonal changes. Recent research has led to a growing consensus x that the various clinical manifestations of chronic pelvic pain are a result of a complex interplay between events occurring in the viscera (urinary tract micobacteria) and CNS leading to: i) enhanced perception of visceral and somatic signals (visceral and somatic hypersensitivity) ii) Altered bladder motility iii) Dysbiosis iv) Altered mood and affect Treatment: Current treatment strategies for pelvic and urogenital pain range from acupuncture to physical therapy to psychological interventions to local and systemic drugs tonerve blocks and neuromodulation. Since multiple different pathogenic pain mechanisms may coexist in patients presenting with chronic pelvic and urogenital pain, a combination of different pharmacological agents or treatment modalities (multidisciplinary approach) might be required to obtain an optimal result. Recent Research xi : i) There is an emerging association between ketamine abuse and the development of urological symptoms including dysuria, frequency and urgency, which have a neurological component xii. ii) iii) Food sensitivity implicated in Interstitial cystitis, Bladder Pain Syndrome (IC/BPS) xiii that urine alkalization therapy is likely to be effective in the treatment for hypersensitive bladder syndrome xiv Summary: This is a complex condition and globally, there is a large amount of ongoing research in the wide spectrum of IC/BPS, chronic pelvic pain, the complexities of the nervous system and neuro-urology, comorbidities and their interactions, biomarkers and many new avenues of research and hopefully this will eventually bear fruit in the form of new treatment. i Baranowski A, Abrams P, Fall M. Urogenital pain in clinical practice. New York: Informa Healthcare; ii Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The standardization of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International ContinenceSociety. Neurourol Urodyn 2002; 21: iii ACOG Committee on Practice Bulletins Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol 2004;103:

5 iv Rana N, Drake MJ, Rinko R, Dawson M, Whitmore KE. The fundamentals of chronic pelvic pain assessment, based on international continence society recommendations. Neurourology and Urodynamics.2018;37:S32 S38. v Krieger JN, LeeSW, JeonJ,CheahPY, LiongML,RileyDE.Epidemiology of prostatitis. Int J Antimicrob Agents 2008; 31(Suppl. 1): S85 90 vi 6 Nickel JC, Tripp DA, Pontari M, et al. Interstitial cystitis/painful bladder syndrome and associated medical conditions with an emphasis on irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome. J Urol 2010; 184: vii Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. Urology 2010; 75: viii Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology. 2006;130: ix Kwon JK, Chang IH. Pain, catastrophizing, and depression in chronic prostatitis/chronic pelvic pain syndrome. Int Neurourol J. 2013;17(2): x Emeran A Mayer et al; Clinical Science of Chronic visceral Pain; 16 th WCP-Refresher Courses xi IPBF e-newsletter and Research Update; Issue 35, January 2014 xii Baker SC, Stahlschmidt J, Oxley J, Hinley J, Eardley I, Marsh F, Gillatt D, Fulford S, Southgate J. Acta Neuropathol Commun Oct 8;1(1):64. xiii Shorter B, Ackerman M, Varvara M, Moldwin RM. J Urol Dec 5. pii: S (13) doi: /j.juro xiv Ueda T, Yoshida T, Tanoue H, Ito M, Tamaki M, Ito Y, Yoshimura N. Int J Urol Nov 13. doi: /iju.12324