The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III

Autonomic Nervous System Dysfunction Is Related to Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common and non-lethal urological condition with painful symptoms. The complexity of CP/CPPS's pathogenesis and lack of efficient etiological diagnosis results in incomplete treatment and recurrent episodes, causing long-term mental and psychological suffering in patients. Recent findings indicate that the autonomic nervous system involves in CP/CPPS, including sensory, sympathetic, parasympathetic, and central nervous systems. Neuro-inflammation and sensitization of sensory nerves lead to persistent inflammation and pain. Sympathetic and parasympathetic alterations affect the cardiovascular and reproductive systems and the development of prostatitis. Central sensitization lowers pain thresholds and increases pelvic pain perception in chronic prostatitis. Therefore, this review summarized the detailed processes and mechanisms of the critical role of the autonomic nervous system in developing CP/CPPS. Furthermore, it describes the neurologically relevant substances and channels or receptors involved in this process, which provides new perspectives for new therapeutic approaches to CP/CPPS.

Clinical Efficacy Analysis of Biofeedback Electrical Stimulation Combined with Doxycycline in the Treatment of Type IIIA Chronic Prostatitis

Purpose

To analyse the clinical efficacy of biofeedback electrical stimulation combined with doxycycline in the treatment of type IIIA chronic prostatitis.

Methods

Eighty patients who met the diagnostic criteria of type IIIA chronic prostatitis in our hospital between February 2020 and February 2022 were selected and equally divided into the drug group and electrical stimulation group according to the random number table method. The drug group was treated with medication alone for 4 weeks; the electrostimulation group was treated with biofeedback electrostimulation on top of medication for 12 weeks. The expressed prostatic secretious (EPS) routine (lecithin bodies, white blood cells) and the maximum urinary flow rate (Q_max) and mean urinary flow rate (Q_ave) were measured before and after treatment in both groups, and the National Institutes of Health chronic prostatitis symptom index (NIH-CPSI) was used to score the urinary symptom, pain or discomfort, and quality of life and determine the efficacy of the treatment in both groups.

Results

After treatment, the number of lecithin bodies and white blood cells in EPS improved significantly in both groups compared to before, and both the electrical stimulation group was better than the drug group (P < 0.05). After treatment, the Q_max and Q_ave were significantly higher in both groups than before, and both the electrical stimulation groups were higher than the drug group (P < 0.05). After treatment, the urinary symptom scores, pain or discomfort scores, quality of life scores, and total NIH-CPSI scores were significantly lower in both groups than before, and all were lower in the electrical stimulation group than in the drug group (P < 0.05). After treatment, the overall efficiency of patients in the electrical stimulation group was significantly higher than that of the drug group (P < 0.05).

Conclusion

Biofeedback electrical stimulation combined with doxycycline in the treatment of type IIIA chronic prostatitis can synergistically improve the patient's inflammation level, urinary dysfunction, relieve pelvic floor tension myalgia, and improve their quality of life, opening up new avenues for the rehabilitation of patients with type IIIA chronic prostatitis.

Impaired Ability to Relax Pelvic Floor Muscles in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome

OBJECTIVE

Excessive pelvic floor muscle activity has been suggested as a source of pain in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Our objective was to determine whether men with CP/CPPS have changes in neural drive that impair their ability to relax pelvic floor muscles.

METHODS

We recruited 90 men (42 with CP/CPPS and 48 in the control group [without a history of pelvic pain]). All completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). We quantified the ability to relax by comparing resting pelvic floor muscle activity under 2 conditions: a "rest-only" condition, in which participants were instructed to simply relax, and a "rest-between-contraction" condition, in which participants were instructed to rest for several seconds between voluntary pelvic floor muscle contractions. We used multivariate mixed-effects models to examine differences between the groups (men with CP/CPPS and men in the control group) as well as the effect of 6 symptoms captured by the NIH-CPSI: pain related to location (perineum, testicles, penis, suprapubic region) and activity (urination, ejaculation).

RESULTS

Men with CP/CPPS were significantly different from men in the control group; men with CP/CPPS had higher resting activity in the rest-between-contraction condition than in the rest-only condition, whereas men in the control group had similar resting activities in both conditions. This effect was strongest in men who reported ejaculation-related pain, which was 70% of the CP/CPPS group.

CONCLUSION

Men without a history of pelvic pain were able to relax their pelvic floor muscles back to baseline after performing voluntary pelvic floor muscle contractions. In contrast, men with CP/CPPS, particularly those with ejaculation-related pain, had an impaired ability to relax their pelvic floor muscles.

IMPACT

This study may support the investigation of more personalized physical therapist approaches for CP/CPPS that enhance the ability to relax pelvic floor muscles as a mechanism for pain reduction.

Effectiveness of self-myofascial release combined with biofeedback and electrical stimulation for the management of myofascial pelvic pain: A randomized controlled trial

BACKGROUND

Myofascial pelvic pain (MFPP) caused by myofascial trigger points (MTrPs) is a major contributor to chronic pelvic pain in women. However, the effect of the patient's self-myofascial release (SMFR) is unclear. This study aimed to investigate the effect of SMFR combined with biofeedback and electrical stimulation (BES) therapy in comparison with BES alone in patients with MFPP.

METHODS

A prospective randomized controlled study was conducted. Sixty-eight patients were randomly allocated into BES-SMFR group (n = 34) and BES group (n = 34). Every patient received 4 weeks of treatment, evaluated at baseline (T0), 4 weeks post-intervention (T4) and 12-week follow-up (T12). The primary outcome was pain intensity. The secondary outcomes were degree of activation of MTrPs, surface electromyography (sEMG) levels and Patient Global Impression of Improvement (PGI-I).

RESULTS

Compared with the effect of BES, BES-SMFR treatment significantly decreased pain intensity and the degree of activation of MTrPs in the levator ani (p = 0.02) and obturator internus (p = 0.03), as well as the sEMG levels of the pre-test resting baseline and post-test resting baseline (all p < 0.01). The degree of activation of MTrPs in the piriformis and coccygeus (all p > 0.05) and the sEMG levels of the quick flicks and endurance contraction were not significantly different. The BES-SMFR treatment improved the PGI-I scale at T4 (p = 0.02) but not at T12 (p = 0.40).

CONCLUSIONS

This study confirmed that the addition of SMFR to BES treatment resulted in superior outcomes compared with those with BES alone in patients with MFPP.

