Chronic pelvic pain syndrome in men, PART II

We will once again be fielding question for Dr. Mailis Gagon who is the Director of the Comprehensive Pain Program and Senior Investigator at the Krembil Neuroscience Centre. If you have any questions you would like to ask our pain specialist, please write to us at [email protected].

In this article I will continue to address CPPS, a serious and disabling problem that affects many men, with the second part of my article.

Physical examination is usually normal or shows non-specific findings such as tight rectal sphincter and tenderness in the prostate gland. The physician should exclude common bacteria and also bacteria that cannot be isolated on standard culture media. In some cases CPPS may be due to occult (hidden) chronic bacterial infection. Prolonged (6-wk) courses of effective antibiotics when used to treat the first bout of acute bacterial prostatitis, may prevent resistant bacteria from remaining at the site and causing chronic problems. A hidden neurological cause or a voiding disorder may be found with specialized studies of the bladder (videourodynamic studies). Clinical inflammation may trigger reflex spasms in the musculature of the pelvic floor that should be treated as well on their own merit.

Before the diagnosis of CPPS is made, several conditions must be excluded. One of those is interstitial cystitis, a painful condition affecting the lining (epithelium) of the urinary bladder. Some researchers feel that prostatitis and interstitial cystitis in men may be part of a continuum of dysfunction of the urinary epithelium. The distinction, as well, between chronic urethritis (inflammation of the male urethra) and CP/CPPS can also prove problematic. Most importantly, any risk of underlying cancer must be addressed urgently. Certain types of bladder cancer are deadly masqueraders. Prostate cancer, as well, can also manifest with symptoms that suggest prostatodynia. Ignoring these possibilities may eventually prove to be a fatal mistake. However, the use of a physically exhaustive gauntlet of tests and procedures is also clearly inappropriate. So the urologist must individualize the approach.

The work-up includes: a) laboratory studies (urinalysis, prostate specific antigen etc); b) imaging studies (examples are kidneys, ureters, and bladder radiography; intravenous pyelography; videocystourethrography; CT scanning; MRI etc), and c) procedural studies (diagnostic prostatic massage, videourodynamics etc). Given the significant cost of all these procedures, a rational step-wise approach tailored to each patient should be used.

Treating a patient with CPPS is difficult and challenges even the most compassionate physician. The patient is often understandably tense, wary, and defensive. Most patients have already encountered frustration and rejection under the care of several unsympathetic physicians. The patient and physician must agree on a workable relationship.

The patient should be told and assured that: a) CPPS is a well-established legitimate condition, notorious for the pain and disability it causes. He should also be advised that although the conditionis treatable, it is not a curable condition ; b) The physician will only administer diagnostic tests that hold a reasonable chance of producing a significant result; c) Many medications and other forms of treatment can help alleviate the symptoms of CPPS; and d) CPPS causes many psychological stresses for the patient. Medications to help calm the patient as well consultation with a psychiatrist or psychologist are very often appropriate.