Symptoms suggestive of chronic pelvic pain syndrome in an urban population: prevalence and associations with lower urinary tract symptoms and erectile function

PURPOSE: We determined the prevalence of symptoms suggestive of chronic pelvic pain syndrome in an urban population and assessed associations with lower urinary tract symptoms and erectile dysfunction. MATERIALS AND METHODS: Men participating in a voluntary health examination free of charge that was organized by the Department of Preventive Health of the City of Vienna were analyzed. All participants completed 3 validated questionnaires on chronic pelvic pain syndrome (National Institutes of Health-Chronic Prostatitis Symptom Index), lower urinary tract symptoms (International Prostate Symptom Score) and erectile dysfunction (International Index of Erectile Function-5). RESULTS: A total of 1,765 men with a mean +/- SD age of 46.3 +/- 0.3 years (range 20 to 79) entered this study. The mean National Institutes of Health-Chronic Prostatitis Symptom Index score increased from 4.0 +/- 0.3 in the youngest age group of 20 to 29-year-old men to 6.3 +/- 0.6 in those 70 to 79 years old. The overall prevalence of symptoms suggestive of chronic pelvic pain syndrome, defined by a pain score of 4 or greater and perineal/ejaculatory pain, was 2.7% and it revealed no age dependence, such as the pain score. In contrast, urinary symptom and quality of life scores increased with age. International Index of Erectile Function-5 score was 20.6 +/- 0.3 for men without chronic pelvic pain symptoms vs 18.3 +/- 0.7 for men with mild symptoms and 16.5 +/- 1.1 for men with moderate/severe symptoms. A National Institutes of Health-Chronic Prostatitis Symptom Index score in the upper quartile was associated with 8.3-fold increased odds of erectile dysfunction. CONCLUSIONS: The prevalence of symptoms suggestive of chronic pelvic pain syndrome in this large cohort of men participating in a health screening project was 2.7% and it revealed no age dependence. Our study suggests that chronic pelvic pain syndrome has a negative impact on erectile function.     

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review

Pessaries have been used to treat women with pelvic organ prolapse (POP) since the beginning of recorded history. This review aims to assess the effect of pessary treatment on the disease-specific, health-related quality of life in women with pelvic organ prolapse. After a Medline search using the Mesh term ‘pessary’ and critical appraisal, 41 articles were selected and used in this review. Pessaries are widely used to treat pelvic organ prolapse. It is minimally invasive and appears to be safe. Although there is evidence that the use of pessaries in the treatment of pelvic organ prolapse is effective in alleviating symptoms and that patient satisfaction is high, the follow-up in many published papers is short, and the use of validated urogynaecological questionnaires is limited. Comparison with surgical treatment of pelvic organ prolapse is rare and not assessed in a randomised controlled trial.     

Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research

The aim of this study was to design and validate an interviewer-administered pelvic floor questionnaire that integrates bladder, bowel and sexual function, pelvic organ prolapse, severity, bothersomeness and condition-specific quality of life. Validation testing of the questionnaire was performed using data from 106 urogynaecological patients and a separately sampled community cohort of 49 women. Missing data did not exceed 2% for any question. It distinguished community and urogynaecological populations regarding pelvic floor dysfunction. The bladder domain correlated with the short version of the Urogenital Distress Inventory, bowel function with an established bowel questionnaire and prolapse symptoms with the International Continence Society prolapse quantification. Sexual function assessment reflected scores on the McCoy Female Sexuality Questionnaire. Cronbach’s α coefficients were acceptable in all domains. Kappa coefficients of agreement for the test–retest analyses varied from 0.5 to 1.0. The interviewer-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion in a typical urogynaecological clinic. The validation of the interviewer-administered pelvic floor questionnaire was presented at the Annual Meeting of the International Continence Society in 2004, Paris (podium presentation; extended abstract): A validated female pelvic floor questionnaire for clinicians and researchers, Baessler K, O’Neill S, Maher C, Battistutta D, Neurourol Urodynam 2004; 23: 398–399.     