SIGNIFICANCE STATEMENT

Myofascial pelvic pain (MFPP) is a major contributor of female chronic pelvic pain. Myofascial release has been used commonly for better pain release; however, poor therapeutic effect due to poor patient compliance is common in clinical practice. Therefore, in future research, there is a need to investigate the effect of patient's self-myofascial release (SMFR) technique, which can eliminate the need for frequent office visits and improve patient compliance to some extent, in patients with MFPP.

Diagnostic and Management Strategies for Patients with Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common and often heterogenous condition that can have severe consequences on patient quality of life. In this review, we describe the pathophysiology, diagnostic work-up, and treatment of patients with CP/CPPS incorporating the most recent literature. Studies have demonstrated that CP/CPPS involves a complex pathophysiology, including infectious, immunologic, neurologic, endocrinologic, and psychologic etiologies, with frequent intersections between the different entities. Despite robust research assessing a variety of therapeutics targeting these etiologies, clinical trials have failed to identify an empiric treatment strategy applicable specifically to older adult male patients with CP/CPPS. As such, it can be challenging to manage older male patients with this condition. The advent of clinical phenotyping of patients with CP/CPPS has led to advances in tailored management strategies. Monomodal therapy has been largely unsuccessful because of the unclear and complex etiology of CPPS. As a result, CP/CPPS therapy has transitioned to a multimodal approach, including both pharmacologic and non-pharmacologic therapies. The best studied pharmacologic therapies include antibiotics, alpha-blockers, anti-inflammatory and immunomodulatory agents, phytotherapies, phosphodiesterase inhibitors, hormonal agents, neuromodulatory agents, and antidepressants. The best studied non-pharmacological therapies include pelvic floor physical therapy, myofascial trigger point release, acupuncture and electroacupuncture, psychological support and biofeedback, and electrocorporeal shockwave therapy and local thermotherapy.

Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy

INTRODUCTION

Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.

OBJECTIVES

To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.

METHODS

PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included. Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients' perceived effect.

RESULTS

The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.

CONCLUSION

The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2021;XX:1-22.

The effect of biofeedback interventions on pain, overall symptoms, quality of life and physiological parameters in patients with pelvic pain : A systematic review

Background

Biofeedback is recognized as an effective additive method for treating certain phenotypes of chronic pelvic pain syndrome and is a therapeutic option in other pelvic pain conditions. This review aims to evaluate evidence from the literature with a focus on the effect of biofeedback on pain reduction, overall symptom relief, physiological parameters and quality of life.

Methods

A systematic literature search was conducted using the databases PubMed, MEDLINE, Embase, Cochrane Library and PEDro from inception to July 2020. Data were tabulated and a narrative synthesis was carried out, since data heterogeneity did not allow a meta-analysis. The PEDro scale and the McMaster Critical Review Form—Quantitative Studies were applied to assess risk of bias.

Results

Out of 651 studies, 37 quantitative studies of primary research evaluating pelvic pain conditions in male and female adults and children were included. They covered biofeedback interventions on anorectal disorders, chronic prostatitis, female chronic pelvic pain conditions, urologic phenotypes in children and adults and a single study on low back pain. For anorectal disorders, several landmark studies demonstrate the efficacy of biofeedback. For other subtypes of chronic pelvic pain conditions there is tentative evidence that biofeedback-assisted training has a positive effect on pain reduction, overall symptoms relief and quality of life. Certain factors have been identified that might be relevant in improving treatment success.

Conclusions

For certain indications, biofeedback has been confirmed to be an effective treatment. For other phenotypes, promising findings should be further investigated in robust and well-designed randomized controlled trials.

Successful Resolution of Chronic Testicular Pain With an Impairment-Based Treatment Program: A Case Study With One-Year Follow-Up

Chronic testicular pain is a condition commonly experienced by males. Potential causes of testicular pain can be pathology localized within the testicle or referred pain from surrounding tissues or spinal conditions. The diagnostic differential is extensive and can be seen as a diagnosis of exclusion after structural disorders specific to the testicle are ruled out. In approximately 50% of the cases, the cause of pain is undetermined. Patients with testicular and inguinal pain may undergo extensive workup that overlooks potential neuropathic and musculoskeletal causes remote to the testicle. This case study describes the application of a conservative treatment program targeting presumptive chronic genitofemoral and/or ilioinguinal nerve entrapment along the course of the inguinal canal for the treatment of chronic testicular pain. By combining sacroiliac joint osteopathic manipulation, iliopsoas stretching, and soft tissue mobilization utilizing a vacuum suction cup, the patient was symptom-free on the fourth visit after suffering from testicular pain for a year. At a one-year follow-up, the patient remains pain-free.

The Reliability of Pelvic Floor Muscle Bioelectrical Activity (sEMG) Assessment Using a Multi-Activity Measurement Protocol in Young Women

The aim of the study was to determine the between-trial and between-day reliability of the Glazer protocol and our multi-activity surface electromyography (sEMG) measurement protocol for pelvic floor muscle (PFM) evaluation. The bioelectrical activity of PFM was collected using an endovaginal electrode in 30 young, Caucasian, nulliparous women (age 22–27, 168.6 ± 5.1 cm, 57.1 ± 11.8 kg). The between-trial and between-day reliability of the original Glazer protocol and the new multi-activity sEMG protocol were assessed during the following phases: pre-baseline rest, phasic (flick) contractions, tonic contractions, endurance contraction, and post-baseline rest. The Glazer protocol was characterized by poor and moderate measurement reliability. The time-domain parameters for the rise and fall of the signal amplitude and median frequency showed poor between-trial and between-day reliability. The mean and peak amplitudes indicated mainly good between-trial and moderate between-days reliability. Our protocol showed moderate to excellent reliability of both time-domain and quantitative parameters of muscle recruitment. In our protocol, the frequency-domain parameters describing muscle fatigue demonstrated much higher reliability than in the case of the Glazer protocol. The most important information obtained in this study was the significant improvement of diagnostic validity in PFM bioelectrical activity evaluation. The higher reliability of our sEMG protocol compared to original Glazer protocol allowed us to suggest that protocol modifications and changes in sEMG signal processing methods were effective in the improvement of PFM assessment quality. The new parameters calculated from the sEMG signal proposed in our sEMG protocol allowed us to obtain additional clinically important information about PFM dysfunctions regarding specific deficits of muscle contraction such as decrease in muscle strength; endurance or coordination related to, e.g., stress urinary incontinence; or pelvic floor muscle imbalance after childbirth.

