Introduction

Urologic disorders and pelvic pain present an obvious relationship. A large proportion of the human population has endured pain or discomfort of a simple urinary tract infection. And one of the earliest adventures in human surgical intervention arose in the centuries BC as the Greeks ‘cut for stone’ to relieve the obstruction and pain of urinary bladder calculi. However, now that most of the urogynaecologic organ maladies of infection, neoplasia and obstruction are understood, we are still left with a noisome bag of discomforts lacking any clear pathogenesis. These are the urologic chronic pelvic pain syndromes (UCPPS). The majority of these conditions arise from either a possible urinary bladder source known as bladder pain syndrome/interstitial cystitis (BPS/IC) or prostate source known as prostate pain syndrome (PPS), named chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in the United States. The European Association of Urology attempted to update and provide a classification of pelvic pain disorders to suggest avenues for further management (Fall et al. 2010). Their pelvic pain descriptions fit into neat little boxes of urological, gynaecological, anorectal, neuromuscular and ‘other’ categories. These non-malignant pain conditions or syndromes perceived in structures related to the pelvis of both males and females do not deserve more specific diagnoses because the aetiology and pathogenesis remains a mystery – ‘a riddle wrapped in a mystery inside an enigma’ – and we depend on a complex symptomatic analysis to help guide us in evaluation and therapy. Regrettably the final common pathway often defaults as a referral to a pain management team. While awaiting elucidation of the cellular and molecular pathogenic mechanisms of UCPPS, we should rely on a diagnostic and therapeutic algorithm to direct logical evaluation and multimodal management. We must develop alternative ways of thinking about managing these urologic pain conditions. UCPPS needs to be viewed as much more than an organ-specific disease, but rather as a biopsychosocial disorder. The central problem is pain. Traditional biomedical treatment for UCPPS has failed (Anderson 2006). Antibiotics, α-blocking agents and anti-inflammatory agents as well as virtually all other pharmaceuticals have shown unimpressive outcomes in ameliorating the effects of these disorders. The biopsychosocial model of this condition rather than the biomedical model holds the key to understanding the pathogenesis and possible future treatments. Phenotyping is one current trend and we recommend it for approaching patients with these disorders allowing specific guideline development for multimodal therapy (Baranowski et al. 2008, Nickel et al. 2009, Shoskes et al. 2009). Some of the recent developments and approaches arose from clinical investigation and treatment protocols supported by the National Institutes of Health (NIH) in the United States over the past 10 years. A descriptive phenotyping classification allows understanding of epidemiology, aetiology and potential design of randomized clinical trials. Clinically identifiable domains suggested include: urinary, psychosocial, organ specific, infection, neurological/systemic and muscle tenderness (Nickel & Shoskes 2009, Shoskes et al. 2009) (Table 12.1).

Table 12.1 Percentage of patients with specific myofascial trigger point tenderness

The early chapters of this book present a diverse range of symptoms and describe multiple aetiological possibilities for chronic pelvic pain (CPP). The aim of this chapter is to review evidence regarding urologic conditions associated with pelvic pain, provide a description of good urologic evaluation, and focus on one specific management approach involving manipulation of the pelvic floor neuromuscular tissue using both physiotherapeutic and psychological maneuvers (the Wise-Anderson Stanford Protocol).

Urologic diagnostic evaluation

Prostate pain syndrome

Chronic prostatitis is an incorrect label; we are dealing with a variable set of pain conditions with no objective markers and multivariate symptoms. The disorder is not prostatocentric symptomatology and pain sites exist between the umbilicus to above the mid thigh. The European Community has promoted the term prostate pain syndrome (PPS) as a more generic term over the NIH category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Still, it smacks of a prostatocentric approach, which is probably to be avoided for lack of evidence, and it encourages the use of antibiotics as standard therapy that clearly lacks efficacy. By definition, PPS is persistent discomfort or pain in the pelvic region with sterile specimen cultures and either significant or insignificant white blood cell counts in prostate specimens: semen, expressed prostatic secretion or urine collected after prostate massage. There does not appear to be any diagnostic or therapeutic advantage to differentiating between those patients with significant or insignificant leucocytes from the prostate (Schaeffer et al. 2002); however, in the author’s experience, men with no prostate inflammation appear to suffer greater degrees and longer duration of pelvic pain on average.

