CHRONIC PELVIC PAIN SYNDROME. Jay Lee, MD, FRCSC Clinical Assistant Professor, University of Calgary

Transcription

1 CHRONIC PELVIC PAIN SYNDROME Jay Lee, MD, FRCSC Clinical Assistant Professor, University of Calgary

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3 CHRONIC SCROTAL PAIN

4 Nomenclature Chronic Orchalgia Chronic Epididymitis Chronic Testicular Pain Chronic Pelvic Pain Syndrome Chronic Scrotal Pain Syndrome Chronic Intrascrotal Pain Syndrome Achy Balls Syndrome

5 Definition intermittent or constant testicular pain, 3 months or longer in duration that significantly interferes with the daily activities of the patient [Davis et al. 1990] Persistent or recurrent episodic scrotal pain associated with symptoms suggestive of urinary tract or sexual dysfunction. No proven epididymoorchitis or other obvious pathology [EAU Guideline]

6 Incidence Actual incidence/prevalence not well studied except post vas Estimate 4.75% of all men presenting to urology clinics; 18.6% do not receive satisfactory explanation of pain 1 Will see multiple urologists Quallich SA et al. J of Men s Health 2013

7 Classification Inflammatory/Infectious Idiopathic Post Surgical/Obstructive (vasectomy, hernia repair)

8 Etiology Infectious Neuropathic (ilioinguinal, genitofemoral) Myofascial (pelvic floor, adductors, abdominal) Inflammatory (IL6, IL8, TNFα) Psychologic/Central Multifactorial Referred Pain (ureteric, hip, back, colon)

9 Post Vasectomy Pain Reports in literature 2-20% Campbell s Urology - <1% AUA Vasectomy Guidelines 2012: Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy in about 1-2% of men. Few of these men require additional surgery.

10 Pathogenesis of Chronic Pain INSULT Infection, Trauma, Surgery INFLAMMATION PERIPHERAL SENSITIZATION MYOFASCIAL RESPONSE FORMATION OF C FIBRES PAIN CENTRAL SENSITIZATION

11 Phenotyping Chronic Urologic Pain UPOINT URINARY TENDERNESS PSYCHOSOCIAL NEUROGENIC/ SYSTEMIC ORGAN CENTRIC INFECTION

12 Phenotypic Approach (UPOINT) to CP/CPPS

13 Unnecessary Testicular Complain Visits Cheaper than Treating Metastatic Testicular CA Cost for advanced-stage seminoma ($48,877) or nonseminoma ($51,592) Equaled the cost of: 313 benign office visits ($156) 180 office visits with scrotal ultrasound ($272) 79 office visits with serial scrotal ultrasounds and labs ($621) 6 office visits resulting in radical inguinal orchiectomy for benign pathology ($7,686) 3 office visits resulting in detection, treatment, and surveillance of an early-stage testicular cancer.

14 Key Points Chronic scrotal pain syndrome represents frequent visits to the urologist with cost to the health care system Etiology is multifactorial There is no ONE treatment for all Consider what you inform patients in terms of post vasectomy pain risk

15 CHRONIC PROSTATITIS

16 Prostatitis: Background Almost 9% of Canadian men experience some prostatitis symptoms over the course of a year Significant impact on QOL and disability 6% are bothered by symptoms One-third usually experience remission within one year Clinically significant prostatitis symptoms account for ~3% of Canadian male outpatient visits < 10% of patients suffer from acute or chronic bacterial prostatitis, which is usually amenable to antimicrobial therapy Majority of men with chronic prostatitis have chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), characterized by pelvic pain, variable urinary symptoms, and sexual dysfunction Nickel JC, et al. J Urol 2001;165:842-45; Nickel JC, et al. BJU Int 2002;90:678-80; Nickel JC, et al. CUAJ 2011;5:306-15

