Understanding chronic pelvic pain syndrome

Perception of chronic pelvic pain in women: predictors and clinical implications

Pain is a complex subjective experience, associated with neurovegetative, affective and cognitive rapid changes. Biological, psychosocial and contextual factors may contribute. Chronic inflammation, of whatever cause, is the leading contributor to chronic pain. The mast cell directs both the inflammatory process and the shift to chronic pain, mediating through the production of Nerve Growth Factor (NGF) and other neurotrophic molecules. Women, in the fertile age, are biologically more vulnerable to chronic inflammation, as fluctuations of estrogens are agonist factors of mast cells degranulation, mostly in the premenstrual phase. Pain is defined as “nociceptive” when it indicates an ongoing damage; “neuropathic” when it becomes a disease per se.

Chronic Pelvic Pain (CPP) indicates an invalidating, persistent or recurrent pelvic pain, persisting for more than 6 months. CPP is the main complaint of 10–15% of gynaecologic consultations, leading to 40% of diagnostic laparoscopies and 15% of hysterectomies. Comorbidity, i.e. the coexistence of pathologies and painful syndromes in different pelvic organs, is another common feature. Cystitis, vulvar vestibulitis, endometriosis, irritable bowel syndrome all play an important role and contribute to identifying the hyperactive mast cell and related chronic inflammation as the common pathophysiologic factor. The paper reviews nociception characteristics, the emerging role of mast cells, the pathophysiology of comorbidity, biological, psychosexual and contextual predictors, and stresses the need to move from a “hyperspecialistic” perspective to a multisystemic reading of CPP, with special attention to the urologic perspective.

Chronic testicular pain in adult men: an integrative literature review

Past investigations of chronic testicular pain provide a sparse representation of the men with this condition and lack key details to aid our understanding of this important men's health condition. As a chronic pain syndrome, more research is necessary to understand the phenomenon of chronic testicular pain and the pain experience of these men. This integrative literature review provides a summary of the current state of the science of chronic testicular pain in men, identifies the gaps in our knowledge, and provides recommendations to address this knowledge gap.

Pregabalin for chronic prostatitis

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a condition that is detrimental to the quality of life of men. Evidence suggests that it may have a neuropathic origin and therefore medications such as pregabalin might have a role in the controlling of symptoms.

OBJECTIVES

The primary objective was to compare pregabalin to other modalities of pain relief to alleviate men's symptoms of CP/CPPS.The secondary objective was to assess the safety and effectiveness of pregabalin to improve various individual symptoms consistent with CP/CPPS.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to May 2012), EMBASE (1980 to May 2012), CINAHL, clinicaltrials.gov, Google Scholar, and reference lists of articles and abstracts from conference proceedings, without language restriction for pregabalin treatment of Class III prostatitis and CP/CPPS.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing pregabalin to placebo or other types of analgesics for the management of patients with CP/CPPS were included. Patients with known causes of pain/discomfort were excluded.

DATA COLLECTION AND ANALYSIS

Only one RCT was included. The trial compared pregabalin to placebo for patients who had CP/CPPS.

MAIN RESULTS

For men who responded clinically (≥ 6-point improvement), there was no difference between the pregabalin (103/218; 47.2%) and placebo (38/106; 35.8%) arms (risk ratio (RR) 1.32; 95% CI 0.99 to 1.76). There was less pain with a higher point improvement in the pregabalin group compared to the placebo group (4.2 points versus 1.7 points, respectively; mean difference (MD) -2.3 points; 95% CI -4.0 to -0.7 points).Though 59% (191/324) of the patients developed side effects, no serious effects were experienced. There were significantly more neurologic side effects in the pregabalin group compared to the placebo group (38.5% (84/218) versus 22.6% (24/106), respectively; RR 1.7; 95% CI 1.15 to 2.51), and less pain in the pregabalin group than in the placebo group (17.4% (38/218) versus 33.3% (35/106), respectively; RR 0.53; 95% CI 0.36 to 0.78). However, no significant differences were seen between the pregabalin and placebo groups with regards to gastrointestinal disturbances (18.3% (40/218) versus 18.9% (20/106), respectively; RR 0.97; 95% CI 0.60 to 1.58), ocular/visual symptoms (6.9% (15/218) versus 2.8% (3/106), respectively; RR 2.43; 95% CI 0.72 to 8.22), and renal/genitourinary symptoms (5.5% (12/218) versus 1.9% (2/106), respectively; RR 3.03; 95% CI 0.67 to 13.79).