Medical history

The typical patient is a young to middle-age man with variable symptoms of chronic, irritative and obstructive voiding accompanied by moderate to severe pain in the pelvis, low back, perineum and genitalia. To qualify as CPP the condition should occur for longer than 6 months and, for research purposes, continuous within the previous 3 months. The healthcare burden of PPS is exemplified by approximately two million physician office visits per year in the United States. It is one of the most common genitourinary diagnoses in men under the age of 50 years. The urologist’s first order of business when referred such a patient is to accept the challenge seriously and treat the man suffering with this condition with respect, interest and compassion. The patient is understandably tense, wary and defensive, having encountered frustration and rejection previously. The physician should listen to the patient’s complaints and accurately document the circumstances surrounding the onset of the disorder – sensory descriptions, various treatment modalities and outcomes, noting particularly the time course of events and associated triggers that may have caused a flare in his symptoms. The US national cohort study by the NIH reported a typical duration of patient complaints averaging 4 years.

The urologist evaluating pelvic pain in a male must rule out associated urinary bladder or prostate diseases. Errors in diagnosis and inappropriate therapeutic pathways may ensue if less than a systematic evaluation is undertaken. Both prostate and bladder cancer as well as urinary calculus disease have been missed because of an inappropriate diagnosis of ‘chronic prostatitis’. It is crucial to have empathy for the suffering patient, documenting his description of the physical characteristics of the pain complex: what makes it worse, what helps, where is the pain referred, and what associations exist with sexual function? The psychosexual behaviour and influence of sexual partner relationships play a significant role. How has the chronic pain affected libido, the ability to attain adequate penile erections, accomplish intercourse, reach orgasm and have pleasurable ejaculation? Associated alimentary tract complaints such as irritable bowel disorder, constipation, dietary exacerbations and bowel function may point to further clarifying aspects of the disorder. Further, the psychosocial medical history should probe for genetic or acquired personality types: tense, anxious, chronic tension-holding patterns, possible childhood issues of sexual or physical abuse, traumatic toilet training, abnormal bowel patterns, teen sexual problems, excessive masturbation, suppressed homosexuality, excessive weight lifting, gymnastic manoeuvres and activities such as dance training. Identifying such issues helps to create a specific phenotype of the pain condition and may ultimately suggest appropriate multimodal therapy.

We utilize symptom questionnaires and validated instruments to detail patient psychological issues. These tools help quantify the baseline, eventual progress and outcome of our management techniques. The most widely used research tool is the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). An alternative type of CPPS symptom questionnaire – the Pelvic Pain Symptom Score (PPSS) – has also been useful in our hands. The PPSS expands the description of named painful anatomical locations and grades the severity of pain (0 to 4+); it includes urinary symptoms that mimic the International Prostate Symptom Score (IPSS), and scores sexual dysfunction aspects of the patient condition as a separate domain. Our group utilized this questionnaire in the treatment outcome analyses of pelvic floor therapy (Anderson et al. 2005, 2006). We have also used other psychosocial instruments including Brief Symptom Inventory, Beck Anxiety, and Perceived Stress Scale to study neuroendocrine psychiatric influences associated with CPPS (Anderson et al. 2008).