17 Categorization of Prostatitis (NIH) Category I: Acute Bacterial Prostatitis (ABP), associated with severe prostatitis symptoms, systemic infection, and acute bacterial urinary tract infection (UTI) Category II: Chronic Bacterial Prostatitis (CBP), caused by chronic bacterial infection of the prostate, with or without prostatitis symptoms, and usually with recurrent UTIs caused by the same bacterial strain Category III: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), characterized by chronic pelvic pain symptoms and possibly voiding symptoms in the absence of UTI Category IV: Asymptomatic Inflammatory Prostatitis (AIP), in which prostate inflammation exists in the absence of genitourinary tract symptoms Krieger JN, et al. JAMA 1999;282:236-7

18 Prostatitis vs. Chronic Pelvic Pain Syndrome Prostatitis can be a source of frustration for the treating physician and the patient Diagnosis of acute or chronic bacterial prostatitis is based on history, physical, and urine culture. Chronic pelvic pain syndrome is more challenging to treat since etiology is poorly understood Nickel JC. The Prostatitis Manual.

19 Prostatitis: Key Elements of History A mandatory history is required for all patients at time of evaluation The following presenting symptoms should be elicited Pain location (severity, frequency, and duration) LUTS (obstructive/voiding and irritative/storage) Associated symptoms (fever, other pain syndromes, etc.) Impact on activities/quality life. Comprehensive systems review should document medical and surgical (particularly urologic) history, history of trauma, medications, and allergies Nickel JC, et al. CUAJ 2011;5:306-15

20 Evaluation of Prostatitis 4-glass test Nickel JC, et al. CUAJ 2011;5:306-15

21 Glass 1: 10 ml of urine (tested for urethral infection) Glass 2: 10 ml of midstream urine (tested for bladder infection) Glass 3: Prostatic massage and collection of expressed prostatic secretions (examine WBCs) Glass 4: Postmassage urine (flush out bacteria) 4-Glass Test

22 2-glass Lower Urinary Tract Localization Test Saving of pre-massage midstream urine followed by prostatic massage followed by post-prostatic massage initial 10 ml urine Category Specimen Pre- Massage Post- Massage II WBC +/- + Culture +/- + IIIA WBC - + Culture - - IIIB WBC - - Culture - -

23 Chronic Bacterial Prostatitis: Clinical Presentation Persistent bacterial infection of the prostate of >3 months Recurrent or relapsing UTI, urethritis, or epididymitis with the same bacterial strain May be asymptomatic between episodes of infection flares but detectable pathogens persist on localized tests (eg, 2 glass pre- and post-massage urine culture) May have irritative voiding symptoms and testicular, perineal, low back, and occasionally distal penile pain On physical exam, patients are usually afebrile; on digital rectal exam, the prostate may feel normal, tender, or boggy Sharp VJ, et al. Am Fam Physician 2010;82(4):

24 Chronic Bacterial Prostatitis: Workup Physical Examination Mandatory: abdomen, external genitalia, perineum, prostate, and pelvic floor Microbiological Localization Cultures of the Lower Urinary Tract 2-glass pre- and post-massage test (PPMT) A simple and reasonably accurate screen for bacteria Microscopy is optional Nickel JC, et al. CUAJ 2011;5:306-15

25 Chronic Bacterial Prostatitis: Treatment Antimicrobial therapy Fluoroquinolones: unique and favourable pharmacokinetic properties, broad antibacterial spectra, comparative clinical trial evidence Consider TMP-SMX (or other antimicrobials) in fluoroquinolone resistance Alpha-blockers Combination antimicrobials + alpha-blockers suggested to reduce high recurrence rate optional in patients with obstructive voiding symptoms Treatment-refractory cases with confirmed uropathogen localized to the prostate Intermittent antimicrobial treatment of acute symptomatic episodes (cystitis) Low-dose antimicrobial suppression Radical TURP or open prostatectomy if all other options have failed Bjerklund Johansen TE, et al. Eur Urol 1998;34: ; Naber KG. Eur Urol Suppl 2003;2:23-6; Naber KG. Eur Urol 2001;40: ; Naber KG. In Nickel JC (ed.) Textbook of Prostatitis. Oxford: ISIS Medical Canada, 1999: ; Barbalias GA, et al. J Urol 1998;159:

