What's in a name? Sometimes referred to as prostatitis, chronic pelvic pain syndrome is really a condition onto itself. Men who have either problem may suffer from groin pain, urination difficulties and even erectile problems. But instead of bacterial infections that are clearly linked to prostatitis, the causes of pelvic pain syndrome are unknown. And there is no simple antibiotic that can ease symptoms.
What is chronic pelvic pain syndrome?
It's a pain syndrome, and although prostatitis is a name that is used by lay people, we tend to call it chronic pelvic pain syndrome to be more accurate. The name reflects the fact that we don't know exactly where the pain is coming from, and in some cases it could be from the prostate, but not necessarily. The prostate may or may not be involved.
What are the main symptoms?
Chronic pelvic pain syndrome causes pain in the pelvic region with or without urinary symptoms, such as an urgency or frequency in the need to go to the bathroom.
How common is chronic pelvic pain syndrome?
The estimates vary depending where you are, but anywhere from two to six percent of men in different parts of the world have chronic pelvic pain.
Do we know what causes chronic pelvic pain?
In general, there are more white blood cells on average in a patient's prostatic fluid, but it's not a clear-cut point. I think one of the more interesting observations is that cytokines, which help control inflammation and can actually attract white blood cells to organs, are found in greater amounts in the prostatic fluid of some men with this condition. That suggests that maybe the prostate is a component of the syndrome.
These cytokines are similar to ones that would draw white blood cells to the joints and cause arthritis. So there may be logical explanations of why some men to have these pelvic pain symptoms.
How do you diagnose chronic pelvic pain syndrome?
The diagnosis is self-made. There is a questionnaire we use to quantify the symptoms. By definition, a syndrome is not a disease. It's not like a tissue diagnosis or a blood test.
Is there any way to treat it?
There's no effective therapy at this point. In the controlled studies that we've done, most notably the one where we gave patients an antimicrobial or an alpha blocker [antibiotics like Cipro or high blood pressure medications like Cardura], the patients did not show any improvement. Now, the negative aspect of the study was that we chose men for the study who had already been exposed to those drugs, and they had pretty severe symptoms. So, it's possible that those drugs may benefit some men who have the earlier onset of the condition.
Hence, if you talk to a patient, he may say, "Gee, I had a mild case of prostatitis and I took some Cipro or something, and I feel much better." That person probably is telling the truth, and he may have had prostatic infection or inflammation that responded because he was treated early. New studies are being launched that are going to look at men with an earlier onset of symptoms to see if antimicrobials or alpha blockers may benefit them.
Pain medicines are being tested as well. If you can't eradicate the problem, but you can at least get rid of the pain, then you've done the patient a service.
Does this syndrome clear up over time?
It can, but evidence shows that it tends to persist.
How difficult is it to live with?
The discomfort and impact of chronic pelvic pain syndrome is as great as it is for things like arthritis and cardiovascular disease. It has a significant negative impact, and it often exceeds the negative impact that you see with chronic, well-defined conditions.
Can it affect a man's sex life?
Sexual symptoms are sometimes associated with this condition. For example, there can be ejaculatory pain. In some cases, chronic pelvic pain syndrome can be a clue that there may be ejaculatory duct obstruction, which, for example, could be a treatable cause of chronic pelvic pain syndrome. But those are unusual cases. I have patients who feel better after ejaculation and those who feel worse.
So, ejaculating more can help?
Well, what you need to know is that, in a nutshell, no one knows what to do. There are a lot of theories, and a lot of people have supported different ideas. But I think the safe thing to say is, if it works for you and it's safe, it's all right to do it. So, anything from ejaculating more or less, to drinking wine or not drinking is pretty much dependent upon the patient's response.
How do you manage patients with chronic pelvic pain?
We first rule out things we can identify and treat, like infection or obstruction. Then, if those things are all negative and you have the syndrome, you're left to try to treat experimentally. Based on the patient's history, you may elect to try some things.
I think if you go about it in an open way and tell the patient, "We're going to try a reasonable course for this drug." And if he does get better, even if it's a placebo effect, you could still argue that it's worthwhile because he's better. But I'm not in favor of long-term medications that can have side effects without showing any measurable improvement.
Are there any lifestyle measures that can help?
Riding a bike can cause perineal nerve discomfort, so that's something that can be changed. I try to figure out what's bothering the patient and make suggestions as to correct it. But it's just common sense. Eliminate the causative problems.