Physical examination

After carefully documenting a thorough medical history of the pelvic pain, it is time to examine the patient. He should be informed that the examination is discovery in nature and will be gentle and avoids any exacerbation of the existing discomfort. The patient removes all clothing from the waist down and assumes a dorsal lithotomy position with the legs spread and heels in the stirrups (as in a female examination). The abdominal exam is easily accomplished under these circumstances. Prior to a prostate examination and massage we palpate the pelvic muscles seeking actual trigger points (TrPs) or specific discomfort zones, particularly the endopelvic muscles and tissue surrounding the prostate. Examination in this position allows palpation of the suprapubic region over the sigmoid bowel, bladder and rectus abdominis and oblique muscles. With the physician sitting at the foot of the examining table the genitalia, spermatic cord and anal areas are inspected. The pull-out extension of the examining table allows the examiner to have elbow leverage for internal pelvic muscle palpation and direct visualization of the penis and the urethral opening to collect prostatic fluid. We find it convenient and efficient to collect the fluid with a sterile glass pipette, the prostatic secretion drops accumulating with capillary action as they appear at the penile meatus; very important when only one or two precious drops are visible to examine and culture. We typically ask the patient not to urinate prior to the examination. This allows palpation of the partially full bladder and tenderness may be found. Furthermore, the patient should void a small amount of urine after a prostate massage to collect prostatic fluid by centrifugation if none is expressed and to provide a culture and sensitivity specimen.

In our evaluation at Stanford, as do most urologists, we examine the prostate for gland consistency, whether it is soft or ‘boggy’, whether there are areas of induration or hardness – this may represent fibrosis or scarring from previous inflammation – but we must remain ever vigilant for adenocarcinoma. It would not be appropriate to massage a prostate gland containing cancer. After checking muscles and tender points, we methodically massage the prostate gland, beginning at the base and milking it toward the centre on each side to express prostatic fluid into the urethra. The prostate is composed of 20–30 small microscopic tunnels (acini) emanating from the periphery of the prostate. Each glandular unit is connected to the outside world by a tiny duct that opens into the urethra on each side of the primary seminal vesicles’ ejaculatory duct in the centre of the prostate – the verumontanum. These tiny prostate ducts expel the enzyme-rich prostatic secretion with smooth muscle prostate contractions at the time of sexual ejaculation. Once the prostatic fluid has been collected, the patient then voids a small volume to provide a washout of prostatic fluid that can be separated, analysed and submitted for bacterial culture. We advise patients to refrain from any sexual ejaculation for 7 days prior to coming in for the examination to afford a better opportunity to maximize collection of prostatic fluid. Older men typically have more prostatic fluid because the gland is larger, having increased in size with age. Younger men find it a challenge to refrain from sexual ejaculation for a week.

We examine the prostatic fluid microscopically in our office laboratory after staining with safranin red and crystal violet; this staining helps identify white cells and improves the microscopic review. We quantify the number of white cells in the prostatic fluid using a haemacytometer and record the result as number of leucocytes per microlitre. This allows us to compare with counts from normal, asymptomatic men and to track changes as a treatment programme is instituted. We conduct this careful analysis of the prostatic fluid partly for academic reasons of clinical research. However, quantifying the degree of inflammation from massaged ducts has failed to yield any correlation with patient pain symptoms. This relationship between pain and prostate gland inflammation is poorly understood.

Prostatic massage has been utilized as treatment for CP by several generations of urologists, particularly prior to the advent of antibiotics. In a report from a popular Philippine study, repeated prostatic massages reveal occult micro-organisms. Therapeutic benefit from massage derives from expression of poorly emptying ductal acini and may diminish smooth muscle prostatic pressure. Some have proposed massage plus antibiotic treatment (Shoskes & Zeitlin 1999). In his study, prostate massage plus antibiotics for 2–8 weeks produced 40% resolution of symptoms, 20% significant improvements; however, 40% had no improvement. There was no correlation between inflammatory content and bacterial cultures. Our opinion favours repetitive massage of the prostate, not for emptying the gland, but rather to relieve pelvic tension and release myofascial TrPs. We continue to be extremely sceptical of the concept of occult bacteria that need to be ‘massaged out’.

