Chronic Pelvic Pain Syndrome in Men – Part I

As promised, men will not be forgotten. Since the purpose of my articles is to provide public education and bring to the forefront important pain-related issues, today’s topic is a very large one that may be relevant to lots of men, although it is certainly not the only painful condition that affects men. The information I summarize here comes from an all inclusive review of the condition that was published in eMedicine, on July 17, 2009, by two very respectable urologists in New Jersey, USA, Drs. Richard A Watson and Robert J Irwin, Jr.

Chronic Prostatitis (inflammation of the prostate gland) is the most common urological diagnosis in men over 50 and is the third most common diagnosis in men under 50. This diagnosis results in at least 2 million office visits per year. The average urologist sees approximately 3 new patients and 7 follow up patients with prostatitis every month. Since specific urinary pathogens are detected infrequently after urine culture, the vast majority of these patients are categorized as having chronic nonbacterial prostatitis or prostatodynia, otherwise known as CPPS (Chronic Pelvic Pain Syndrome) in men. This is the subject of this article which will be published in two parts.

The term CPPS describes variable symptoms of chronic, irritative, and/or obstructive voiding accompanied by moderate to severe pain in the pelvis, lower back, perineum, and/or genitalia. No pus cells or bacteria are seen on microscopic analysis of the urine. However, in another testing method (Gram stain and culture of expressed prostatic secretions) excess pus cells or bacteria may be found.

This original term prostatodynia has been considered a “wastebasket” designation for a pot-pouri of psychosomatic symptoms and assumes that the problem is within the prostate gland. I avoid using this term in this article. Current research has given us evidence of numerous causes that lie outside the prostate. This is why the term CPPS is preferred.

The etiology (or etiologies) of CPPS remains unknown. Each of the findings below (as confirmed by research studies) has been identified as playing a role in CPPS. In some cases, more than one factor is found. Studies have shown the following:
• The number of White Blood Cells (WBCs or pus cells) found in the prostatic fluid under microscopic examination is not correlated to the degree of pain or to other symptoms experienced by patients with CPPS. However, special signaling molecules called cytokines associated with inflammation (produced by WBCs and by other cells), may play a role.
• Some people may have a genetic predisposition to CPPS due to differences in the way their bodies regulate the production and action of these cytokines.
• Autoimmunity, the abnormal tendency of the body to react against itself, has long been thought to play a role in the development of CPPS.
• Low testosterone level (or, more likely, a breakdown of the ability of testosterone to block inflammation in the prostate) may be also involved in some men with CPPS.
• Abnormal functioning of the local nerves and/or within the Central Nervous System, may also play a role in the development of CPPS.
• Psychological stress and depression have been clearly shown to influence the local production of cytokines in the pelvis, making the CPPS inflammation worse.
• Recent studies show that in some cases gram-positive bacteria, which are considered normal inhabitants of the prostatic fluid, may not be so normal in some men with CPPS. This theory helps explain why prolonged courses of antibiotics sometimes provide relief for men with CPPS even when we cannot find bacteria traditionally considered pathogenic.