Pelvic-floor relaxation techniques using biofeedback – more effective therapy for chronic prostatitis/chronic pelvic pain syndrome

Objective:

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by pelvic pain and voiding symptoms, the management of which is challenging. The present study was designed to assess the efficacy of biofeedback and pelvic-floor relaxation treatment for CP/CPPS.

Methods:

A total of 84 patients diagnosed with CP/CPPS were randomly assigned to one of the two groups: conventional therapy (group A) and pelvic-floor muscle relaxation and biofeedback (group B). The Biofeedback and Electrical Stimulation apparatus was used for pelvic-floor muscle electrical stimulation and relaxation with biofeedback. National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scores were evaluated at the start of therapy, after 3 months of treatment and at 6 months (3 months after last treatment received).

Results:

At 3 months, patients in both groups had a significant decrease (improvement in symptoms) in NIH-CPSI scoring. However, at 6 months, only 19 (47.5%) patients in group A maintained a fall in NIH-CPSI score >6 compared with 37 (94.8%) patients in group B ( p<0.05). At 6 months, there was significant decrease in NIH-CPSI score in group B, whereas in group A, scores had increased (worsening of symptoms).

Conclusions:

Pelvic-floor muscle relaxation and biofeedback training is a safe and effective treatment for CP/CPPS with sustained efficacy.

The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment

INTRODUCTION

Many conditions of pelvic and sexual dysfunction can be addressed successfully through pelvic floor physical therapy (PFPT) through various manual therapy techniques, neuromuscular reeducation, and behavioral modifications. The field of pelvic rehabilitation, including sexual health, continues to advance to modify these techniques according to a biopsychosocial model.

AIM

To provide an update on peer-reviewed literature on the role of PFPT in the evaluation and treatment of pelvic and sexual dysfunctions in men and women owing to the overactive and the underactive pelvic floor.

METHODS

A literature review to provide an update on the advances of a neuromusculoskeletal approach to PFPT evaluation and treatment.

MAIN OUTCOME MEASURE

The use and advancement of PFPT methods can help in successfully treating pelvic and sexual disorders.

RESULTS

PFPT for pelvic muscle overactivity and underactivity has been proven to be a successful option for pelvic and sexual dysfunction. Understanding the role of the organs, nerves, fascia, and musculoskeletal system in the abdomino-pelvic and lumbo-sacro-hip region and how pelvic floor physical therapists can effectively evaluate and treat pelvic and sexual health. It is important for the treating practitioner to know when to refer to PFPT.

CONCLUSION

Neuromusculoskeletal causes of pelvic floor disorders affect a substantial proportion of men, women, and children and PFPT is a successful and non-invasive option. Pelvic floor examination by healthcare practitioners is essential in identifying when to refer to PFPT. Use of a biopsychosocial model is important for the overall well-being of each patient. Further research is needed. Stein A, Sauder SK, Reale J. The role of physical therapy in sexual health in men and women: Evaluation and treatment. Sex Med Rev 2019;7:46-56.

Changes in brain white matter structure are associated with urine proteins in urologic chronic pelvic pain syndrome (UCPPS): A MAPP Network study

The Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network has yielded neuroimaging and urinary biomarker findings that highlight unique alterations in brain structure and in urinary proteins related to tissue remodeling and vascular structure in patients with Urological Chronic Pelvic Pain Syndrome (UCPPS). We hypothesized that localized changes in diffusion tensor imaging (DTI) measurements might be associated with corresponding changes in urinary protein levels in UCPPS. To test this hypothesis, we created statistical parameter maps depicting the linear correlation between DTI measurements (fractional anisotropy (FA) and apparent diffusion coefficient (ADC)) and urinary protein quantification (MMP2, MMP9, NGAL, MMP9/NGAL complex, and VEGF) in 30 UCPPS patients from the MAPP Research Network, after accounting for clinical covariates. Results identified a brainstem region that showed a strong correlation between both ADC (R² = 0.49, P<0.0001) and FA (R² = 0.39, P = 0.0002) with urinary MMP9 levels as well as a correlation between both ADC (R² = 0.42, P = 0.0001) and FA (R² = 0.29, P = 0.0020) and urinary MMP9/NGAL complex. Results also identified significant correlations between FA and urinary MMP9 in white matter adjacent to sensorimotor regions (R² = 0.30, P = 0.002; R² = 0.36, P = 0.0005, respectively), as well as a correlation in similar sensorimotor regions when examining ADC and urinary MMP2 levels (R² = 0.42, P<0.0001) as well as FA and urinary MMP9/NGAL complex (R² = 0.33, P = 0.0008). A large, diffuse cluster of white matter was identified as having a strong correlation between both ADC (R² = 0.35, P = 0.0006) and FA (R² = 0.43, P<0.0001) with urinary NGAL levels. In contrast, no significant association between DTI measurements and VEGF was observed. Results suggest that elevated MMP9 or MMP9/NGAL in UCPPS may be related to degenerative neuronal changes in brainstem nuclei through excitotoxicity, while also facilitating synaptic plasticity in sensorimotor regions.

Chronic Prostatitis and/or Chronic Pelvic Pain as a Psychoneuromuscular Disorder-A Meta-analysis

OBJECTIVE

To evaluate effectiveness of physical therapy, biofeedback, and/or cognitive behavioral therapy for chronic prostatitis/chronic pelvic pain syndrome (CP and/or CPPS). This symptom complex has resisted resolution from conventional urologic treatment of the prostate, which includes antibiotics, alpha-blockers, and analgesics. Beginning in 1995, a new paradigm was introduced viewing CP and/or CPPS as a psychoneuromuscular disorder driven by protective pelvic floor guarding and psychosocial stress.

METHODS

A literature search (PubMed, Google Scholar, and the Cochran Library) was conducted from inception through December 2017 using key words related to CP and/or CPPS (eg, prostatitis and pelvic pain) with physical therapy (eg, myofascial trigger point release) and/or biofeedback or cognitive behavioral treatment. Studies were required to include pre- and post-treatment with the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI) scores.

RESULTS

Eight studies inclusive of 280 patients met primary inclusion criteria. Study sample sizes ranged from 8 to 116 men (mean = 35); treatment duration ranged from 8 to 26 weeks (mean = 14). Pretreatment mean CPSI scores ranged from 21.7 to 33.5. The nonstandardized weighted mean reduction of CPSI score from baseline was 8.8 points; 95% confidence interval (7.5, 11.1); P <.001. The I² statistic = 18.5% indicating little heterogeneity between studies. A sensitivity analysis including an additional multimodal intervention study of with 100 patients produced similar findings.

CONCLUSION

Conventional medical treatment often fails to resolve CP and/or CPPS. A 6-point reduction in CPSI score is considered a clinically meaningful improvement of symptoms. This meta-analysis shows that treating CP and/or CPPS as a psychoneuromuscular disorder can significantly exceed this clinical threshold.

Physiotherapy management of patients with chronic pelvic pain (CPP): A systematic review

INTRODUCTION

Chronic pelvic pain (CPP) is a common pain condition. However, treatment remains challenging. Musculoskeletal findings are frequent; therefore physiotherapy might be helpful. The purpose of this review was to evaluate the current evidence on physiotherapy in patients with CPP (PROSPERO registration number CRD42016037516).

METHODS

Six databases were searched and additional hand searches were performed. Two reviewers independently conducted the database search and selected studies using a two-step approach. The methodological quality was assessed applying the Critical Review Form - Quantitative Studies.

RESULTS

A total of eight studies were included. Trigger point therapy was examined in four studies; two of which were randomized controlled trials. All studies indicate a significant change in pain measurement. The other four studies evaluated the effect of biofeedback, Thiele massage, Mensendieck somatocognitive therapy and aerobic exercises, whereas the last two were tested in controlled trials. All studies showed significant improvements in pain assessment.

CONCLUSIONS

The evidence currently available is sparse with methodological flaws, making it difficult to recommend a specific physiotherapy option. There is an urgent need for high-quality randomized controlled trials to identify the most effective physiotherapy management strategy for patients with CPP.

Comprehensive pelvic floor physical therapy program for men with idiopathic chronic pelvic pain syndrome: a prospective study

Background

Male chronic pelvic pain syndrome (CPPS) is a heterogeneous constellation of symptoms that causes significant impairment and is often challenging to treat. In this prospective study, we evaluated men with CPPS who underwent comprehensive pelvic floor physical therapy (PFPT) program. We used the previously validated Genitourinary Pain Index (GUPI) to measure outcomes.

Methods

We included 14 men who underwent physical therapy for idiopathic CPPS from October 2015 to October 2016. Men with clearly identifiable causes of pelvic pain, such as previous surgery, chronic infection, trauma, prostatitis and epididymitis were excluded. Treatment included: (I) manual therapy (internal and external) of pelvic floor and abdominal musculature to facilitate relaxation of muscles; (II) therapeutic exercises to promote range of motion, improve mobility/flexibility and strengthen weak muscles; (III) biofeedback to facilitate strengthening and relaxation of pelvic floor musculature; (IV) neuromodulation for pelvic floor muscle relaxation and pain relief. GUPI questionnaires were collected at initial evaluation and after the 10th visit. Higher scores reflect worse symptoms. Previous validation of the GUPI calculated a reduction of 7 points to robustly predict being a treatment responder (sensitivity 100%, specificity 76%) and a change in 4 points to predict modest response. Data are presented as medians (ranges).

Results

A total of 10 patients completed 10 visits, and the remaining four patients completed between 5 and 9 visits. The median National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) score at initial evaluation was 30.8 [16–39] and decreased to 22.2 [7–37] at the tenth visit. Five of the 10 patients (50%) in the study had a reduction of greater than 7 points indicating a robust treatment response, and two (20%) had a change of greater than 4 indicating moderate response. Three patients (30%) did not have any meaningful change in NIH-CPSI and the remaining four are in the process of completing 10 sessions. Duration of therapy appears to predict treatment response. Longer duration has better response.

Conclusions

Male CPPS is difficult to treat and often requires a multimodal approach. Based on the results of our pilot study, pelvic floor rehabilitation may be an effective treatment option for select patients. A larger study with a control group is needed to validate the routine use of pelvic floor rehabilitation in men with CPPS and predict characteristics of men who would respond to therapy.

Chronic scrotal pain and microsurgical spermatic cord denervation: tricks of the trade

Every practicing urologist encounters patients complaining of chronic scrotal content pain (CSCP). This condition can be equally frustrating for both patients and clinicians as there are no clear treatment guidelines, or pathways, for urologists to follow. As a result, most patients typically seek out multiple providers without improvements in their symptoms. Fortunately, microsurgical spermatic cord denervation (MSCD) is becoming an accepted, reliable and reproducible technique for definitively addressing CSCP in select patients. This manuscript reviews the background, effectiveness and current practice guidelines for scrotal pain in general, and MSCD in particular. Technical insights into how this technique can be performed both safely, and efficaciously, are provided. Finally, the manuscript presents a simple, yet detailed, easy to follow treatment algorithm to aid all urologists in the management of patients presenting with chronic pain.

Retrograde ejaculation, painful ejaculation and hematospermia

Although there has been an increased interest on premature ejaculation in the recent years, our understanding regarding the disorders of retrograde ejaculation, painful ejaculation and hematospermia remain limited. All three of these conditions require a keen clinical acumen and willingness to engage in thinking outside of the standard established treatment paradigm. The development of novel investigational techniques and treatments has led to progress in the management of these conditions symptoms; however, the literature almost uniformly is limited to small series and rare randomised trials. Further investigation and randomised controlled trials are needed for progress in these often challenging cases.

Novel Treatment of Chronic Bladder Pain Syndrome and Other Pelvic Pain Disorders by OnabotulinumtoxinA Injection

Chronic pelvic pain (CPP) is defined as pain in the pelvic organs and related structures of at least 6 months' duration. The pathophysiology of CPP is uncertain, and its treatment presents challenges. Botulinum toxin A (BoNT-A), known for its antinociceptive, anti-inflammatory, and muscle relaxant activity, has been used recently to treat refractory CPP with promising results. In patients with interstitial cystitis/bladder pain syndrome, most studies suggest intravesical BoNT-A injection reduces bladder pain and increases bladder capacity. Repeated BoNT-A injection is also effective and reduces inflammation in the bladder. Intraprostatic BoNT-A injection could significantly improve prostate pain and urinary frequency in the patients with chronic prostatitis/chronic pelvic pain syndrome. Animal studies also suggest BoNT-A injection in the prostate decreases inflammation in the prostate. Patients with CPP due to pelvic muscle pain and spasm also benefit from localized BoNT-A injections. BoNT-A injection in the pelvic floor muscle improves dyspareunia and decreases pelvic floor pressure. Preliminary studies show intravesical BoNT-A injection is useful in inflammatory bladder diseases such as chemical cystitis, radiation cystitis, and ketamine related cystitis. Dysuria is the most common adverse effect after BoNT-A injection. Very few patients develop acute urinary retention after treatment.