The prudent physician must rule out other diagnostic possibilities, including urethral stricture, urethritis, epididymitis, seminal vesicle cysts, cancer of the prostate, urethra, bladder or testis, tuberculosis of the urinary or genital tract, urinary calculus disease (urolithiasis) and other treatable entities. A serum PSA (prostate-specific antigen) laboratory test should be done for men over the age of 40, and men with a long smoking history or age greater than 60 years should have a urinary cytology done. Some of these other diagnostic possibilities associated with UCPPS may require ancillary examinations such as cystoscopy, transrectal ultrasound, CT scans, urodynamic studies and even magnetic resonance studies of the pelvis and lower spine. These ancillary examinations should be carefully considered and selected out of significant clinical suspicion, not as a systematic course of evaluation.

Imaging of the prostate in chronic prostatitis

We recommend transrectal ultrasound (TRUS) to image the prostate gland. It has not gained wide acceptance as a method of evaluation for PPS but may provide valuable information demonstrating inflamed tissue, the presence of stones in the ducts (representing urinary mineral deposits), swelling and thickening of seminal vesicles (semen storage organs behind the prostate) and accurate measurement of the size of the gland. Abdominal ultrasound and CT are inaccurate and magnetic resonance of the prostate is not cost-effective. Many urologists have observed intraprostatic calcifications on TRUS. Older men (55+) develop benign prostatic hyperplasia (BPH) and it commonly associates with PPS. Most workers believe the ultrasound hyperdense areas represent deposits of urinary metabolite crystals and inspissated secretions within the ducts. These concretions are commonly seen exuding from the peripheral zone of the prostate at the time of transurethral resection. It has been noted, however, that a substantial percentage of younger men with chronic prostate or pelvic pain have such calcifications (Geramoutsos et al. 2004). Shoskes et al. (2007) imaged 47 men with PPS symptoms averaging 60 months and reported 47% of them had such calcifications. There was no difference in the CPSI score between those who did or did not have the finding; however, the men with stones had less discomfort and greater leucocyte presence.

Japanese investigators utilized computerized X-ray images and angiography to evaluate CPP. They demonstrated excellent three-dimensional graphic images of veins around the prostate and found considerable congestion in these veins behind the bladder and along the sides of the prostate in patients suffering with pain. The veins on the surface of the prostate were much thicker in diameter than in subjects with no pain – essentially varicose veins of the prostate. It suggests heightened tension in the muscles of the pelvic floor and supports our view that CPP syndromes are associated with chronic pelvic muscle tension.

Cystoscopy

It is common for urologists to use cystoscopy to visualize the urethra, prostate and bladder in patients suffering from CPP. This consists of passing a pencil-sized flexible probe with magnifying optical lenses, high-intensity fibreoptic light and associated video camera up the penile urethra. However, cystoscopy may be the least productive investigative procedure. Some urologists say to the patient, ‘Oh, yes, I see some inflammation in the prostate’. This is anatomically impossible as they are only looking at the surface of the urethra and not at the prostatic tissue itself. There is rarely, if ever, any obvious inflammation on the surface of the prostatic urethra in the condition of CP/CPPS.

Urodynamics

One investigative tool to evaluate urinary and prostate function consists of neurophysiological measurements with urodynamics. This diagnostic approach evaluates sensory and physiological function of the related smooth and striated muscle in the bladder, prostate and external sphincter. This testing consists of placing a small pressure-sensing catheter into the bladder to detect changes in bladder pressure with filling, sensation of urgency, simultaneously monitoring the urethral voluntary sphincter pressure activity and associated pelvic floor function. An important component of this testing requires a pressure sensor in the rectum to monitor simultaneous abdominal pressure. We utilize electrical sensors patched to the skin around the anal verge to detect action motor potentials within the superficial pelvic floor, both with relaxation and voluntary contraction, but primarily to determine how much relaxation is achieved when attempting to urinate. Bladder pressure and flow dynamics reveal the synergy with the pelvic floor, demonstrating the effects of chronic tension or lack of efferent stimulation. At the minimum one should perform a urinary free-flow rate with voided volume, resting water cystometry, a pressure-flow study of micturition and electromyographic (EMG) studies of external sphincter. Independent anal or vaginal probe EMG studies as performed with biofeedback can also be quite revealing in these patients.

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