What causes chronic pelvic pain and how is it treated?

Chronic pelvic pain syndrome refers to a number of symptoms related to the prostate area, i.e. its surrounding structures and organs or the prostate itself.

The resultant pain in the pelvic floor area is also present. These problems have been named as chronic pelvic pain syndrome.

If someone asks what then is prostatic syndrome, the answer is: it is exactly the same. Just like chronic prostatitis or chronic pancreatitis.

Names behind us, let's look at the essence.

Anatomically, according to the location of the prostate gland in the human body, its direct connection with the lower part of the bladder. Other contact areas are the front of the rectum and the pelvic floor.

This is where the direct link to chronic pelvic pain begins.

In men, the pelvic floor has a dual function. It serves as a support for the closure mechanism of the rectum and urethra. It also contributes to correct posture.

Pathophysiology of chronic pelvic pain

Clear facts emerge from the first function of the pelvic floor. During the emptying of urine from the bladder or stool from the rectum, this area must relax, that is, relax.

Even during intercourse, its role is one of contraction and relaxation.

The second main function of the pelvic floor is its involvement in posture itself. It supports the trunk, the pelvis and the muscles of the internal stabilisation system, the so-called core.

Men are more likely to find increased activity in this area of the body rather than decreased, simply due to micturition problems.

These are those that are related to urination. Specifically:

• Slowed flow
• use of the abdominal muscles during urination
• frequent urination
• the presence of residual urine after urination
• problems with defecation
• inability to achieve an erection

All this arises on the basis of certain risk factors.

It is directly related to the constant and frequent retention of urine. Especially in people who do not have the opportunity at work to leave for a small need when they need it.

They don't urinate when they should, but when they have time.

They hold their urine by contracting their pelvic floor muscles. When they do urinate, it is usually in a weak stream. Then they try to speed up the process by using their abdominal muscles. This increases the tone, or tension, in the pelvic floor area.

Read more in this article:
More about the cause of chronic pelvic pain.
Classification of prostatitis.
Treatment of prostatitis.

If urination is forced, so to speak, against tight pelvic floor muscles, the risk of developing a coordination disorder increases. This is associated with other difficulties.

This is a condition where urination is weak and as if through an obstruction. The obstruction involves the urinary tract connected to the lower part of the bladder.

This is associated with urinary retention, i.e. the inability to urinate and thus retention of urine in the bladder.

Paradoxical ischuria occurs. That is, leakage of urine caused by retention of urine when the bladder is full. Over time, other unwanted complications are added. Inflammation, blood in the urine or reduced kidney function.

The disorder arises mainly in the bladder system. Then it progresses to the rectum and genitals.

Cause and definition of pelvic pain syndrome

The cause is not entirely clear.

The innervation of the pelvic floor muscles and the genital area originates from the same segment of the spinal cord. However, with pain in this area, the side from which the pain originates cannot be determined precisely. The pelvic floor muscles do not have as much lateralisation as, for example, the muscles of the legs or back.

This results in further disturbances and creates a closed circle of cause and effect.

Pelvic organs such as the bladder, urethra, rectum and genitals are innervated from the same network of nerves. Therefore, pelvic pain connects to the same nerve pathways. Often these symptoms look like prostate problems, although their source may be elsewhere.

Pelvic pain syndrome has two definitions.

The International Continence Society (ICS) refers to it as persistent episodes of pelvic pain that are associated with symptoms suggesting inadequate lower urinary tract function and bowel or sexual problems.

This definition is based on another published by the International Association for the Study of Pain (IASP).

This states that chronic pelvic pain is non-malignant pain felt in structures associated with the pelvis. Pain that progresses to chronicity must last or recur for at least six months. It must be associated with negative psychological and social consequences.

The specificity of the affected person's condition depends on the possibility of reliable confirmation of a specific disorder. This must correspond to:

• systemic - somatic, visceral (involving internal organs), neuropathic disorder
• organ - muscle, bladder
• a specific disease - cystitis (inflammation of the bladder), endometriosis, fissure, etc.

Sufferers visit the outpatient clinic of a urologist with a variety of non-specific manifestations.

Pain in the lower abdomen, perineum, testicles, groin pain, radiating to the lumbar and sacral region or penis. Often in the clinical picture there is painful urination (professionally stranguria), frequent urination, pain during defecation or pressure in the rectum.

Sexual dysfunction (decrease in libido, erectile dysfunction) may be added.

These disorders often respond to external and internal environmental stimuli (temperature changes, cycling, prolonged sitting, sexual intercourse, alcohol). Psychological influences are also common.

The impact and duration of these problems changes the quality of life of patients.

Read also: Chlamydia infection: why does it occur and how does it manifest itself in men or women?

Prostatitis and its classification

If we look at chronic pelvic pain syndrome from the point of view of the male population, the most common reason is just prostatitis. Simply inflammation of the prostate gland.

In terms of incidence, it is almost at the level of diabetes mellitus, that is, diabetes.

Interesting article on diabetes and its complications.

The diagnosis of prostatitis itself includes a group of inflammatory diseases of the prostate. It is referred to as prostatic syndrome. Its chronic version is referred to as chronic pelvic pain.

The prevalence of prostatitis in the population is up to 11%.

