Urogenital Pain Syndrome

What is urogenital pain?
Spectrum of chronic pelvic pain syndrome (CPPS), predominantly related to urological and genital areas. Described as aching, burning, stabbing or electric shock like sensation Besides negative psychological consequences they are often linked to functional disturbances of the lower urinary tract and sexual dysfunction

Contributory Factors

  • PROSTATE PAIN SYNDROME: Potential initiating factors: infectious, genetic, anatomical, neuromuscular, endocrine, immune (including autoimmune), or psychological mechanisms
  • BLADDER PAIN SYNDROME: Multiple aetiological or pathophysiological mechanisms have been proposed, Associated syndromes: With non-bladder syndromes (NBSs) such as fibromyalgia (FM), chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), vulvodynia, depression, panic disorders, migraine, sicca syndrome, TMJ disorder, allergy, asthma and SLE


Causes

Where does the problem lie?

  • UROLOGICAL : prostate, bladder, scrotum, testis, epididymis, penis, urethra and postvasectomy
  • GYNAECOLOGICAL: vulvar, vestibular, clitoral, endometriosis associated, dysmenorrhea, CPPS with cyclical exacerbations

Clinical Presentation

PROSTATE PAIN SYNDROME
  • Persistent or recurrent episodic pain in the region of prostrate over at least 3 out of 6 months, reproduced by prostate palpation.
  • Frequency, urgency, nocturia, hesitancy, dysfunctional flow, incontinence
  • Associated behavioural, cognitive and sexual dysfunction
  • Often linked with prostatitis in 10% of cases
  • No proven infection or other obvious local pathology in 90%
  • Potential initiating factors: infectious, genetic, anatomical, neuromuscular, endocrine, immune (including autoimmune), or psychological mechanisms
  • Diagnosis: Symptomatic diagnosis

    • Specific conditions such as infection, cancer or stricture to be ruled out
    • Urine culture after prostatic massage
    • Two-glass test or pre-post-massage test (PPMT)
    • Pressure flow study, video urodynamics (flow-electromyography), cystoscopy(if severe LUTS)
BLADDER PAIN SYNDROME
  • Distressing bladder condition encompassing heterogeneous spectrum of disorders, with different endoscopic and histopathological presentations. Multiple aetiological or pathophysiological mechanisms have been proposed.
  • Initial unidentified insult to the bladder, triggering inflammatory, endocrine and neural phenomena. No infection is implicated yet.
  • Frequent UTI and urgency during childhood and adolescence. Associated syndromes: With non-bladder syndromes (NBSs) such as fibromyalgia (FM), chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), vulvodynia, depression, panic disorders, migraine, sicca syndrome, TMJ disorder, allergy, asthma and SLE
  • Diagnosis

    • Nature of pain- key to diagnosis
    • located suprapubically, sometimes radiating to groin, vagina, rectum and sacrum
    • relieved by voiding but soon returns.
    • aggravated by food or drink
    • O’Leary-Sant Symptom Index, also known as the Interstitial Cystitis Symptom Index (ICSI). Pelvic Pain and Urgency/Frequency Symptom Scale (PUF)
GENITAL PAIN SYNDROME
  • Scrotal pain syndrome : persistent or recurrent episodic pain localised within the organs of the scrotum, and may be with symptoms s/o urinary tract or sexual dysfunction. Associated with negative cognitive, behavioural, sexual or emotional consequences.
  • pain is not in the skin of the scrotum as such, but perceived within its contents, in a similar way to idiopathic chest pain.
  • Cause: Direct pain is located in the testes, epididymis, inguinal nerves or the vas deferens( post vasectomy pain syndrome), referred pain: of myofascial origin, especially the trigger points; Problems inside the bladder or abdominal cavity can also give rise to pain in the scrotal area.
  • Diagnosis