AUTHORS' CONCLUSIONS

There is evidence from one RCT that pregabalin does not improve CP/CPPS symptoms and causes adverse effects in a large percentage of men. However, research is required to assess further whether pregabalin has a role in patients with CP/CPPS for symptom control.

The DABBEC phenotyping system: towards a mechanistic understanding of CP/CPPS

There is an urgent need to elucidate the mechanistic basis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), as the current methods of symptom-based diagnosis and treatment have failed. Here, we propose a phenotyping system that bridges the gap between the symptom-based diagnosis and treatment of the present and the mechanistic approach of the future. Our phenotyping system uses the Chronic Prostatitis Collaborative Research Network (CPCRN)-recommended algorithm in combination with the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) as a basis for diagnosis, while incorporating novel domains for quantitative assessment and stratification of CP/CPPS patients. We believe this novel system will serve to help advance our understanding of the roles of the patient's genome and proteome in the etiology of CP/CPPS. We predict that, as we begin to understand the mechanistic basis of CP/CPPS pathology and progression, we will develop specific treatments that will aim to cure the disease, rather than merely quell the symptoms.

Gene expression profile of bladder tissue of patients with ulcerative interstitial cystitis

Background

Interstitial cystitis (IC), a chronic bladder disease with an increasing incidence, is diagnosed using subjective symptoms in combination with cystoscopic and histological evidence. By cystoscopic examination, IC can be classified into an ulcerative and a non-ulcerative subtype. To better understand this debilitating disease on a molecular level, a comparative gene expression profile of bladder biopsies from patients with ulcerative IC and control patients has been performed.

Results

Gene expression profiles from bladder biopsies of five patients with ulcerative IC and six control patients were generated using Affymetrix GeneChip expression arrays (Affymetrix – GeneChip^® Human Genome U133 Plus 2.0). More than 31,000 of > 54,000 tested probe sets were present (detection p-value < 0.05). The difference between the two groups was significant for over 3,500 signals (t-test p-value < 0.01), and approximately 2,000 of the signals (corresponding to approximately 1,000 genes) showed an IC-to-healthy expression ratio greater than two. The IC pattern had similarities to patterns from immune system, lymphatic, and autoimmune diseases. The dominant biological processes were the immune and inflammatory responses. Many of the up-regulated genes were expressed in leukocytes, suggesting that leukocyte invasion into the bladder wall is a dominant feature of ulcerative IC. Histopathological data supported these findings.

Conclusion

GeneChip expression arrays present a global picture of ulcerative IC and provide us with a series of marker genes characteristic for this subtype of the disease. Evaluation of biopsies from other bladder patients with similar symptoms (e.g. patients with non-ulcerative IC) will further indicate whether the data presented here will be valuable for the diagnosis of IC.

Impact of vitamin D receptor activity on experimental autoimmune prostatitis

Chronic non bacterial prostatitis is a chronic inflammatory syndrome. Its etiology and physiopathology are unclear and treatments are empirical and ineffective in most cases. Autoimmunity has been proposed as an etiology. In the present report, we investigated the impact of vitamin D receptor silencing, by use of VDR-KO NOD mice and the immune-modulating effect of the vitamin D3 analog TX527 on the development of Experimental Autoimmune Prostatitis in NOD mice. VDR-KO NOD mice developed a more aggressive form of autoimmune prostatitis characterized by a greater lymphoproliferative response against prostate antigen in vitro (6.92+/-4.77 vs. 2.47+/-0.41 21 days after disease induction, p<0.05) and higher levels of specific INFgamma secretion (471+/-6 vs. 386+/-5pg/ml, p<0.01). This was accompanied in vivo by more severe lesions and augmented mononuclear cell infiltration in the prostate gland. On the other hand, although analog-treated mice showed a significant reduction in the spleen T-cell specific proliferative response against prostate antigen in vitro, no effect on disease development was observed. We conclude that vitamin D receptor modulation holds the promise of interfering with autoimmune prostatitis. Introduction of more powerful analogs, or combinations with anti-T-cell reagents may represent therapeutic solutions for these group of patients.