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline

Objectives

To improve awareness and recognition of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) among non‐specialists and patients. To provide guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non‐specialist and specialist settings. To promote efficient referral of care between non‐specialists and specialists and the involvement of the multidisciplinary team (MDT).

Patients and Methods

The guideline population were men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months). Consensus recommendations for the guidelines were based on a search to identify literature on the diagnosis and management of CBP and CP/CPPS (published between 1999 and February 2014). A Delphi panel process was used where high‐quality, published evidence was lacking.

Results

CBP and CP/CPPS can present with a wide range of clinical manifestations. The four main symptom domains are urogenital pain, lower urinary tract symptoms (LUTS – voiding or storage symptoms), psychological issues and sexual dysfunction. Patients should be managed according to their individual symptom pattern. Options for first‐line treatment include antibiotics, α‐adrenergic antagonists (if voiding LUTS are present) and simple analgesics. Repeated use of antibiotics, such as quinolones, should be avoided if there is no obvious symptomatic benefit from infection control or cultures do not support an infectious cause. Early use of treatments targeting neuropathic pain and/or referral to specialist services should be considered for patients who do not respond to initial measures. An MDT approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, general practitioners, cognitive behavioural therapists/psychologists, and sexual health specialists) is recommended. Patients should be fully informed about the possible underlying causes and treatment options, including an explanation of the chronic pain cycle.

Conclusion

Chronic prostatitis can present with a wide variety of signs and symptoms. Identification of individual symptom patterns and a symptom‐based treatment approach are recommended. Further research is required to evaluate management options for CBP and CP/CPPS.

Altered resting state neuromotor connectivity in men with chronic prostatitis/chronic pelvic pain syndrome: A MAPP: Research Network Neuroimaging Study

Brain network activity associated with altered motor control in individuals with chronic pain is not well understood. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a debilitating condition in which previous studies have revealed altered resting pelvic floor muscle activity in men with CP/CPPS compared to healthy controls. We hypothesized that the brain networks controlling pelvic floor muscles would also show altered resting state function in men with CP/CPPS. Here we describe the results of the first test of this hypothesis focusing on the motor cortical regions, termed pelvic-motor, that can directly activate pelvic floor muscles. A group of men with CP/CPPS (N = 28), as well as group of age-matched healthy male controls (N = 27), had resting state functional magnetic resonance imaging scans as part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network study. Brain maps of the functional connectivity of pelvic-motor were compared between groups. A significant group difference was observed in the functional connectivity between pelvic-motor and the right posterior insula. The effect size of this group difference was among the largest effect sizes in functional connectivity between all pairs of 165 anatomically-defined subregions of the brain. Interestingly, many of the atlas region pairs with large effect sizes also involved other subregions of the insular cortices. We conclude that functional connectivity between motor cortex and the posterior insula may be among the most important markers of altered brain function in men with CP/CPPS, and may represent changes in the integration of viscerosensory and motor processing.

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We studied men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

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First resting state neuroimaging comparison CP/CPPS and healthy controls (HC)

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Motor cortex connectivity to insula distinguishes CP/CPPS from HC.

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Motor cortex connectivity to insula is among largest changes in CP/CPPS resting brain.

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Results provide additional evidence of motor network changes in chronic pain.

Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome

Prostatitis comprises of a group of syndromes that affect almost 50% of men at least once in their lifetime and makeup the majority of visits to the Urology Clinics. After much debate, it has been divided into four distinct categories by National Institutes of Health namely (1) acute bacterial prostatitis; (2) chronic bacterial prostatitis; (3) chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) which is further divided into inflammatory and non-inflammatory CP/CPPS; and (4) asymptomatic inflammatory prostatitis. CP/CPPS has been a cause of great concern for both patients and physicians because of the lack of presence of thorough information about the etiological factors along with the difficult-to-treat nature of the syndrome. For the presented manuscript an extensive search on PubMed was conducted for CP/CPPS aimed to present an updated review on the evaluation and treatment options available for patients with CP/CPPS. Several diagnostic criteria’s have been established to diagnose CP/CPPS, with prostatic/pelvic pain for at least 3 mo being the major classifying symptom along with the presence of lower urinary tract symptoms and/or ejaculatory pain. Diagnostic tests can help differentiate CP/CPPS from other syndromes that come under the heading of prostatitis by ruling out active urinary tract infection and/or prostatic infection with uropathogen by performing urine cultures, Meares-Stamey Four Glass Test, Pre- and Post-Massage Two Glass Test. Asymptomatic inflammatory prostatitis is confirmed through prostate biopsy done for elevated serum prostate-specific antigen levels or abnormal digital rectal examination. Researchers have been unable to link a single etiological factor to the pathogenesis of CP/CPPS, instead a cluster of potential etiologies including atypical bacterial or nanobacterial infection, autoimmunity, neurological dysfunction and pelvic floor muscle dysfunction are most commonly implicated. Initially monotherapy with anti-biotics and alpha adrenergic-blockers can be tried, but its success has only been observed in treatment naïve population. Other pharmacotherapies including phytotherapy, neuromodulatory drugs and anti-inflammatories achieved limited success in trials. Complementary and interventional therapies including acupuncture, myofascial trigger point release and pelvic floor biofeedback have been employed. This review points towards the fact that treatment should be tailored individually for patients based on their symptoms. Patients can be stratified phenotypically based on the UPOINT system constituting of Urinary, Psychosocial, Organ-specific, Infectious, Neurologic/Systemic and symptoms of muscular Tenderness and the treatment algorithm should be proposed accordingly. Treatment of CP/CPPS should be aimed towards treating local as well as central factors causing the symptoms. Surgical intervention can cause significant morbidity and should only be reserved for treatment-refractory patients that have previously failed to respond to multiple drug therapies.

Reliability of superficial male pelvic floor structural measurements using linear-array transperineal sonography

This study evaluated reliability of measures for superficial structures of the male pelvic floor (PF) obtained via transperineal sonography. Two embalmed cadavers were dissected to identify positioning of muscles on and around the bulb of the penis and to confirm the PF protocol. Cross-sectional area (CSA) and linear thickness of the bulb of the penis, urethra, bulbospongiosus (BS) muscles, and ischiocavernosus (IC) muscles were measured on 38 transverse images from 20 male patients by three raters with varied study knowledge and sonographic experience. Intra- and inter-rater reliability were calculated with two-way, mixed effects intra-class correlation coefficients. Measures of the bulb of the penis had the best reliability. CSA of all muscles and sagittal thickness of the BS near the central tendon had good reliability. Reliability varied for rater-identified thickest muscle region and measures of the urethra. Our study suggests that structures of the male PF can be reliably evaluated using a transperineal sonographic approach.