Correlation between ultrasound alterations of the preprostatic sphincter and symptoms in patients with chronic prostatitis-chronic pelvic pain syndrome

PURPOSE: We investigated ultrasound alterations of the preprostatic sphincter in patients with chronic prostatitis-chronic pelvic pain syndrome. We evaluated the frequency of these alterations, standardized their ultrasound measurement and correlated them with symptoms in patients with chronic prostatitis-chronic pelvic pain syndrome. MATERIALS AND METHODS: In 37 patients with chronic prostatitis-chronic pelvic pain syndrome and 23 healthy volunteers certain parameters were measured by transrectal ultrasound, including prostate volume, hypoechoic periurethral zone volume, posterior prostate lip thickness, bladder neck thickness, detrusor thickness and the degree of echogenicity of the anterior fibromuscular stroma. All patients were evaluated with the International Prostate Symptom Score and National Institutes of Health Chronic Prostatitis Symptom Index. Urinary flow rate and post-void residual urine volume were also considered in each patient. All assessments were done independently and consecutively by 3 operators. RESULTS: A hypoechoic periurethral zone volume was found in 36 of 37 patients with chronic prostatitis-chronic pelvic pain syndrome. No significant intra-observer and interobserver differences were found in ultrasound parameter measurements. In the chronic prostatitis-chronic pelvic pain syndrome group ultrasound findings showed greater post-void residual urine volume, detrusor thickness and hypoechoic periurethral zone volume, increased posterior prostate lip thickness and bladder neck thickness, and greater anterior fibromuscular stroma hyperechogenicity. On multivariate analysis hypoechoic periurethral zone volume was an independent predictive factor for worse National Institutes of Health Chronic Prostatitis Symptom Index pain, urinary and total scores. Posterior prostate lip thickness was the only factor predictive of a worse International Prostate Symptom Score in patients with chronic prostatitis-chronic pelvic pain syndrome. A hypoechoic periurethral zone volume, posterior prostate lip thickness and bladder neck thickness with calculated threshold values revealed fair to excellent accuracy for identifying a patient with chronic prostatitis-chronic pelvic pain syndrome. CONCLUSIONS: Ultrasound evaluation of the bladder neck-posterior urethra in patients with chronic prostatitis-chronic pelvic pain syndrome led us to identify a set of lesions that cannot be found in healthy subjects. The measurement of hypoechoic periurethral zone volume, posterior prostate lip thickness and bladder neck thickness could be useful for following patients with chronic prostatitis-chronic pelvic pain syndrome and maybe for better understanding the complicated pathophysiological mechanisms of chronic nonbacterial prostatitis.     

Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized,placebo controlled trial

PURPOSE: We evaluate terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: The study included 100, 20 to-50-year-old subjects who met the consensus criteria for chronic prostatitis/chronic pelvic pain syndrome and had not received previous alpha-blockers. Subjects were randomized to receive terazosin with dose escalation from 1 to 5 mg. daily or placebo for 14 weeks. The primary criterion for response was scoring 2 or less ("delighted-to-mostly satisfied") on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) quality of life item. The secondary criterion for response was greater than 50% reduction in NIH-CPSI pain score at 14 weeks. Other outcomes included total and NIH-CPSI domain scores, International Prostate Symptom Score, peak urinary flow rate, post-void residual urine and adverse effects. RESULTS: Using the primary criterion 24 of 43 evaluable subjects (56%) responded in the terazosin group compared to 14 of 43 (36%) in the placebo group (p = 0.03). Using the secondary criterion 26 of 43 subjects (60%) responded in the terazosin group compared to 16 of 43 (37%) in the placebo group (p = 0.03). The terazosin group had greater reductions (p <0.05) in NIH-CPSI total score, individual domain scores and International Prostate Symptom Score than the placebo group. There was no difference in peak urinary flow rate or post-void residual. In the terazosin group 18 patients (42%) had side effects compared to 9 (21%) in the placebo group (p = 0.04). CONCLUSIONS: Terazosin proved superior to placebo for patients with chronic prostatitis/chronic pelvic pain syndrome who had not received alpha-blockers previously.     