Autoimmune prostatitis: state of the art

The prostate is one of the main male sex accessory glands and the target of many pathological conditions affecting men of all ages. Pathological conditions of the prostate gland range from infections, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) of a still unknown aetiology to benign hyperplasia and cancer. CP/CPPS is one of the most prevalent diseases in the urologic clinic and affects men younger than 50 years old. A significant advance in the understanding of CP/CPPS was made when an autoimmune response against prostate antigens was revealed in a considerable number of patients. During the last 30 years, extensive work has been done regarding the development and characterization of different rodent models of experimental autoimmune prostatitis (EAP). It has been demonstrated that tolerance to prostate antigens can be disrupted in some strains of rats and mice and cellular and humoral responses to prostate antigens are elicited. A Th1 pattern has been described and the cellular response seems to be the major pathogenic mechanism involved. Immune cells infiltrate the gland and induce prostate lesions. The genetic background and hormonal imbalance are factors that could contribute to the onset of the disease in susceptible young males. Moreover, spontaneous autoimmune prostatitis could also occur with advanced age in susceptible strains. In this review, we summarize the current knowledge regarding rodent models of EAP and the immunological alterations present in CP/CPPS patients. We also discuss the reliability of these experimental approaches as genuine tools for the study of human disease.

Reduced semen quality in chronic prostatitis patients that induce the release of apoptotic protein Omi/HtrA2 from spermatozoa

The relationship between chronic prostatitis and fertility has been disputed for many years. Several groups have shown infection and autoimmune response against prostate antigens could have a deleterious effect on semen quality and fertility. This study was conducted to test the hypothesis that Omi/HtrA2-induced apoptosis in chronic prostatitis could be a mechanism underlying the observed clinical benefit. The Omi/HtrA2 serine protease is a nuclear-encoded mitochondrial protein, which can be released from mitochondria into the cytosol after apoptosis stimuli, inducing apoptosis in caspase-dependent and independent manners. Forty-one patients diagnosed as suffering from chronic prostatitis were included. Healthy normal individuals were included as controls. Human spermatozoa in the semen were purified by Percoll-gradient technique to separate the seminal plasma and other round cells. Measurements for sperm concentration, motility, morphology, proinflammatory cytokines, Omi/HtrA2 mRNA and protein levels in spermatozoa of chronic protatitis patients, were performed accordingly. Significantly increased levels of proinflammatory cytokines were detected in seminal plasma from these prostatitis patients. Omi/HtrA2 mRNA and protein levels were significantly higher in prostatitis men than in normal men. This study shows that chronic prostatitis patients present important alterations in their semen quality parameters, Omi/HtrA2 mRNA and protein levels of spermatozoa. We speculate that the inflammatory process involved may affect male fertility by release of proapoptotic protein Omi/HtrA2.

Pathogenic Consequences in Semen Quality of an Autoimmune Response against the Prostate Gland: From Animal Models to Human Disease

We have recently proposed an autoimmune etiology in approximately 35% of chronic nonbacterial prostatitis patients, the most frequent form of prostatitis observed, because they exhibit IFN-gamma-secreting lymphocytes specific to prostate Ags. Interestingly, this particular group of patients, but not the rest of chronic nonbacterial prostatitis patients, also presented striking abnormalities in their semen quality. In this work, we use an experimental animal model of autoimmune prostatitis on Wistar rats developed in our laboratory to investigate when, where, and how sperm cells from autoimmune prostatitis individuals are being damaged. As in patients, a marked reduction in sperm concentration, almost null sperm motility and viability, and an increased percentage of apoptotic spermatozoa were detected in samples from animals with the disease. Prostate-specific autoantibodies as well as elevated levels of NO, TNF-alpha, and IFN-gamma were also detected in their seminal plasma. In contrast, epididymal spermatozoa remain intact, indicating that sperm damage occurs at the moment of joining of prostate secretion to sperm cells during ejaculation. These results were further supported by experiments in which mixture of normal sperm cells with autoimmune seminal plasma were performed. We hypothesize that sperm damage in experimental autoimmune prostatitis can be the consequence of an inflammatory milieu, originally produced by an autoimmune response in the prostate; a diminished prostate functionality, evidenced by reduced levels of citric acid in semen or by both mechanisms simultaneously. Once more, we suggest that autoimmunity to prostate may have consequences on fertility.

