The European Association of Urology considers that chronic pelvic pain is that located in the pelvic area, genital area (scrotum / penis / vulva), inguinal region and perineum, which persists for at least 3 months. Some international societies consider any persistent pain lasting more than 6 weeks to be chronic pain.

However, beyond the question of the time of evolution of pain, the problem is that it is a symptomatic condition that can be due to multiple causes and come from different organs or tissues of the pelvis in the absence of an acute injury and is often associated with changes in the central nervous system that causes phenomena of excess sensitivity that we call hypersensitivity (when the pain is amplified in its intensity, duration or body territory affected) and allodynia (when we perceive as painful sensations that usually should not be, for example touch). All this is also associated with a profound impact on the affective and emotional sphere, as a result of such prolonged and sometimes intense pain.

It is important to understand that when we talk about pelvic pain syndrome we refer to a picture whose cause is not identified. In order to exclude causes that may cause pain, in addition to a systematic and exhaustive physical examination, various more or less invasive examinations (as the case may be) can be performed:

Urine, semen or blood tests
Urinary cytology
Urinary, gynecological, or testicular ultrasound
Pelvic CT scan
Pelvic resonance
Lumbosacral spine resonance
3T resonance of puddendos and pelvic muscles
Cystoscopy
Gynecologic laparoscopy
Neurophysiological studies of sacral roots
Diagnostic nerve and nerve root blocks

In general, scans seek to EXCLUDE pathology, especially tumors, as a possible cause of pain.

Unfortunately, studies are often completely normal, which does not allow us to find a cause to which to attribute pain, however, their realization allows us to exclude the possibility that there is some serious disease. Right now we talk about “chronic pelvic pain syndrome.” The pain is real and so are its consequences, but there is no identifiable cause to treat. It can be perceived in different areas, and we can attribute it to different tissues or viscera of the pelvis such as the bladder (we speak then of bladder pain syndrome), the prostate (prostate pain syndrome), the vulvar region (vulvodynia), the scrotum (chronic scrotal pain syndrome), etc.

Other times there is, as a cause or consequence of the existing pain, a contracture also painful, of the muscles of the pelvis that must be identified and treated properly. There may also be an involvement of the nerves responsible for the sensitivity of the area, especially the pudendal nerve. It should be clarified that the existence of pain of pudendal origin does not mean that there is a nerve entrapment syndrome, which is a specific and very rare disease, which has its diagnosis and may sometimes require surgical release treatment.

What is important to understand, when we talk about chronic pelvic pain syndrome, is that it is only a picture of pain and that the disease is pain itself. Because the different organs and tissues of the pelvis, its muscles and nerves are so interconnected with each other, pain can be perceived in one or many areas and involve only one or more of them. During the diagnosis our mission is to:

Rule out major diseases that may cause pain (especially tumors).
Identify which organs, muscles and nerves are involved and prescribe specific treatments: drugs, infiltrations of nerves or muscles, instillations in the bladder, physiotherapy treatments, treatments in the pain clinic, etc.
Assess if there are phenomena that indicate that there may be a centralization or amplification of pain caused in the central nervous system to try to mitigate it.
Evaluate the emotional impact and propose (often an essential complement) a psychological support, because all pain maintained over time inevitably causes emotional consequences that must be controlled by the specialists who know them best.

Treatments, like diagnosis, are not simple and sometimes not without side effects. We try to administer them in a progressive way to assess their effectiveness and tolerance and they are prescribed in a very personalized way because as already indicated, chronic pelvic pain syndrome is a very heterogeneous painful entity and each person requires individualized treatment and has a different way of responding to each drug.

As it is a chronic pathology, without clear cause and even imprecise when identifying the specific origin of the pain, treatments are mainly aimed at relieving the symptom and usually long treatments are prescribed that offer slow and sometimes scarce relief. They are, therefore, complex pictures in their diagnosis and treatment, but in no case do they hide a cancer or a serious illness (which will have already been excluded with the examinations performed), beyond the importance of pain in itself and the impact it may have on the life of the person who suffers from it.