Treatment of myofascial pain

SUMMARY The objective of this article was to perform a narrative review regarding the treatment of myofascial pain syndrome and to provide clinicians with treatment recommendations. This paper reviews the efficacy of various myofascial pain syndrome treatment modalities, including pharmacological therapy, injection-based therapies and physical therapy interventions. Outcomes evaluated included pain (visual analog scale), pain pressure threshold and range of motion. The evidence found significant benefit with multiple treatments, including diclofenac patch, thiocolchicoside and lidocaine patches. Trigger point injections, ischemic compression therapy, transcutaneous electrical nerve stimulation, spray and stretch, and myofascial release were also efficacious. The authors recommend focusing on treating underlying pathologies, including spinal conditions, postural abnormalities and underlying behavioral issues. To achieve maximum pain reduction and improve function, we recommend physicians approach myofascial pain syndrome with a multimodal plan, which includes a combination of pharmacologic therapies, various physical therapeutic modalities and injection therapies.

Prostatitis and chronic prostatitis/chronic pelvic pain syndrome

The prevalence of prostatitis is extremely high, with up to 16% of men diagnosed with prostatitis at some point throughout their lifetime. However, the etiology appears to be multifactorial and standard treatment regimens have been altered significantly in recent years. The purpose of this review is to examine the changing scientific views on the causes and treatment of prostatitis, chronic prostaitis and chronic pelvic pain syndrome. We review the infectious and noninfectious etiology of the disease, examining the role of antimicrobial treatment in eradicating infection as well as ameliorating symptoms. Current NIH classifications, which stratify prostatitis into four categories, are discussed, as is the NIH Chronic Prostatitis Symptom Index, the primary tool used to assess symptomatology. Diagnostic examinations are studying the need for the four-glass test and its practical replacement by the two-glass test. Multimodal treatment therapy is then discussed, including recent data on biofeedback and evaluation of the role of pelvic floor dysfunction in prostatitis.

Successful management of chronic pelvic pain

Chronic pelvic pain is a common, multifactorial complaint that affects both women and men, causing disability and frustration for patients. The exact aetiology remains unknown, although several theories have been proposed. Assessment should be undertaken with care and compassion, while considering the sensitive nature of the area. Management involves ruling out treatable pathology concomitant with strategies to control pain. Novel treatment approaches have been investigated for specific clinical scenarios. The more severe CPP cases are best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and including musculoskeletal, neurologic and psychological mechanisms.

Transperineal Sonography Evaluation of Muscles and Vascularity in the Male Pelvic Floor

Idiopathic chronic male pelvic pain is difficult to diagnose and treat. Currently, diagnosis relies on subjective symptoms; objective measures of neuromuscular mechanisms have not been investigated. Sonographic imaging has been used to investigate these neuromuscular mechanisms in the female pelvic floor, but neither research nor books describe sonography evaluation of the male pelvic floor. The purpose of this study was to develop and evaluate a perineal sonographic technique for the examination of the male pelvic floor muscles. Anatomic landmarks were identified with images collected from two subjects, one with intermittent reports of pelvic pain and one with no history of pain in the pelvic region. A description of the equipment settings, the examination protocol, and the resulting comparative image analysis is included. A validated protocol such as this may be useful in documenting differences in the soft tissue structures between asymptomatic individuals and patients with chronic pelvic pain to aid in diagnosis and treatment. This is the first known study to report sonographic findings of the individual muscles in the male pelvic floor, and additional research is needed to validate the techniques that have been deemed feasible.

Alternative therapies in the management of chronic prostatitis/chronic pelvic pain syndrome

PURPOSE

Standard medical therapy for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) including such agents as nonsteriodal anti-inflammatories, alpha-blockers, antimicrobial therapy, and 5a-reductase inhibitors has not been uniformly effective. The purpose of this review is to focus on the role of alternative therapies available for the management of CP/CPPS.

METHODS

We performed a systematic review of the literature for articles published in PubMed up to 2012 pertaining to commonly employed alternative therapies.

RESULTS

The evidence for alternative therapies such as diet and lifestyle modifications, phytotherapy, acupuncture, myofascial physical therapy, and stress management/cognitive behavioral therapy is reviewed.

CONCLUSION

CP/CPPS often requires a multimodal approach and alternative therapies should be considered as adjuncts in the treatment of refractory CP/CPPS patients.

Consolidation therapy is necessary following successful biofeedback treatment for pubertal chronic prostatitis patients: a 3-year follow-up study

OBJECTIVE

To assess long-term effects of biofeedback training on pubertal chronic prostatitis (CP).

METHODS

Pubertal CP patients received 12-week intensive biofeedback training and were divided into two groups: group 1 received further monthly training ≥ 24 (26-36) months; group 2 received further monthly training <24 (13-23) months. National Institutes of Health-CP Symptom Index (NIH-CPSI) scores, maximum urinary flow rate (Qmax) and postvoid residual urine volume (PVR) were recorded monthly.

RESULTS

Total NIH-CPSI scores decreased significantly in group 1 (n = 10; mean age ± SD 16.5 ± 1.1 years) together with all subdomain scores (pain, urination, life impact). Total NIH-CPSI scores increased significantly in group 2 (n = 12; mean age ± SD 16.3 ± 1.2 years) at 30 and 36 months, and were significantly different from group 1 at these time points. Urination and life-impact scores increased significantly and Qmax decreased significantly in group 2 at 30 and 36 months. PVR was unchanged in either group.

CONCLUSIONS

Twelve-week intensive biofeedback training requires lengthy consolidation sessions to achieve long-term success. Further investigation should assess longer intervals between consolidation sessions, for improving patient compliance and outcome.

Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes

PURPOSE

We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes.

MATERIALS AND METHODS

We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods.

RESULTS

There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03).

CONCLUSIONS

We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study.

National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) symptom evaluation in multinational cohorts of patients with chronic prostatitis/chronic pelvic pain syndrome

BACKGROUND

The assessment of patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in everyday practice and clinical studies relies on National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scores for symptom appraisal, inclusion criteria for clinical trials, follow-up, and response evaluation.