26 Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Epidemiology No clear understanding of etiology: suggestions include infection, autoimmunity, and neuromuscular spasm Symptoms vary widely among patients; no evidence that disease worsens; approximately one-third of patients improve with or without treatment Sharp VJ, et al. Am Fam Physician 2010;82(4):

27 Clinical Presentation of Chronic Prostatitis/Chronic Pelvic Pain Syndrome Perineal pain Lower abdominal pain Penile pain (especially penile tip) Testicular pain Rectal and lower back pain Ejaculatory pain Variable irritative and obstructive symptoms and/or ejaculatory disturbance Kreiger JN, et al. NEJM 1999;81:236-7 Krieger JN, et al. Urology 1996;48:715-22

28 Workup of Chronic Prostatitis/Chronic Pelvic Pain Syndrome No gold standard diagnostic test CP/CPPS is a diagnosis of exclusion Diagnosis usually made on a typical history Initial screening: Complete history Assessment of pelvic floor muscle spasm/pain Exam: DRE, urinalysis, MSSU and post-prostatic massage urine culture McNaughton Collins M, et al. Ann Intern Med 2000;133: Nickel JC. Eur Urol 2003;(Suppl) 68;1-4 Nickel JC. Urol 2002;60(suppl 6A):20-3

29 Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Treatment Antimicrobials not recommended for men with long-standing, previously treated CP/CPPS Alpha-blockers recommended first-line, particularly in alphablocker-naïve men with moderately severe symptoms who have relatively recent onset of symptoms Alpha-blockers not recommended in men with long-standing CP/CPPS who have tried and failed alpha-blockers in the past Anti-inflammatories, 5-ARIs, pentosan polysulfate not recommended as primary treatment but may have a role in a multimodal therapeutic regimen Phytotherapies (quercetin and cernilton) optional Nickel JC. Int J Antimicrob Agents 2008;31 Suppl 1:S112-6.

30 CP/CPPS: Treatment (cont.) Other potential medical therapies Muscle relaxants, saw palmetto, corticosteroids, and tricyclic antidepressants have been suggested and used Lack of data from properly designed, randomized, placebo-controlled trials Physiotherapies Many physical therapies suggested and used Lack of prospective controlled data Psychotherapies Psychological support and therapy has been advocated based on new psychosocial modeling of this syndrome, ideally incorporating cognitive behavioural therapy (CBT) Referral to a psychologist of psychiatrist should be mandatory in patients with severe depression and/or suicidal tendencies Nickel JC. Chapter 11 in Wein AJ, et al. (eds) Campell-Walsh Urology Elsevier, Philadelphia, PA, 2011: in press Nickel JC, et al. World J Urol 2008;26:

31 CP/CPPS: Treatment (cont.) Surgery Pudendal nerve blocks or neurolysis surgery have been suggested for CPPS that can be shown to be secondary to pudendal nerve entrapment Radical transurethral resection and total prostatectomy not recommended for CP/CPPS Multimodal therapy A number of uncontrolled studies have strongly suggested that multimodal therapy is more effective than monotherapy in patients with long-term symptoms Individualized personal therapy algorithms directed toward clinically defined presenting phenotypes have been proposed and look promising Nickel JC. Chapter 11 in Wein AJ, et al. (eds) Campell-Walsh Urology Elsevier, Philadelphia, PA, 2011; Nickel JC, et al. J Urol 2004;172:551-4; Shoskes DA, et al. Curr Urol Rep 2005;6:296-9; Nickel JC, et al. BJU Int 2010;106: ; Shoskes DA, et al. Urol 2010;75: