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PROSTATIC PAIN SYNDROME


Semir A. S. Al Samarrai

 

Chronic Pain in the region of the Prostate, is in 90% of the cases with no proven infection of the prostate gland or other obvious pathology.PPS should classified by only 10% of the cases with preven bacterial infection.(1,2)

The definition of the Prostatic Pain Syndrome is the occurrence of Persistent or recurrent episodic pain in the region of the prostate over at least 3 out of the past 6 months, which is convincingly reproduced by prostate palpation. (3) There is no proven infection or other obvious pathology.

The Pain is the main symptom in PPS. As a common feature of chronic pain syndrome, no single etiological explanation has been found. (5)

One explanation (5) is that the condition probably occurs in susceptible men exposed to one or more initiating factors, which may be single, repetition or continuous.

Several of these potential initiating factors have been proposed, including

Infection
Genetic
Anatomical
Neuromuscular
Endocrine
Immune (including autoimmune)
Psychological mechanisms

These factors may then lead to a peripheral self-prepetuating immunological inflammatory state and/ or neurogenic injury, creating acute and then chronic pain. (6)

Based on the peripheral and the central nervous system, sensitisation involving neuroplasticity may lead to a centralized neuropathic pain state. (5) 

This could also explain why tissue damage is not usually found in PPS.There is growing evidence for a neuropathic origin and association with central nervous system changes of pain found in PPS.

In the systematic review of the literature, the population-based prevalence of prostatitis symptoms was found to be 8.2%. (6) The risk of prostatitis increased with age (men aged 50-59 years had 3.1-fold greater risk than those aged 20-39 years) (1)

Diagnosis:

Prostate pain syndrome is a symptomatic diagnosis, which is diagnosed from history of pain perceived in the region of the prostate (convincingly reproduced by prostate palpation), and absence of other lower urinary tract pathology, for a minimum of 3 out of the past 6 months.

This implies that specific disease-associated pelvic pain caused by bacterial infection, urogenital cancer, urinary tract disease, urethral stricture, and neurogenic disease of the bladder must be ruled out.A thorough history is an important first step in the evaluation of prostatic pain and localization. Pain is after reported in other pelvic areas outside the prostate such as perineum, rectum, penis, testicles and abdomen.(7)

In addition, associated lower urinary tract symptoms (LUT’s), sexual function, psychological, social and economic factors should be addressed. (1)

There is no single “Gold Standard” diagnostic test for PPS, therefore, procedures are on the one hand directed towards identification and exclusion of specific diseases associated with pelvic pain, and on the other hand may be used for phenotypic description.Physical examination includingdigital rectal examination should be carried out, muscle tenderness and trigger points in the pelvic floor may be palpated. Measurement of resting urine by ultrasound should exclude incomplete voiding.(1)

Prostatic specific antigen (PSA) testing does not help to diagnose PPS but can exclude prostate cancer in patients at risk. Laboratory diagnosis has been classically based on the four-glass test for bacterial localization. (8)Besidessterile pre-massage urine (voided bladder urine-2) PPS shows < 10,000 cfu of uropathogonic bacteria in expressed prostatic secretions (EPS) and significant numbers of leukocytes or bacterial growth in ejaculates, but the two-glass test or pre-post-massage test(PPMT) are diagnostically efficience and may enhanced cost effectively by this simple screening procedure (9), PPMT was able to indicate the correct diagnosis in >96% of patients.(10)Overall, these tests help only a little in the diagnosis of PPS, because 8% of patients 

with suggested PPS have been found to have positive prostatic localization cultures, similar to the percentage of asymptomatic. (11)

In PPS, urodynamic studies should be considered in patients with significant LUTS. They may demonstrate decrease urinary flow rates, incomplete relaxation of the bladder neck and prostatic urethra, as well as an abnormally high urethral closure pressure at rest. The external urethral sphincter maybe dysfunctional (non-relaxing) during voiding (12). As for non-PPS cases, cystoscopy maybe considered for further evaluation of micturation symptoms to exclude bladder outlet or urethral pathology, or if haematuria or infection has been found to excludeintravesical pathology.

Treatment

As a result of the multifactorial origin of PPS, one reason for treatment failure may be the heterogeneity of the patient population. Thus, one strategy for improving treatment effects may be stratification of patient phenotypes. Monotherapeutic strategies for the treatment of PPS may fail (13), therefore, most patients require multimodal treatment aimed at the main symptoms, and taking comorbidity into account.