Uric acid crystals in the semen of a patient with symptoms of chronic prostatitis

OBJECTIVE

To report the finding of red and brownish precipitates with morphology and chemistry compatible with uric acid crystals in semen in a patient with symptoms of chronic prostatitis.

DESIGN

Case report.

SETTING

Academic clinical biochemistry and immunology laboratory.

PATIENT(S)

A 35-year-old man with clinical symptoms of prostatitis.

INTERVENTION(S)

Uric acid crystals were detected in the semen samples. Treatment with a low purine diet relieved the symptoms.

MAIN OUTCOME MEASURE(S)

Study of chemical and morphological characteristics of crystals found in the semen using standard semen analysis and transrectal ultrasound. Analysis of serum, urine, and seminal plasma uric acid levels.

RESULT(S)

Uric acid crystals were detected in semen. A transrectal ultrasound revealed the presence of microcalcifications in the prostate gland. After treatment with a low purine diet, the patient experienced considerable relief of the clinical symptoms. Determination of uric acid and creatinine levels in serum and seminal plasma were carried out before and after treatment. There were no abnormalities or presence of crystals in the post-treatment semen analysis.

CONCLUSION(S)

The presence of uric acid crystals in semen of a patient with symptoms of chronic prostatitis can be attributed to the pelvic pain.

Chronic pelvic pain syndrome/chronic prostatitis affect the acrosome reaction in human spermatozoa

Male genital tract inflammations constitute an important factor of male subfertility in which different mediators are discussed damaging sperm membranes. As acrosome reaction (AR) is ultimately a membrane function, this study aimed at investigating the effects of the chronic pelvic pain syndrome on AR. In a total of 56 patients with chronic pelvic pain syndrome NIH IIIA and NIH IIIB, AR, concentration of leucocytes in ejaculate and urine after prostate massage, sperm concentration, motility, vitality and morphology were determined. The control group (n = 95) consisted of patients with normozoospermia and proven absence of signs of inflammation. Compared to the control, both patients groups showed poorer sperm morphology (P < 0.0001) and sperm concentration (P < 0.002). In addition, while maximum AR was not affected, inducibility of AR was significantly lower (P < 0.004) and spontaneous AR increased (P < 0.02). Our data clearly demonstrate a significant influence of the inflammation on acrosomal functionality, which could be mediated by inflammatory mediators like ROS.

Reduced semen quality in chronic prostatitis patients that have cellular autoimmune response to prostate antigens

BACKGROUND

The relationship between chronic prostatitis and fertility has been controversial for many years. We have previously shown the presence of a cellular autoimmune response against prostate antigens in a group of chronic prostatitis patients. Our main goal was to investigate whether chronic prostatitis (either caused by an infection or an autoimmune response to the prostate gland) could have a deleterious effect on semen quality.

METHODS

Forty-four patients diagnosed as suffering from chronic prostatitis were included and divided into groups according to the presence of infection and/or cellular autoimmune response against prostate antigens. Healthy normal individuals were included as controls. Measurements for sperm concentration, motility, morphology, prostate and seminal vesicle markers, antisperm antibodies, white blood cells and pro-inflammatory cytokines were performed accordingly.

RESULTS

The most severe abnormalities were seen in patients with no evident infection and an autoimmune response against prostate antigens. Moreover, significantly increased levels of pro-inflammatory cytokines were detected in seminal plasma from these patients.

CONCLUSIONS

This study shows that chronic prostatitis patients with cellular autoimmune response to prostate antigens present important alterations in their semen quality parameters. We speculate that an autoimmune response against prostate antigens and the inflammatory process involved may affect male fertility.

