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.

Many workers suggest relationships between chronic pain and smooth or striated muscle function of the urinary bladder, prostate or sexual organs. Small, undocumented reports of findings in PPS patients suggest possible avenues of scientific pursuit. Comparison of symptoms, morphological, microbiological and urodynamic findings in patients with PPS have existed for decades (Strohmaier & Bichler 2000, Lee 2001, Hetrick et al. 2006, Hafez 2009). A common theme emerges suggesting functional obstruction at the level of the bladder neck and external sphincter, high sensitivity during filling cystometry, and poor or interrupted urinary flow. Abnormally low urinary flow rates <15 ml/s were found in 65% of patients. Some patients respond to α-blocking agents as therapy for UCPPS while most do not.

Medical assessment

The initial evaluation should include a urinary frequency and voided volume chart (preferably including timed fluid intake as well), focused physical examination looking for TrPs, urinalysis and urine culture. Surprisingly, about 30% of patients are found to have a bacterial infection history and these patients will often demonstrate recurrent bacteriuria when followed on a long-term basis. However, the presence of bacteria does not impact the pelvic pain symptoms and treating with antibiotics makes no difference in the symptom complex. There has been no scientific evidence that bacteriuria itself induces or plays a pathogenic role in IC.

Cytology and cystoscopy are recommended if clinically indicated. It is reasonable to consider urodynamics if there are elements of dysfunctional voiding, particularly if overactive bladder contractility is suggested. Pelvic imaging should be reserved for specific indications. Most of the time gynaecologic evaluation has been accomplished utilizing laparoscopy if there exists any suspicion of gynaecologic disorder.

If cystoscopy is indicated then it is most appropriate to perform the examination with hydrodistension of the bladder under general or spinal anaesthesia to physical capacity at 80 cm water pressure. More advanced and longer-duration bladder disease often associates with lower physical capacity at these pressures. Upon endoscopic emptying, typical petechial haemorrhages appear within the submucosal capillary vessels, with or without evidence of mucosal ulceration. This has been an accepted diagnostic and research criterion for diagnosis of IC when occurring with the clinical picture of painful bladder syndrome (PBS). The hydrodistension under anaesthesia may provide beneficial therapy in that about 30% of patients find relief from their bladder pain, often for several months. Aside from bladder stretching under anaesthesia, local therapy includes intermittent vesical instillations of agents such as heparin, cortisone, buffered lidocaine, and experimental approaches such as capsaicin solution to eliminate C-fibre activation. There are current clinical trials underway demonstrating the safety and efficacy of detrusor muscle injections of botulinum toxin A to alleviate the pain of IC. When pelvic pain involves the fascia and muscles outside of the bladder a neuromuscular approach is more effective.

Progress of discovery and understanding of chronic pain syndromes and myofascial trigger points

George Thiele, M.D., was a colorectal surgeon who developed a physical treatment for pelvic pain that he generally included under the name coccygynia (pain of the coccyx or tail bone). Thiele’s findings were later confirmed by Shapiro in 1937, who referred to pain around the coccyx as the Thiele syndrome. In an article in 1963, Thiele reported on 324 patients who had pelvic pain in and around the rectum and anus. He, along with several other researchers, realized that removal of the coccyx failed to help anyone with pelvic pain other than those who had severe trauma to the tailbone. Furthermore, he acknowledged that there was no evidence of any disease of the coccyx or adjacent areas.

Mehrsheed Sinaki, M.D., was a physician at the Mayo Clinic in the department of physical medicine and rehabilitation throughout most of the 1970s. Doctor Sinaki reviewed the medical records of patients who had a diagnosis of pelvic pain in general, but at that time more often referred to by the terms piriformis syndrome, coccygodynia, levator ani spasm syndrome, proctalgia fugax, or simply rectal pain. Absent were reports of urinary symptoms or of diagnoses including prostatitis, IC, or some of the other conditions we include in this book. Sinaki acknowledged that the conditions he examined were obscured by many vague and chronic complaints. Furthermore, he found, as we do today, that a general medical exam and routine laboratory and X-ray exam are unremarkable. He wrote:

Sinaki believed that the definitive test for the conditions he was reviewing was the digital–rectal examination in which the doctor inserts a gloved lubricated finger into the rectum to feel the state of the muscles. He observed, however, that the normal digital–rectal examination was inadequate to assess the tenderness of the muscles. Figures 12.1–12.5 demonstrate the internal pelvic muscle palpations and typical referral of discomfort when a TrP is involved. Figures 12.6 and 12.7 show typical pain referral patterns from external palpations.

Figure 12.1 • Anterior levator trigger points and typical pain referral pattern

Figure 12.2 • Mid-level levator muscle trigger points and typical pain referral pattern

Figure 12.3 • Obturator internus muscle trigger points and typical pain referral pattern

Figure 12.4 • Coccygeus muscle trigger points and typical pain referral pattern

Figure 12.5 • Iliopsoas muscle trigger point pain referral pattern

Figure 12.6 • Lateral abdominal muscle trigger point pain referral pattern

Figure 12.7 • Pyramidalis muscle trigger point and pain referral pattern

We previously indirectly measured the internal pelvic level of muscle tension via the rectum and vagina of patients consulting us for pelvic pain and dysfunction. Men with PPS show an increased level of pelvic floor muscle tension on EMG. Many women demonstrate weakness and inability to contract pelvic muscles; however, this is only a surface recording of the anal or vaginal muscles not the entire pelvic floor or deeper pelvic muscles around the prostate. There is emerging interest in utilizing behavioural pelvic floor rehabilitation techniques in treating male CPPS. A group from Northwestern University Medical School in Chicago used biofeedback in pelvic floor re-education as well as bladder training for this disorder (Clemens et al. 2000). They recognized that pelvic floor tension myalgia contributes to the symptoms. They studied a small group of 19 men, average age of 36 years, and treated them with this non-interventional process. The men showed improvement, particularly in their urinary scores, but also had a significant decrease in their median pain scores, from 5 to 1 on a scale of 0 (no symptoms) to 10 (worse symptoms). Dr. Howard Glazer reports on his extensive experience utilizing biofeedback in a previous chapter.

The International Association for the Study of Pain defines pain using descriptions and does not address the mechanism of pain. Zermann et al. (2001) found 88% of men with PPS had tender myofascial palpation. Berger et al. (2007) also showed that pelvic tenderness is not limited to the prostate in men with PPS. They studied 62 men with PPS and 98 men without pelvic pain, examining tenderness of ten external pelvic tender points, seven internal pelvic tender points, and other tender points as described by the American College of Rheumatology for evaluation of fibromyalgia. They found 75% of men with PPS had prostate tenderness but so did 50% of normal controls. They also observed no correlation with leucocytosis in expressed prostatic fluid.

Similarly, a recent collaborative network study of 384 symptomatic men with PPS and 121 asymptomatic controls revealed that 51% of PPS patients had tenderness at 11 anatomical sites versus 7% of controls. The most common tender site in this survey was the prostate itself, but once again tenderness specifically did not correlate with any inflammation in the gland as determined by analysis of expressed prostate secretion. The prostate is anatomically intimate with the levator muscles and fascia of puborectalis and pubococcygeus and therefore these muscles would undoubtedly be stimulated during prostate manipulation.

Sites of pain have also been recently described for PBS by Warren and colleagues (2008) who hypothesized that careful, systematic analysis of pain experienced by such patients would indicate patterns that might provide clues to pathogenesis. In the 226 women surveyed, 66% reported two or more pain sites; mean of 2.1 sites per patient. Suprapubic prominence and changes in the voiding cycle are consistent with the bladder being the site of pain generation, but do not prove the point. Women with vulvodynia or urethral syndrome do not differ in these pain sites. When specific TrPs are discovered in females, it is feasible to augment myofascial release therapy with TrP injection utilizing local anaesthetic. In a limited study by Langford et al. (2007) 18 women were treated with localized injection and 13 of the 18 women (72%) were improved at 3 months follow-up; six were completely pain-free.

Painful TrPs, areas of restriction and associated pain location

Table 12.3 presents the muscles palpated and frequencies of referred pain to specific locations, whether or not the patient had initially complained of pain in that anatomical area. For example, palpation of the puborectalis and/or pubococcygeus muscles elicited pain in the penis in 93% (67/72) of the patients. At least two of the ten TrPs could elicit or refer pain to every one of the anatomical sites in a statistically significant proportion of patients (P values determined by the Fisher’s exact test) and every TrP was able to reproduce pain in at least one site. The most reactive muscles were the rectus abdominis and external obliques; palpation of TrPs in these muscles elicited pain in four of the seven sites. Perineal pain was the most reproducible, being elicited by eight out of ten TrPs.

The frequency with which TrP palpation referred pain to a patient’s self-reported chronic pain location is presented in Table 12.3. The odds ratio is shown when calculable. For example, among the 66 patients with penile pain, 64 (97%) experienced this pain after palpation of TrPs in the puborectalis and/or pubococcygeus muscles. The odds ratio of 32.0; 95% CI (2.3, 461.0) implies that these patients were 32 times more likely to have penile pain reproduced with this muscle palpation than patients without penile pain. However, a more conservative interpretation lies with the lower limit of the CI. Thus with 95% certainty, patients with penile pain are at least 2.3 times more likely to have their pain reproduced with this TrP than patients who do not report penile pain. The odds ratio or P value could not be derived in some cases because of zero cell counts. For example, eight of 20 patients (40%) had coccyx or buttocks pain elicited by palpation of the gluteus maximus. None of the patients without coccyx or buttocks pain experienced pain in this location after palpation (0/52 without pain versus 8/20 with pain, P < 0.001, Fisher’s exact test); the odds ratio was not calculable because of the zero cell count. Table 12.3 reveals that pain in each location could be reproduced by at least one TrP in a statistically significant proportion of patients with that prior pain report; rectal and coccyx/buttocks pain were each elicited by four different TrPs. Palpation of the external oblique muscles referred pain to the suprapubic area, testes and groin at least 80% of the time in patients with pain in these locations. Moreover, 80% (8/10) of the TrP palpations reproduced pain in at least one location, and palpation of the rectus abdominis elicited pain in four locations (penis, perineum, rectum and suprapubic area). Repeated palpation of a muscle group had a consistent effect in pain referral. These physical examination findings may lead to greater understanding of pathogenic mechanisms and lead to more focused therapy.

Our sample size of 72 subjects is small, although we were able to demonstrate both statistically and clinically significant associations between certain TrPs and specific pain locations. No asymptomatic men were examined as control subjects; therefore we are unable to compare how patients without CPPS would respond to these palpations. However, the purpose of this study was to examine patients with CPPS rather than compare their responses to normal subjects. Finally, it is difficult to objectively measure pain and thus we relied on patients’ self-reported responses. If a painful location was not reported during the initial history, we could not account for it in our later analyses. We recognize that some individuals may be naturally more sensitive to muscle palpations and pressure that could cause pain in the pelvic region even though they do not suffer from CPPS.