1) Alpha-blockers i.e terazosin (14, 15) alfuzosin (16) doxazosin (17, 18) and tamsulosin (19) are effective in the treatment of PPS, because of the improved outflow performance by blocking the alpha-receptors at the bladderneck and prostate and by direct action on alpha IA/ID receptors in the central nervous system (CNS) (19).
2) Antibiotic therapy: Overall; antibiotic treatment of PPS is based on weak evidence. It may be speculated that that patients profiting from antibiotic treatment have some unrecognized uropathogens if antibiotics one used, other therapeutic options should be offered after one successful course of a quinolone or tetracycline antibiotic over 6 weeks.
3) Anti-inflammatory drugs: Overall, a moderate treatment effect has been shown for anti-inflammatory drugs, but larger studies should be done for final confirmation, and long term side effects have to be taken into account. (1)
4) Phytotherapy: The effect mainly based on a significant effect on pain. Quercetin, a polyphonic bioflavonoid has been provided with documented antioxidant and anti-inflammatory properties. Overall response rate in network- analysis was in favour of the phytotherapy. (1) 
5) Botulinum toxin A (BTX-A)
Botulinum toxin A may have pain alleviating effects through non-neuromuscular action on afferent nociceptive pathway. Local treatment with periurethral injection of BTX-A (200u) has been tested in a small pilot study with improvement in pain and changes in urethral pressure profile. (20) However, patient number was too low and follow-up was too short to know definitive conclusions. (1)
6) Surgical Management:
Surgical management including transurethral incision of the baldderneck, radical transurethral resection of the prostate, or in particular, radical prostatectomy has been a very limited role and requires an additional specific indication.
7) Psychological treatment:
It is of note that QoL decreases as symptoms increase. Tripp et al (21) have completed a feasibility trial, which represent the only known account of psychological treatment. Their 8-h intervention improved pain, catastrophising, and QoL, but not depression or some urinary symptoms.

References:

1. Engeler D, Baranowski AP, Elneil S, et al: Guidelines on Chronic Pelvic Pain 2012
http:/www.urowe.org/guidelines/online-guidelines/.
2. De la Rosette JJ, Hubregtse MR, Meuleman EJ, et al. Diagnosis and treatment of 409 patients with prostatitis syndromes. Urology 1993 Apr;41(4):301-7.

3. Tripp DA, Nickel JC Wang Y, et al. Catastrophizing and pain-contingent rest predict patient adjustment in men with chronic prostatitis/chronic pelvic pain syndrome. J Pain.2006 Oct;7(10):697-708.


4. Nickel JC.Prostatitis: myths and realities. Urology. 1998 Mar;51(3):362-6.

5. Nickel JC, Baranowski AP, Pontari m, et al. management of men diagnosed with prostatitis/chronic pelvic pain syndrome who have failed traditional management. Rev Urol. 2007;9(2):63-72.

6. Krieger JN, Lee SW, Jeon J, et al. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008 Feb;31Suppl 1:S85-90.

7. Litwin MS, McNaughton-Collons M, Fowler FJ Jr, et al. The National Institutes of Health chronic prostatitis symptoms index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999 Aug;162(2):369-75. 

8. Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and uretritis. Invest Urol 1968 Mar; 5(5):492-518.

9. Nickel JC. The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol 1997 Spring;3(1):38-43.

10. Nickel JC, Shoskes D, Wang Y, et al. How does the pre-massage and postmassage 2-glass test compare to the Mears-Stamey 4-glass test in men with chronic prostatitis/ chronic pelvic pain syndrome? J Urol 2006 Jul;176(1):119-24.

11. Nickel JC, Pontari M, Moon T, et al; Rofecoxib Prostatitis Investigator Team. A ramdomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis. J Urol 2003 Apr;169(4):1401-5.

12. Zermann DH, Ishigooka M, Doggweiler R, et al. Neurological insights into the etiology of genitourinary pain in men. J Urol. 1999 Mar;161(3):903-8.

13. Nickel JC, Narayan P, McKay J, et al. Treatment of chronic prostatitis/chronic pain syndrome with tamsulosin: a randomized double blind trial. J Urol 2004 Apr;171(4):1594-7.

14. Chear PY, liong ML, Yuen KH, etal.Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized, placebo controlled trial. J Urol 2003 Feb; 169(2):592-6.

15. Gül O, Eroglu M, Osok U. Use of terazosine in patients with chronic pelvic pain syndrome and evaluation by prostatitis symptom score index. IntUrol Nephrol.2001;32(3):433-6.

16. Mehik A, Alas P, Nickel JC, et al. alfozosin treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, ramdomized, double-blind, placebo controlled, pilot study. Urology 2003 Sep;62(3):425-9.

17. Evliyaoglu Y, Burgut R. Lower urinary tract symptoms, pain and quality of life assessment in chronic non-bacterial prostatitis patients treated with alpha-blocking agent doxazosin; versus placebo. IntUrolNephrol 2002;34(3):351-6.

18. Tugcu V, Tasci Al, Fazlioglu, Gurbuz G, Ozbek E, Sahin S, Kurtulus F, Cek M. A placebo-controlled comparison of the efficiency of triple- and monotherapy in category III B chronic pelvic pain syndrome (PPS).EurUrol 2007 Apr; 51(4):1113-7;discussion 1118.

19. Nickel JC, Downey J, Pontari MA, et al. A randomized placebo-controlled multicentre study to evaluate the safety and efficacy of finasteride for male chronic pain syndrome (category IIIA chronic nonbacterial prostatitis). BJU Int 2004 May;93(7):991-5. 

20. Zermann D, Ishigooka M, Schubert J. Perisphincteric injection of botulinum toxin type A. A treatment option for patients with chronic prostatic pain?Eur Urol. 2000 Oct;38(4):393-9.

21. Tripp DA, Nickel JC, Katz L. A feasibility trial of a cognitive-behavioural symptom management program for chronic pelvic pain for men with refractory chronic prostatitis/chronic pelvic pain syndrome. Can UrolAssoc J. 2011 Oct;5(5):328-32.

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae