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CHRONIC PELVIC PAIN SYNDROME

An agonizing dilemma

   Prostatitis is indeed a complex disease that covers a broad spectrum of symptoms ranging from various Lower Urinary Tract Symptoms (LUTS), Sexual Dysfunction, male Infertility, enlargement of the Prostate, elevated PSA and Prostate Cancer. Aside from these, Prostatitis has been found also to cause various Pain Symptoms that may manifest by itself or in combination with other Prostatitis symptoms.

    Among all the problems caused by Prostatitis, its Pain Symptoms may have been the least understood. These various Pain Symptoms were classified by the American National Institute of Health (NIH) as Chronic Pelvic Pain Syndrome (CPPS), as comprising of:

  1. Pain in the lower back 

  2. Pain/discomfort in the testicles 

  3. Pain between the anus and testicles (Perineum) 

  4. Pain/discomfort near the tip of the penis

  5. Pain in the lower abdomen 

  6. Pain/Discomfort during ejaculation 

  7. Pain during urination 

  8. Pain in the rectal area 

 

    There were many speculations on how CPPS has produced the pain or discomfort in different areas. Accordingly, it is likely that the causes of CPPS are multifactorial mechanism initiated by infection, perineal/pelvic trauma, and/or psychological stress that apparently starts a cascade of events in an anatomically or genetically susceptible man, resulting in either inflammation or neurogenic injury, thus causing pain symptoms (J. C Nickel, Campbell-Walsh Urology 2007). 

    But there is little proof to validate these nor are there clear-cut explanations on how these various pains are produced.

    Some researchers viewed this syndrome as a psychosomatic disorder (Mendlewich 1971). I think this may be quite unfair to the sufferers. I believe in the reality of the existence of the Pain Syndrome in patients. Although in some cases, the pain may be magnified in men with a lower pain threshold, or in those who have become more anxious and frustrated as a result of the lack of pain relief they got from all their previous hopping from one doctor to another for treatment.

    The challenge is understanding how all the various Pain Symptoms of CPPS can be attributed to Prostatitis as well as how to delineate CPPS symptoms from other conditions that manifest the same symptomatology.

 

Diagnosing a Potential Cause of CPPS

 

    Since Prostatitis is one of the more common potential causes of a Pain Syndrome, a complete diagnostic test for Prostatitis should be routinely done to identify the organism/s that may be causing the congestion or inflammation of the Prostate or a passive contraction of its smooth muscles that may produce these referred pains. This entails doing:

 

  1. Grams' Stain of the Urethra and Prostate Fluid (EPS) should be routinely done.

  2. Chlamydia test of the Prostate Fluid (EPS) of men should also be done. I highly recommend using a Direct Fluorescence Antibody test (DFA) through Immunofluorescence Microscopy as I find this to be the most reliable Chlamydia test.

  3. Culture and Sensitivity of EPS and Semen for men for Ureaplasma, Mycoplasma, Staphylococcus, Streptococcus, and the Coliforms, including the Neisseria strains.

 

Other diagnostic test for CPPS: 

  1. Ultrasound of the Prostate, Urinary Bladder and the Testicles may reveal other potential causes of the Pain Syndrome.

  2. X-Ray of the lumbar area may help rule out any skeletal or muscular cause of low back pains.

  3. Blood test for uric acid as a higher than normal level may trigger pain in the lower back, or the buttocks and may radiate to the thigh, or heel.

 

Treatment of CPPS

 

    If Chronic Bacterial Prostatitis  (CBP) is documented, it is essential that the patient be treated with culture-based antibiotics and antifungal medications when necessary and this should be combined with at least thrice a week Prostate Massage, as this would help expel the various organisms lodged in the Prostate through the years. At the same time, this would allow the continuous replenishment of new Prostatic Fluid which could dilute the concentration of the organisms and facilitate the entry of the antibiotics and WBC in the thousands of Prostate Glands or sacs, until the condition has completely resolved. Otherwise, antibiotics do not readily enter the Prostate sacs without repetitive Prostate Massage.

    Prostate Massage is a technique that has to be learned and a skill that has to be developed. Prostate Massage is not about brute force it is about feel and touch. Prostate Massage should be done by an experienced physician. A variation in technique and skill could spell a difference at times in terms of the volume of Prostate Fluid that is expressed from the glands and the completeness or effectiveness of the Prostate Massage, which is one of the more essential component of an adequate diagnosis and treatment of Prostatitis.

    One of the greater challenges a doctor has to face in the treatment of Prostatitis is how to interpret the test results that would indicate that the susceptible organisms have been fully eradicated as his experiences in interpreting the results of the WBC count of the the EPS will play a role in making a decision on when to stop the use of antibiotics. This decision could spell the difference between the success or failure of the course of a treatment. 

    Prostatitis treatment could be easy, moderately complicated or frustratingly difficult. So it is best to diagnose and adequately treat Prostatitis early on while it is easier and less complicated. Any inadequately treated stage of Prostatitis treatment could make the problem more difficult to solve.

    As I have said earlier, among all the problems caused by Prostatitis, Chronic Pelvic Pain Syndrome (CPPS) is the most difficult. Despite the lesser experience I have in handling patients with CPPS compared to the other problems that Prostatitis brings, this has taught me that not all instances of pain syndrome come from Prostatitis. For those CPPS that are caused by Prostatitis, Prostate Massage with or without medication can greatly alleviate the pain syndrome if it does not completely relieve it.

    

PROSTATITIS IS NOT AMENABLE TO SURGERY

    Surgical treatment by Transurethral Resection of the Prostate (TURP), which scrapes the inner section, is fundamentally ineffective for Prostatitis and may even make it worse, since the peripheral zone of the Prostate is not effectively removed by this procedure and may even seal off the infected glands which could lead to Prostate Cancer.

 

Other remedies tried in the past

 

    Direct injection of the Prostate gland with antiseptic and various chemicals have been tried in 1917 and 1936 but all these were doomed to fail because the Prostate gland is not a single gland wherein antiseptics can diffuse; rather, it is made up of thousands of very tiny individual glands that are separate from one another. Therefore, whatever substance (Chemicals or antibiotics and others) injected into the Prostate will not diffuse or spread into other glands and whatever ducts or glands that has been hit by the needle would be cut and damaged which may cause fibrosis (scarring) or, if the ducts were cut, the organisms in the glands that drain in those ducts may be trapped and become inaccessible even by massage. These trapped organisms could be a precursor to the development of Prostate Cancer.

 

Know more about Prostatitis Treatment in this webpage.