Prostate pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a syndrome characterized by localized pain in the perineum, suprapubic area, and external genitalia accompanied by variable problems in urination or ejaculation. It is considered that prostatitis globally is very prevalent (11-16% according to the Anglo-Saxon literature) and up to 50% of men in the 50s will have presented some episode of prostatitis in their lives.

The terminology review carried out during the Annual Congress of the International Continence Society (ICS) and the ICI (International Consultation on Incontinence) held in Tokyo in 2016 establishes that the pathology should be referred to as “Prostate pain syndrome”.

It is important to note that the concept “chronic” refers to the time of evolution of pain (more than 6 months), not to the prognosis.

With the new classification of prostate problems appeared in the 90s, there was a change in the vision of CP/CPPS by including a type III of non-infectious prostatic involvement that was subdivided into a group IIIa if there were inflammatory changes and IIIb if it was only a painful picture without inflammatory manifestations.

Chronic prostatitis also includes those of infectious cause, which would be included within group II. Patients presenting with chronic prostate pain should be studied for a possible infectious cause and once this etiology has been ruled out, antibiotic treatments should be excluded, although it should not be ignored that patients with chronic non-infectious prostatitis may present with superinfections that are more a consequence than a cause of pain.

During the evaluation of these patients, validated questionnaires such as the NIH-CPSI (National Institutes of Health Chronic Prostatitis Syndrome Index) are used, which constitute a good reference to assess the symptomatic impact and quality of life of patients with CP/CPPS as well as being useful in monitoring the response to the treatments administered.

There is no single cause responsible for the development of this disease, in fact in many cases it is impossible to determine a specific cause. Infectious factors, dysfunctional emptying (obstructive urination) causing intra-prostatic reflux of urine, inflammation resulting from autoimmune responses or neuromuscular disorders have been implicated.

The absence of a specific cause and the non-specific symptomatology, together with the fact that it involves various organs and tissues of the pelvis, requires a study that rules out confusing pathologies or finds a potential cause of pain. The physical examination is undoubtedly the key piece that will later be complemented with different analytical studies (urine, blood and semen), radiological (ultrasound, tomography or pelvic and lumbosacral spine resonance) and even functional studies such as flowmetry or complete urodynamic study.

The lack of specific knowledge about each particular case of CP/CPPS motivates the use of a potpourri of empirical treatments, without concrete planning and with often insufficient responses that cause frustration in patients and doctors.

The increased prevalence of sexual dysfunction in even young patients with CP/CPPS suggests that not only should it be sought in all patients with CP/CPPS, but also that there may be pathophysiological mechanisms common to both pathologies.

CP/CPPS is a painful syndrome of the pelvis but can be accompanied by neurological or psychological problems that transcend the pelvis. It can also be associated with other painful or dysfunctional syndromes such as irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome.

The best approach to diagnosis and treatment in CP/CPPS is based on typing following the UPOINT pattern (described by Shoskes in 2009). Following the UPOINT phenotype, two predominant subgroups are identified: a “pelvic” group with a predominance of urinary symptoms, and other pelvic organs and myofascial involvement and a second “systemic” group with neurological involvement, infectious factors and psychosocial disorders. There is a cross-relationship between the nerves of the digestive and genitourinary system that makes possible an interrelation of symptoms of one and another systems and can justify that diseases of one induce symptoms in the other and vice versa. There is also scientific evidence implicating neuroinflammation phenomena in the genesis of CP/CPPS. The detection of increased levels of pain and inflammation mediators in these patients supports these theories. Evidence supporting the autoimmune theory has also been found in some patients.

Epidemiological studies show a higher prevalence of hypertension and risk of cardiovascular disease in addition to a different pattern of psychological response in patients with CP/CPPS probably as a consequence of the same pain and dysfunctional stress response.

Given the complexity of the pathology that affects different areas, it is important to properly identify those involved in each patient in order to establish a personalized therapeutic strategy as complete as possible. In this sense, typification has progressively become more relevant, following the UPOINT pattern that directs in a more systematic way the areas to be treated and that includes genitourinary alterations, psychosocial, organ-specific, inflammatory-infectious, neurological and myofascial alterations.

Within the therapeutic arsenal there is modification of habits and particularly diet, antibiotics, anti-inflammatories (corticosteroids or not), modulators of neuronal sensitivity, antidepressants, myorelaxants and sedatives, relaxing drugs of the prostatic smooth muscles and alpha sympathetic receptors, physiotherapy that includes manual myofascial therapy, radiofrequency, correction or readjustment of body static, Cancellation of trigger points, osteopathic treatments, injection of corticosteroids, anesthetics or botulinum toxin. Alternative therapies aimed at stress control and muscle relaxation, mindfulness and cognitive pain management, acupuncture, etc. And finally and in very specific and limited circumstances the surgery that includes the release of nerve compressions.

Chronic pelvic pain are complex entities that require a diagnosis and treatment process that can extend over time. Many of the treatments are prescribed in an “empirical” way to prove their usefulness and for this reason it takes time to evaluate their effectiveness. Not all treatments are equally useful in each patient and there are no patterns of conduct in terms of diagnosis or treatment that can be generalized to all patients. It is the doctor who must plan the behavior to follow in conjunction with the patient according to their symptoms, their preferences, and their tolerance.

Chronic neuropathic scrotal, penile and testicular pain syndromes

Neuropathic involvement responds to a similar pathophysiological pattern regardless of the organ, viscera or tissue that finally manifests the painful symptom.

Often the nervous affectation is a consequence of a compressive problem that generates degenerative changes in the sensory neurons which triggers different chronic pains. Depending on the nerve involved or the specific branch of it, the territory that will manifest the pain will be different.

It is often the pudendal nerve that is affected in its main trunk (especially as it passes between the sacrosciatic and sacrospinatus ligaments or through Alcock’s myofascial duct) or any of its branches (posterior or anal, middle or perineal and anterior or penile). Its involvement, either compressive or simply as a manifestation of a pathological transmission of painful information (neuralgia) translates into anal, perineo-scrotal or penile pain. However, there are other nerves likely to cause pain related to the genitourinary area of the male: iliohypogastric, ilioinguinal and genitocrural. These are pains of neuropathic characteristics with burning sensation, paresthesias or tingling sensation referred to the pubic area and skin of the penile, scrotal and perineal area. Usually these pains are the result of entrapment in scar areas (usually after abdominal or groin surgeries) but can also be caused by other pathologies such as polyneuropathies, diabetic neuropathy, chemotherapy or after an infection by the herpes zoster virus.

Inguinal hernia correction surgery or vasectomies can cause entrapment or compromise of the sensory nerves that innervate the epididymis and testicle causing entrapment neuropathy or pathological neural scarring (neuromas). Similarly, non-compressive neuralgia is possible as a consequence of infections (genitourinary tuberculosis, chronic bacterial, viral or fungal infections), chronic ischemic disorders or in the context of other generalized neuropathies when not of unknown origin (idiopathic).

However, there is a neuralgia caused by a response of the nerves of the sympathetic vegetative nervous system as a response usually to a painful problem in some viscera. This manifestation is part of the so-called complex regional pain syndromes (type 1 if there is no nerve injury and type 2 if there is). This sympathetic manifestation causes in addition to pain, changes in the territory involved in the form of edema (swelling), erythema (redness), atrophy, exudation or sweating. The sensation of inflammation and edema in the glans and urethral orifice falsely suggests an infection, particularly a sexually transmitted disease that is repeatedly pursued without success motivating countless antibiotic treatments, corticosteroids etc. whose ineffectiveness generates frustration, uncertainty, anxiety and distrust.

Epididymal and testicular involvement is another manifestation of pain of vegetative origin. This type of persistent and disabling pain sometimes also suggests infections or undiagnosed tumors. The response to conventional analgesics, anti-inflammatories and antibiotics is very poor. The treatment of these neuropathies does not differ from the treatment of any other neuropathic pain: pharmacological neuromodulators (tricyclic antidepressants, antiepileptics), morphic analgesics, nerve blocks and scar infiltration with anesthetics and corticosteroids, electrical neuromodulation and nerve release surgery.

It is the task of the doctor to perform the pertinent examinations in order to rule out potentially causing pathology, identify the affected nerve and assess the most appropriate therapeutic sequence.

Dr. Eduardo Vicente Palacio
Uros Associats