Quantifying symptoms in men with interstitial cystitis/prostatitis, and its correlation with potassium-sensitivity testing

OBJECTIVE

To determine whether men previously diagnosed with prostatitis also have pathology originating in the bladder.

PATIENTS, SUBJECTS AND METHODS

We administered the pelvic pain and urgency/frequency (PUF) questionnaire and the potassium-sensitivity test (PST) to 50 patients with prostatitis presenting in urological and primary care, and to 14 controls. In a separate control group of 22 men, the urethra was irrigated with KCl or NaCl (11 each) before and after experimental injury of the urethral mucosa.

RESULTS

All 50 patients with prostatitis had PUF scores of > or = 7; 77% were positive for the PST. All 14 controls had PUF scores of 1 or 0 and a negative PST. In the urethral irrigation study in controls, KCl but not NaCl provoked urethral pain after mucosal injury. Before injury, neither KCl nor NaCl caused symptoms.

CONCLUSION

The high rate of positive PST in patients with "classic" prostatitis indicates that pathology originating in the bladder may be an important source of symptoms in most. In patients with prostatitis and female patients with interstitial cystitis, symptoms may arise not from separate disease entities but from a continuum of epithelial dysfunction and potassium cycling that may be present throughout the lower urinary tract.

Adhesions in patients with chronic pelvic pain: A role for adhesiolysis?

OBJECTIVE

To review the relation between adhesions and pelvic pain and the effectiveness of adhesiolysis in pain control.

DESIGN

Selective review of the literature.

PATIENT(S)

Patients with pelvic pain and/or undergoing adhesiolysis for pain control.

RESULT(S)

Intraabdominal adhesions are accepted as etiologic factors for infertility and small bowel obstruction; however, the contribution of adhesions to pelvic pain is less clear. The most common laparoscopic findings in patients with and without pelvic pain were endometriosis and adhesions. Immunohistologic studies also have shown evidence of nerve fibers in adhesions that had been removed from patients with and without pelvic pain. Multiple adhesiolysis techniques have been employed, with outcome of surgical procedures ranging from no pain relief to pain relief in 90% of patients. However, randomized trials have shown that adhesiolysis is ineffective in improving the outcome of the treatment of pelvic pain, possibly because of adhesion reformation. Interestingly, adhesions are usually not described as an etiologic factor for pelvic pain in men; this might be related to a gender difference in pain perception or the possibility that adhesions per se do not cause pain.

CONCLUSION(S)

The correlation between pelvic pain and adhesions is uncertain. Adhesiolysis has not been shown to be effective in achieving pain control in randomized clinical studies.

Interstitial cystitis: an update

PURPOSE OF REVIEW

Interstitial cystitis is a chronically progressive, severely debilitating, heterogeneous syndrome affecting the urinary bladder, mainly associated with urgency, frequency and pain. Though known for over a century, its etiology is poorly understood and universally effective treatments are lacking. This review focuses on recently published literature on the disorder.

RECENT FINDINGS

Appropriate diagnostic tests for interstitial cystitis remain uncertain. The diagnostic criteria developed by the US National Institutes of Health represent research definitions which are subject to controversial debate for their overenthusiastic clinical application. The diagnosis is made clinically and by cystoscopy with hydrodistention and sometimes biopsy when other pathologies have been excluded. In symptomatic patients, glomerulations upon bladder distension are indicative but not pathognomonic for nonulcerative interstitial cystitis. Patients with ulcerative disease represent a separate subgroup with distinct characteristics and treatment implications. The role of bladder permeability tests remains controversial. Promising noninvasive markers for interstitial cystitis have been described but are not yet clinically available. Validated symptom scores are appropriate to assist in diagnostics and to monitor disease course and treatment efficacy. Lately investigated hypotheses for causative factors include occult or resistant microorganisms, urothelial hyperpermeability, neurogenic or hormonal pathomechanisms, and mast cell activation. Increasing evidence for a genetic susceptibility is emerging.

SUMMARY

Among the multitude of oral, intravesical, interventional and complementary treatments suggested few studies have high levels of evidence. Newly proposed agents must await further controlled studies. Treatment remains empiric until radical surgical procedures should ultimately be considered for severe refractory cases.