OBJECTIVE

We investigated multiple databases of CP/CPPS patients to determine the prevalence and impact of pain locations and types to improve our strategy of individualized phenotypically guided treatment.

DESIGN, SETTING, AND PARTICIPANTS

Four major databases with CPSI scores for nonselected CP/CPPS clinic patients from Canada, Germany, Italy, and the United States.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Individual question scores and subtotal and total scores of CPSI were described and correlated with each other. Ordinal regression analysis was performed to define pain severity categories.

RESULTS AND LIMITATIONS

A total of 1563 CP/CPPS patients were included. Perineal pain/discomfort was the most prevalent pain symptom (63%) followed by testicular pain (58%), pain in the pubic area (42%) and penis (32%); reports of pain during ejaculation and voiding were 45% and 43%, respectively. European patients had a significantly higher number of pain localizations and symptoms compared with North American patients (p<0.001). Severity of pain correlated well with frequency of pain (r = 0.645). No specific pain localization/type was associated with more severe pain. Correlation of pain domain with quality of life (QoL) (r = 0.678) was higher than the urinary domain (r = 0.320). Individually, pain severity (r = 0.627) and pain frequency (r = 0.594) correlated better with QoL than pain localization (r = 0.354). Pain severity categories results for NIH-CPSI item 4 (0-10 numerical rating scale for average pain) were mild, 0-3; moderate, 4-6; severe, 7-10; CPSI pain domain (0-21): mild, 0-7; moderate, 8-13; and severe, 14-21.

CONCLUSIONS

Pain has more impact on QoL than urinary symptoms. Pain severity and frequency are more important than pain localization/type. Cut-off levels for disease severity categories have been identified that will prove valuable in symptom assessment and the development of therapeutic strategies.

Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVE

To investigate the pelvic floor muscle motion in men with and without chronic prostatitic/chronic pelvic pain syndrome using transabdominal ultrasound. No study has directly evaluated pelvic floor muscle mobility in individuals with and without chronic pelvic pain syndrome.

METHODS

A convenience sample of 40 males participated in the study. Subjects were categorized into 2 groups: those with chronic pelvic pain syndrome (n = 20) and those without chronic pelvic pain syndrome (n = 20). The amount of bladder base movement on ultrasound (normalized to body mass index) was measured in all subjects and considered as an indicator of pelvic floor muscle mobility.

RESULTS

Statistical analysis (independent t-test) revealed significant difference in transabdominal ultrasound measurements for pelvic floor muscle function between the 2 groups (P = .03, 95% CI -0.26 to -0.01).

CONCLUSION

The results of this study indicate that pelvic floor muscle mobility differs in the 2 groups.

Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness

PURPOSE

We determined the efficacy and safety of pelvic floor myofascial physical therapy compared to global therapeutic massage in women with newly symptomatic interstitial cystitis/painful bladder syndrome.

MATERIALS AND METHODS

A randomized controlled trial of 10 scheduled treatments of myofascial physical therapy vs global therapeutic massage was performed at 11 clinical centers in North America. We recruited women with interstitial cystitis/painful bladder syndrome with demonstrable pelvic floor tenderness on physical examination and a limitation of no more than 3 years' symptom duration. The primary outcome was the proportion of responders defined as moderately improved or markedly improved in overall symptoms compared to baseline on a 7-point global response assessment scale. Secondary outcomes included ratings for pain, urgency and frequency, the O'Leary-Sant IC Symptom and Problem Index, and reports of adverse events. We compared response rates between treatment arms using the exact conditional version of the Mantel-Haenszel test to control for clustering by clinical center. For secondary efficacy outcomes cross-sectional descriptive statistics and changes from baseline were calculated.

RESULTS

A total of 81 women randomized to the 2 treatment groups had similar symptoms at baseline. The global response assessment response rate was 26% in the global therapeutic massage group and 59% in the myofascial physical therapy group (p=0.0012). Pain, urgency and frequency ratings, and O'Leary-Sant IC Symptom and Problem Index decreased in both groups during followup, and were not significantly different between the groups. Pain was the most common adverse event, occurring at similar rates in both groups. No serious adverse events were reported.

CONCLUSIONS

A significantly higher proportion of women with interstitial cystitis/painful bladder syndrome responded to treatment with myofascial physical therapy than to global therapeutic massage. Myofascial physical therapy may be a beneficial therapy in women with this syndrome.

Chronic prostatitis: approaches for best management

Prostatitis is a prevalent condition that encompasses a large array of clinical symptoms with significant impacts on men's life. The diagnosis and treatment of this disorder presents numerous challenges for urologists, most notably, a lack of specific and effective diagnostic methods. Chronic bacterial prostatitis is successfully treated with appropriate antibiotics that penetrate the prostate and kill the causative organisms. Prostatitis category III (chronic pelvic pain syndrome) is common, very bothersome, and enigmatic. Symptoms are usually prolonged and, generally speaking, treatment results are unsatisfactory. During the last decade, research has focused on the distress caused by the condition, but although our knowledge has certainly increased, there have been no real breakthroughs; controversies and many unanswered questions remain. Furthermore, the optimal management of category III prostatitis is not known. Conventional prolonged courses of antibiotic therapy have not proven to be efficacious. Novel therapies providing some evidence for efficacy include alpha-blocker, anti-inflammatory phytotherapy, physiotherapy, neuroleptics, and others, each offering therapeutic mechanisms. A stepwise approach involving multimodal therapy is often successful for treating patients. The UPOINT technique has been used to clinically phenotype these patients and drive the appropriate selection of multimodal therapy.

Alternative therapies for the treatment of chronic prostatitis

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a prevalent disease for which there is no standardized therapy. Traditional treatments have included antibiotics, α-blockers, and anti-inflammatories, but those have not proven to be efficacious therapies through many clinical trials. Alternative therapies, such as phytotherapy, acupuncture, and pelvic floor physical therapy, have grown in popularity for the treatment of CP/CPPS. As clinicians continue to explore these alternative therapies, there is an accumulation of strong evidence demonstrating the success of these alternative therapies.

Use of pelvic floor ultrasound to assess pelvic floor muscle function in Urological Chronic Pelvic Pain Syndrome in men

INTRODUCTION

An important cause or maintaining factor for pain in Urological Chronic Pelvic Pain Syndrome (UCPPS) may be pelvic floor muscle (PFM) dysfunction, which may also be implicated in sexual dysfunction and influenced by psychosocial factors. Pelvic floor ultrasound is a noninvasive, reliable, and relatively simple method to assess PFM morphology and function and can be assessed by the anorectal angle (ARA) and levator plate angle (LPA).

AIMS

The aim of the present study was to examine PFM morphology in men with UCPPS as compared with controls and to examine the correlation with pain and psychosocial measures.

METHODS

Our participants were 24 men with UCPPS and 26 controls. A GE Voluson E8 ultrasound probe was placed on the perineum, and three-dimensional images were taken at rest and during PFM contraction.

MAIN OUTCOME MEASURES

The main outcomes were ARA and LPA at rest and contraction. Participants also completed the National Institute of Health (NIH) Chronic Prostatitis Symptom Index, Male Sexual Health Questionnaire, State Anxiety Inventory, and Pain Catastrophizing Scale.

RESULTS

Men with UCPPS had more acute ARAs than controls both at rest and during contraction. The two groups did not differ in LPA at rest; however, men with UCPPS had significantly more acute angles during contraction and LP excursion. Acute ARAs were positively correlated with greater pain report and sexual dysfunction. Anxiety was correlated with more acute ARAs and more obtuse LPAs.

CONCLUSIONS

Three implications can be drawn from the findings. First, ARA at rest and during contraction as well as LP angle during contraction and LPA excursion separates men with UCPPS from controls. Second, ARA at rest and during contraction was correlated with pain and sexual dysfunction, while LPA at rest was related to anxiety. Third, pelvic floor ultrasound has the potential to be a useful and objective method of assessing PFM morphology in UCPPS.

6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training

PURPOSE

Chronic prostatitis/chronic pelvic pain syndrome continues to elude conventional therapy. Evidence supports the concept that phenotypes of pelvic muscular tenderness and psychosocial distress respond to myofascial trigger point release and specific relaxation training. This case series reports long-term outcomes of a 6-day intensive combination of such therapies in refractory cases.

MATERIALS AND METHODS

A total of 200 men with pain for a median of 4.8 years referred themselves to Stanford University Urology for participation in an established protocol. Daily 3 to 5-hour sessions including intrapelvic/extrapelvic physiotherapy, self-treatment training and paradoxical relaxation training provided a solid introduction to facilitate self-management. Subjects answered baseline and followup questionnaires at variable intervals after initiation of therapy including the National Institutes of Health Chronic Prostatitis Symptom Index, global response assessment and a psychological query.

RESULTS

We followed 116 men for a median of 6 months. Baseline total symptom index was 26 out of a maximum 43 points. Scores decreased by 30% (p <0.001) at followup with 60% of subjects demonstrating a 6-point or greater decrease (range 6 to 30). Domains of pain, urinary dysfunction and quality of life showed significant improvement (p <0.001). Global response assessment revealed that 82% of subjects reported improvement (59% marked to moderate, 23% slight).

CONCLUSIONS

Men with chronic pelvic pain refractory to traditional treatment benefit from intensive myofascial trigger point therapy and concomitant paradoxical relaxation training. Education in techniques for self-administered trigger point release and continued pelvic muscle relaxation help patients reduce pain and dysfunction. Refinement of clinical phenotyping and selection of patients with pelvic muscle tenderness should enhance the success rate with this treatment modality.

[Specific treatments for chronic bacterial prostatitis and chronic pelvic pain syndrome]

OBJECTIVE

To review the treatment of chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

MATERIAL AND METHODS

A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either Medical subject heading (MeSH) keywords (antibacterial agents, pelvic pain, placebos, prostatitis, treatment) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time.

RESULTS

The treatment of chronic bacterial prostatitis is based on the use of antibiotics, primarily fluoroquinolones, for 4 to 6 weeks, but no consensus has been reached concerning the standard treatment of CP/CPPS. A review of the literature failed to identify any recognized and validated treatments for CP/CPPS, but several conclusions can be drawn: placebo gives satisfactory results in a considerable number of patients; antibiotics are not recommended; alpha-blocking agents may be effective in recently diagnosed, previously untreated patients, provided they are prescribed for 12 weeks to 6 months; invasive surgery of the prostate and bladder neck is not recommended.

CONCLUSION

Progress in the treatment of CP/CPPS will require more extensive basic and clinical research. Only randomized, placebo-controlled clinical trials including a large number of patients, and using the NIH-Chronic Prostatitis Symptom Index questionnaire (NIH-CPSI) as evaluation tool will be able to provide reliable conclusions. The use of patient subgroups selected according to the predominant symptoms could be contributive.

Pharmacotherapy strategies in chronic prostatitis/chronic pelvic pain syndrome management

IMPORTANCE OF THE FIELD

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is one of the most common diagnoses arising out of urologic office visits. It is a costly problem and sufferers compare the effect of this syndrome on quality of life as being similar to the effects of diabetes mellitus and myocardial infarction. The syndrome is variable in presentation and symptom management and efficacy will vary between inflicted men.

AREAS COVERED IN THIS REVIEW

CP/CPPS is not highly responsive to therapy. As such, it is often a waxing and waning illness with symptoms in multiple domains, including urinary symptoms, pain and ejaculatory dysfunction. The pharmacotherapeutic options and management strategies for CP/CPPS presented in this review are based on the published literature from September 1989 to January 2010. When available, randomized, placebo-controlled studies were reviewed to aid in making definitive recommendations for treatment strategies.

WHAT THE READER WILL GAIN

The reader will be familiarized with the commonly used classes of pharmaceutical and non-pharmaceutical therapies. Readers will then use the efficacy data to inform treatment decisions for patients with disparate symptomatology. This will be crystallized in the author's treatment algorithm and summary statement.

TAKE HOME MESSAGE

Many practitioners use antimicrobials as a first-line agent, particularly a fluoroquinolone, such as levofloxacin. Trimethoprim/sulfamethoxazole is another medication alternative, with comparable response rates. Many afflicted men will have significant improvement on a 4- to 6-week regimen of a fluoroquinolone antibiotic. Second-line pharmacotherapy includes alpha-blockers, 5-alpha reductase inhibitors and anti-inflammatories for men with urinary symptoms or pain as a predominant symptom domain. Other pharmacotherapy includes steroids, glycosaminoglycans and phytotherapy. Surgical options are generally not recommended for CP/CPPS. Despite the lack of curative therapies, effective symptom management can be achieved with knowledge of the classes of pharmacotherapy. Therapeutic decisions can be based on the symptoms of the patient. Pelvic floor physical therapy is a useful second-line therapy in the author's opinion, but randomized controlled trials and standardization of technique for CP/CPPS are needed before recommendations can be substantiated.