Chronic Pelvic Pain in Men

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-Definition

As in the case of women, a significant percentage of men suffer during their lifetime from pelvic pain that is not precisely localised. When the pain is present for a period longer than 3 months, it is called chronic pelvic pain. It is located in the pelvis, perineum or genitals. There may also be pain in the suprapubic area, also in the penis or testicles.
There may also be urinary signs such as dysuria (discomfort in urination) and pain when ejaculating, decreased jet and urinary urgency and even sexual dysfunction, in general there may be tiredness, unexplained muscle and joint pains, in addition sex is usually painful, so they tend to avoid. It is more frequent in youth and middle age. It can be due to the following causes:
-Pelvic Pain due to Chronic Prostatitis:
A percentage of these patients present inflammatory alterations of the prostate, which translate into non-specific alterations of the spermiogram and into specific alterations of the prostate secretions. The diagnosis of chronic pelvic pain in men is complex and requires a thorough diagnostic evaluation. A useful tool for assessing the severity of symptoms is the CPSI (Chronic Prostatitis Symptom Index) score.
Basically, the current classification of the different diagnostic entities is based on the interpretation of the test of the four vessels. This test makes it possible to differentiate between pains whose origin is most likely prostatic or extraprostatic.
The specific treatments of each diagnostic entity must be adjusted according to the findings present in each patient. In spite of the different treatments, in a significant percentage of patients the symptoms tend to recur over time.
-Chronic Testicular Pain:
Pain that affects any of the organs contained in the scrotum, with a duration greater than 3 months. The structures generally involved are: epididymis, prostate and testicle.
The causes of pain are mostly unknown. In some patients there is a history of infectious pictures of epididymis, prostate or testicle, traumas or previous genital surgeries that later evolved into chronic pain. There may be an inflammation caused by a non-infectious origin: autoimmune or neurogenic, dysfunctional evacuation or spasm of the pelvic muscles.

– Case of Chronic Prostatitis:

In the case of chronic prostatitis, painless rectal examination and diffuse symptomatology are accompanied by the difficult isolation of the germ in some cases.
Of the different attempts to isolate the bacteria causing chronic bacterial prostatitis, the only useful method at that time is the so-called Stamey-Meares test, known as the four-vessel test or Stamey test to determine the pathogenesis of chronic prostatitis, since not all of them have a bacterial origin.
Thus, the initial objective was to verify in how many patients there was evidence of an infectious process and in how many of them, in the absence of demonstrable infection, there was an inflammatory process, revealed by recognizable alterations in prostatic secretion, after an intense massage, which allowed the identification, under the microscope, especially the phase contrast microscope, of a greater number of leukocytes than in normal individuals. All of which can be summarized in these two questions: are all chronic infectious prostatitis or are they motivated by an inflammatory process of another nature? Is the accompanying pelvic pain, sometimes the most relevant symptom of these processes, of prostatic origin?.
Stamey and Meares attempted to answer the first question by means of differentiated counting of bacteria and leukocytes in sequential samples, each of them representative of an area of the lower urinary tract, as follows: the initial samples (called M1 and M2) correspond to a few cubic centimetres of urine obtained in the initial phase of urination, the next sample (M3) represents the secretion obtained after an intense prostate massage, the next sample (M4) is obtained from urination after massage.
The result of these differentiated studies of sequential samples was based, more than on absolute values of bacterial counts or leukocytes, on the quantitative differences observed in the different samples, understanding that a greater number of bacteria or leukocytes in the latter directed towards an infectious process, simply inflammatory, or absence of any inflammation.
Chronic bacterial prostatitis is characterized by the presence in the prostatic fraction (EPS), postmasage urine (M3) or semen of one or more gram (-) bacteria that do not grow in the initial (M1) or middle (M2) fractions, or higher colony counts.
If the EPS or postmasage fraction (M3) is cultivated because NPML (nuclear polymorphous leukocytes) have been evidenced under the microscope and no germs grow, these cases are catalogued as abacterial prostatitis.
In an additional category are catalogued the patients who present themselves afflicted with the same symptoms, absence of LPMN in the fresh examination to the microscope of the EPS, negativity of the cultures and it in repeated investigations: in this case we speak of prostatodinia. Sperm culture alone is useful if it is positive.

-Pudendal nerve entrapment:

Also known as Alcock channel syndrome, it is an uncommon source of chronic pain, in which the pudendal nerve (located in the pelvis) is trapped or compressed. The pain is positional and worsens when sitting. Other symptoms include genital numbness and urinary dysfunction.
The term pudendal neuralgia (PN) is used interchangeably with “pudendal nerve entrapment,” but a 2009 review study found that “the prevalence of PN is unknown and appears to be a rare event” and that “there is no evidence to support matching.” The presence of this syndrome with a diagnosis of pudendal nerve entrapment “means that it is possible to have all the symptoms of pudendal nerve entrapment are not due to actual compression.

-Conclusions:

It is essential for these patients to have a complete clinical evaluation, including a scrotal ultrasound to rule out any type of malignant pathology (e.g. testicular tumour). Once the diagnosis has been made and correctable causes have been ruled out (e.g. infections, inguinal hernias), the first line of treatment is anti-inflammatory. In extreme cases, surgical treatments, such as microsurgical denervation of the spermatic cord, seek to cut the nerves that cause pain, providing a definitive solution. The success rate of this surgery is 75-80% and requires to be done by a specialist with experience in microsurgery.
The treatment options are multifactorial, taking into account the impact on the relief of pain and sexual function. Some measures are usually: local thermotherapy, moderate exercises such as walking, swimming, stretching and yoga, antibiotics, only in cases where there is an infectious cause, alpha adrenergic blockers and muscle relaxants. In some cases, tricyclic and gabapentinoid psychotropes are useful.

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