It can be defined as a febrile disease associated with difficult and painful urination, pain in the lower abdomen and perineum. It can arise suddenly often in association with obstructive symptoms in the lower urinary tract and urinary retention. That is, retention of urine due to inability to urinate.

This is usually due to pain or the aforementioned obstruction.

It is classified as a urological infection.

According to the National Institute of Health (NIH) classification, it is divided into four groups.

The table below shows the NIH classification of prostatitis

Acute prostatitis

Acute prostatitis is usually caused by various bacteria. In patients with reduced immunity induced by drugs or for other reasons, mycobacteria or fungi are also the causative agents.

These infections often arise in an ascending pattern after a blockage from the urethra or in the opposite direction after a urinary tract infection.

It is also common after long-term insertion of a urinary indwelling catheter.

The clinical picture is one of fever and abdominal pain. The patient cannot urinate properly. This is due to restrictive pain which prevents this.

This results in urinary retention and other associated difficulties.

If it develops completely, sepsis may occur. In this case, hospitalization and complex treatment is necessary.

On examination via the rectum, swelling and tenderness of the prostate is evident. In some cases, this examination is difficult to perform because of severe pain in the rectal area. Palpation is accompanied by lower abdominal pain.

Antibiotics are used in the treatment, lasting 4 to 6 weeks.

Chronic bacterial prostatitis

In view of the fact that this is a chronic disease, the trouble must last longer.

In this case, the manifestations last more than three months in the last six. A large group of these patients have recurrent inflammation of the urinary tract.

The causative bacteria are the same as in the acute form (E. coli, enterococci and others).

Often there are acute relapses after a previous improvement in the disease. Depending on what stage the disease is in, the clinical picture may change. It may look like the acute form as well as the normal state.

It is important to re-examine the patient to determine the underlying cause.

Treatment tends to be antibiotic for two weeks, followed by another 4 to 6 weeks after reduction of medication.

Chronic non-bacterial prostatitis

This is exactly the chronic pelvic pain syndrome we write about at the beginning of this article.

It involves pelvic pain, discomfort and sexual dysfunction. Its duration, is of at least 3 months out of the last six, as it is chronic.

There are two categories. III A is inflammatory and III B is non-inflammatory.

The symptoms include discomfort and pain in the pelvic area. Often the pain is localized in the perineum and testicles or penis.

Sexual dysfunction is associated. In many cases the symptoms are similar to lower urinary tract inflammation.

As this is a long-standing problem that patients have to resist, it often leaves its mark on their psychological state. It is manifested by changes in mood and behaviour.

When making a diagnosis, other diseases must first be ruled out. For example, inflammation of the urinary tract, neurological disorders, anatomical abnormalities or others. Equally important is the examination of so-called trigger points in the small pelvis.

These are places in the muscle sheaths where, for various reasons, the inability to contract and relax the muscle has arisen.

At the forefront is the classic urological examination of the abdomen, the external genital organs and the examination per rectum, i.e. through the rectum.

The per rectum examination is not only used to examine the prostate itself. It is also used to determine the tone and contractility, i.e. the ability to retract the rectal sphincter.

The urodynamic examination is performed on patients who have problems with urination. It is used to assess the functional state of the bladder and urethra. It measures the pressure in this area during urination.

As far as laboratory examinations are concerned, the main parameter is culture and microscopic examination of the urine. In addition, secretions from the prostate or ejaculate are taken.

Ultrasound is used as an imaging method of examination. However, this is particularly necessary in patients with micturition problems or ejaculation disorders, especially if they do not respond to treatment.

Cystoscopy is used as an excretory method to detect obstruction in the urinary tract.

The treatment of chronic pelvic pain syndrome is currently affected by the lack of knowledge about this disease.

It is long-term and does not always succeed in completely relieving the patient of the problem. The aim is therefore to relieve the symptoms without further complications.

General recommendations include:

• limiting the diet to irritating foods such as paprika and pepper
• avoidance of hard alcohol
• avoiding prolonged sitting or cycling
• regular physical exercise is important
• maintaining regular bowel movements and treating bowel disorders

Pharmacotherapy and the choice of medication should be tailored to the patient's difficulties.

Antibiotics are used if there is already some inflammation, as well as drugs that affect the lower urinary tract. Analgesics, which are used to relieve pain, and antiphlogistics, which have an anti-inflammatory effect, are also important.

Physical treatment is based on regular massage of the prostate. Two to three times a week for 4 to 6 weeks.

Regular prostate massage has a positive effect on up to two thirds of patients using this treatment method.

Asymptomatic prostatitis

In this diagnosis, the patient has no symptoms. Treatment is not indicated.

Finally, it should be added that this is a group of diseases with different symptoms. Group III, i.e. chronic non-bacterial prostatitis or chronic pelvic pain syndrome, is the most problematic.

This diagnosis is mainly based on the identification of other causes of the problem. According to the examination, prostatic hyperplasia (enlargement of the prostate) should be excluded. Furthermore, other inflammatory diseases, a source of pain from another area that is transmitted to the pelvis, causes of obstruction in the urinary tract, neurogenic or psychogenic causes should be excluded.

Read also the article on urinary tract inflammation in women