Pelvic Pain in Men: Is It Always an Infection?

Pelvic Pain in Men: Is It Always an Infection? by:

Hello again uh this lecture is entitled chronic prostatitis it’s not always an infection uh the reason for this uh specific title is that so many patients um are given a diagnosis of prostatitis uh they’re empirically started on on antibiotics but the antibiotics yes in some cases work but in many cases they’re not working at all and patients need other forms

Of care and that’s really what this lecture is devoted to the symptoms of chronic prostatitis what we now call cpcpps chronic prostatitis chronic pelvic pain syndrome include things like pain at the tip of the penis and of course as i mentioned in a previous lecture the pain usually isn’t at the tip of the penis it’s usually way back uh either by the prostate

Or by the pelvic floor muscles there can be perineal pain this is pain between the scrotum and the anus the testicular discomfort urinary hesitancy uh the sensation of incomplete emptying pelvic pressure constipation all some of these symptoms don’t even sound virtually like the prostate at all and in fact some some of the patients come in with a lot of bladder

Related pain and it’s not infrequent that we ultimately make a diagnosis of interstitial cystitis well the symptoms continue on and a large part of them may be related to sexual dysfunction that can be in the form of erectile dysfunction the inability to attain a a a reasonable hardness and firmness for penetration premature ejaculation ejaculatory pain and

Even changes in libido well chronic prostatitis chronic pelvic pain syndrome doesn’t only have it’s not just the the symptoms that cause problems it’s the result of those symptoms in terms of social functioning in terms of stress depression anxiety and so forth so we really need to keep this in mind what toll it takes on on our patients let’s back up for a moment

Let’s talk about some prostate anatomy and as you can see here in this what’s called a sagittal view a cross-sectional view the prostate gland over here sits right underneath the bladder and on the other side is the rectum the other side is the sort of the root of the of the penis and all the uh structures that allow one to uh attain an erection lots of muscles

Over here that you see here around the rectal area and also muscles that control um ejaculation here you see this on a side view this is called the coronal view the prostate over here and these muscles called the levator anai musculature also so it’s being in such uh close proximity and the fact that the nerves that run in this area also affect the the muscles uh

The prostate and the bladder it’s sometimes hard to figure out where the pain is coming from prostatitis syndromes can be broken down into different categories and uh not just for the sake of simplicity i just want to make mention that most patients that we see in practice and worldwide essentially fall into category three what used to be called non-bacterial

Prostatitis or prostatidinia the ones that typically everybody thinks about are the first two categories acute prostatitis and chronic bacterial prostatitis these categories represent maybe only about five maybe ten percent of patients um but they use most of these patients will have some history of a documented urinary tract infection somewhere along the way

That leaves us with a dilemma because it means that most patients are not going to respond or minimally respond to antibiotic therapy so as i mentioned earlier in an earlier lecture we need to sort of break down the symptoms and where this pain is actually coming from because it may not just be the prostate and this is a a this is something called viewpoint it’s

A way to essentially break the patients down phenotypically meaning by what we see how they present to us whether it be urinary complaints uh whether there’s for example the n stands for neurological dysfunction t stands for tenderness of the muscles and a new one over here not just you point but you point stands for the sexual dysfunction and we need to address

Many of these factors when sort of evaluating patients and ultimately developing a treatment strategy one of the major players that we see in the majority of patients is some type of muscular dysfunction and this slide really just goes to show the complexity of this area so here you can see the phallus here the anus over here and all the structures nearby so

You see the nerves that come right over here you can see its association with these what we call the ischial tuberosities are the sit bones and you can understand perhaps why patients don’t really uh care to sit down for long periods of time it worsens symptoms for so many people maybe it’s because we’re compressing this nerve the perineal nerve into the that

These bony structures here maybe it’s just the fact that we’re applying pressure to the nerves and the muscles in this area to cause discomfort and often on physical examination we are picking up tenderness in many of these regions tenderness that we can then hopefully apply some therapies to one of the basic therapies that we typically uh apply and my patients

Listening today will definitely they’ve heard this before is the you need to stop pushing and straining many people come in with some urinary hesitancy or they’re just tightening up there all the time because they’re in pain so they guard they they tighten up more and that seems to worsen this whole cycle of pain we need to watch out what we’re doing in gym not

In the gym activities because we don’t want to inadvertently recruit those muscles and tighten them up and cause more discomfort at least temporarily we want to stop doing that and certainly no kegel exercises we want to do the reverse of kegels we want to relax those muscles we want to make sure when we talked about the bowel uh bladder connection we want to

Make sure that the that there’s no constipation present and we want to apply usually some heat to that area we have patients in the bathtub often twice a day especially when they’re not feeling well and does seem to relieve some of the discomfort relax the muscles and to that point we also not in all cases but often apply skeletal muscle relaxants really the corner

Stone of therapy is physical therapy where specialized physical therapists intervene and i can tell you again profound improvements for many patients using very simple techniques and devices as you can see over here i mentioned muscle relaxants and you can see a whole wide assortment of different types of agents that have been used we often use diazepam either

In pill form or in rectal suppository form um but the the and this is a controlled substance uh we tend to use it only because it does tend not to it tends not to cause a lot of fatigue uh but there are lots of other options available in in practice but i really think the take home message here on this particular slide is not not the medications themselves but

The fact that they’re only going to take the edge off none no skeletal muscle relaxant will zip into those pelvic floor muscles and take away pain and just relax those muscles they’re going to hit all the muscles of your body so in order for us to really relax them to a significant degree we’d have to relax all the muscles of the body and then you’d be so fatigued

You wouldn’t be able to function so it’s essentially i always tell patients so like baking a cake it’s a little pinch of this that’s a little pinch of that the muscle relaxants are helpful but you got to do all these other things because the muscle relaxants alone i don’t think are the way to go and also you don’t want to become just i need to continue on and on

And on you would like to use muscle relaxants more or less on an as needed basis as opposed to taking them all the time if at all possible when the that when the level of discomfort really is not we’re not we’re not getting there the patients are either plateauing or we need to do something a little more aggressive sometimes we will reach out to injecting those

Areas with anesthetics uh we can uh botox has been used uh but essentially the the the the take home message here is that we can inject the specific muscle groups and or the nerves in the area to sometimes calm things down and sometimes these injections can give patients uh hours to days to weeks to even months of of pain relief well sometimes simple therapies

Really work well for patients you don’t have to always attack muscles and the prostate directly oftentimes just dietary changes can have a great impact i just wanted to bring to your attention the similarities often found between interstitial cystitis the bladder pain syndrome and cpc-ppps the chronic prostatitis chronic pelvic pain syndrome how simply spicy

Foods acidic foods uh alcoholic beverages and so forth seem to worsen symptoms for not everybody for but for many patients and sometimes dietary changes are reasonable to to move forward with um on the converse side you can see that there are some medications and dietary supplements that can help improve some of the discomfort interestingly many of them are

Directed towards improving bowel function and you can see again that bowel bladder or pelvic pain connection medications that are available for prostatitis tight syndromes uh go from nutraceuticals like quercetin which is a bioflavonoid uh to be pollen all the way down to more traditional medications such as alpha blockers medicines that are typically used for

Prostate enlargement and blockages to uh to dala fill which is a medication when used in low doses uh improves erectile dysfunction to infla anti-inflammatories as we mentioned muscle relaxants uh some of the medicines used for interstitial cystitis like tricyclic antidepressants and even anti-seizure medications so a whole host of different remedies that can be

Used unfortunately none of them are uh fda approved for the treatment of these conditions there are unconventional therapies whether it be acupuncture or extracorporeal shock wave treatment extracorporeal shockwave treatment is something relatively new where little mini waves are given usually through the perineum that region between the scrotum and the anus to

Uh improve pain in certain very selective cases nerve disentrapment surgery can be performed and even prostate massage to may perhaps remove some of the prostatic secretions can have some favorable impact for again a certain group of patients perhaps are not responding to other forms of care but in summary uh as i mentioned earlier earlier on in this symposium

Uh chronic prostatitis chronic pelvic pain syndrome and all these pelvic pain syndromes are much more common than one might imagine uh the symptoms vary quite a bit some patients just have sexual side effects some patients seem to really have a great deal of pain associated with these problems it’s important to keep in mind all of us to keep in mind that these

Problems can have a significant impact on the quality of life we are always looking for pelvic floor dysfunction in patients because that’s a quick simple thing to address and to keep in mind that very simple therapies of course can result in profound improvements so again i thank you for your attention and have a great day

Transcribed from video
Pelvic Pain in Men: Is It Always an Infection? By Interstitial Cystitis Association