    • Gentle palpation to search for masses and painful spots. rectal examination for prostate abnormalities and the pelvic floor muscles.
    • Semen culture, Scrotal ultrasound: to rule out hydroceles, spermatoceles, cysts and varicoceles, Pelvic floor muscle testing
URETHRAL PAIN SYNDROME
  • May occur in men and women. Chronic or recurrent episodic pain perceived in the urethra, in the absence of proven infection or other obvious local pathology. Often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction
  • Dysuria in the presence of negative rigorous investigation of the bladder and urethra
  • Neuropathic hypersensitivity following UTI
  • Referred pain from other organs or from the myofascial system
GYNAECOLOGICAL PAIN SYNDROME
  • External genitalia

    • Vaginal or Vulvar pain syndrome/Vulvodynia (Generalisedor Localise)
    • vestibular pain syndrome
    • clitoral pain syndrome
  • Internal pelvic pain syndromes

    • Endometriosis associated pain and dysmenorrhea
    • CPPS with cyclical exacerbations
  • Clinical history

    • Nature, frequency and site of the pain, and its relationship to precipitating factors and the menstrual cycle
    • menstrual and sexual history
  • Examination

    • Abdominal and pelvic examination
    • Tenderness of the muscles and on the perineum (perineal body, levators and obturator internus)
  • Diagnosis

    • Vaginal and endocervical swabs
    • Pelvic imaging
    • Laparoscopy: to r/o treatable causes

Treatment

PROSTATE PAIN SYNDROME: Treatment of chronic prostatitis:

  • Multimodal treatment aimed at the main symptoms, and taking comorbidity into account
  • Alpha-blockers
    • Tamsulosin, 0.4 mg daily; Alfuzosin, 10 mg daily for 12 weeks
    • 5-alpha-reductase inhibitors
    • Finasteride
  • Antibiotics for 4-6 weeks or even longer
  • NSAIDS and steroids for pain
  • Opioids: for refractory PPS
  • Allopurinol; phytotherapy, muscle relaxants
  • Botulinum toxin
  • Surgical management- has a very limited role and requires an additional, specific indication
  • Transurethral Needle Ablation
  • Psychological treatment: Cognitive Behavioral Therapy (CBT)

BLADDER PAIN SYNDROME

MEDICAL
  • Multimodal behavioral, physical and psychological techniques
  • Analgesics/Antibiotics
  • Corticosteroids, Antiallergics : Histamine receptor antagonists
  • Amitriptyline
  • Pentosan polysulfate sodium (PPS)
  • Immunosuppressants
  • Gabapentin/Pregabalin/Duloxetine
  • Oxybutynin
INTRAVESICAL TREATMENT
  • Intravesical Local anaesthetics/ Pentosan polysulphate sodium
  • Intravesical hyaluronic acid, chondroitin sulphate, Dimethyl sulphoxide (DMSO)
  • Intravesical heparin/ BCG/vanilloids
INTERVENTIONAL TREATMENT
  • Bladder distension
  • Transurethral Laser
  • Botulinum toxin
NON PHARMACOLOGICAL
  • CBT and psychotherapy
SURGICAL
  • Supratrigonal or subtrigonal cystectomy

GENITAL PAIN SYNDROME

  • multidisciplinary pain team or pain centre
  • pharmacotherapy
  • myofascial therapy: applying pressure to the trigger point and stretching the muscle in pelvic floor and lower abdominal musculature
  • Surgery:
    • Epididymectomy in selected cases
    • Orchiectomy
    • Vasovasostomy
    • Microsurgical denervation of spermatic cord

URETHRAL PAIN SYNDROME

  • Multidisciplinary and multimodal
  • General treatment for chronic pelvic pain
  • Psychotherapy enables to recognize “the emotional implications” of urinary problem, leading to both physical and psychological improvement
  • Laser therapy of trigonal area
  • Cognitive

GYNAECOLOGICAL PAIN SYNDROME

  • Multidisciplinary pain management approach;
  • hormonal therapy;
  • cognitive behavioural therapy, supportive psychotherapy