Managing novel orally administered anticoagulants in patients undergoing urogynaecological surgery

The use of novel orally administered anticoagulant agents (NOACs) provides new challenges to clinicians in the perioperative care of patients undergoing urogynaecological surgery. We aimed to assess evidence for managing patients taking NOACs before and after urogynaecological surgery. We conducted a literature search in CINAHL, MEDLINE, CENTRAL, Cochrane Library and PubMed for original research articles in the English language on this topic. However, despite initially identifying 556 articles, no articles pertained to the use of NOACs in urogynaecological surgery. We subsequently reviewed national and international guidance on managing patients prescribed NOACs and created a concise guideline to aid urogynaecologists in the perioperative care of these patients. Consensus is needed on perioperative optimisation of anticoagulation in urogynaecological patients using NOACs.     

Patients With Chronic Pelvic Pain: Endometriosis or Interstitial Cystitis/Painful Bladder Syndrome?

BACKGROUND: Endometriosis and interstitial cystitis/painful bladder syndrome share similar symptoms. Interstitial cystitis was once considered rare, but it is now recognized as more common than previously thought. This review examines evidence that patients presenting with symptoms typically attributed to endometriosis or with unresolved pelvic pain after treatment for endometriosis may, in fact, have interstitial cystitis, and suggests approaches for appropriate diagnosis. METHODS: A MedLine search using "chronic pelvic pain," "endometriosis," "interstitial cystitis," and "bladder origin pain" as key words was performed for the most recent English-language articles. Additional references were obtained through cross-referencing the bibliography cited in each publication. DISCUSSION: The symptoms of endometriosis and interstitial cystitis frequently overlap, and these 2 conditions may even coexist in the same patient. In cases of unresolved endometriosis and persistent pelvic pain, patients may have interstitial cystitis. A variety of tools are available to aid in identifying interstitial cystitis. CONCLUSION: Gynecologists should be alert to the possible presence of interstitial cystitis in patients who present with chronic pelvic pain typical of endometriosis.     

The role of diagnostic laparoscopy for chronic abdominal conditions: an evidence-based review

Background  Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for chronic intraabdominal conditions. Methods  A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995–2006. The level of evidence in the identified articles was graded. The search identified and reviewed six main categories that have received attention in the literature: pelvic pain and endometriosis, primary and secondary infertility, nonpalpable testis, and liver disease. Results  The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. Conclusions  The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.     

Lumbar paraspinal compartment syndrome

The purpose of this study was to systematically review the available evidence on lumbar paraspinal compartment syndrome with specific reference to patient demographics, aetiology, types, diagnosis, clinical features, and treatment. This was an Institutional Review Board-exempt study performed at a Level 1 trauma center. A PubMed search was conducted with the title query: lumbar paraspinal compartment syndrome. Eleven articles met our search criteria. Three of the patients with acute paraspinal compartmental syndrome treated with fasciotomy had a full recovery and were able to resume skiing after four months. The aetiology of the onset of lumbar paraspinal compartment syndrome is broadly divided into acute and chronic. Lumbar paraspinal compartment syndrome is one of the causes of back pain with diagnostic clinical features which should be considered in the differential diagnosis of a patient with low back pain. Prospective multicentre trials may provide the surgeon with more insight into the diagnosis and management of lumbar paraspinal compartment syndrome.     

The role of diagnostic laparoscopy for acute abdominal conditions: an evidence-based review

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. This study aim was a critical examination of the available literature on the role of laparoscopy for the diagnosis and treatment of acute intraabdominal conditions. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. This review examines the role of diagnostic laparoscopy for acute nonspecific abdominal pain, trauma, and the acute abdomen experienced by the critically ill patient. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of diagnostic laparoscopy to determine acute intraabdominal conditions are provided.     

Stapled transanal rectal resection (STARR) in the treatment of rectocele: personal experience

Rectocele is an organic cause of chronic constipation, with a prevalence ranging from 8.95% to 12% in Europe and United States. Necessarily, the approach for rectocele repair is a surgical operation. Stapled transanal rectal resection (STARR) is safe and effective in the treatment of obstructed defecation syndrome. The authors' experience suggests that the surgical operation needs to be combined to rehabilitation exercises, before and after the surgical treatment, in order to strengthen the muscles of the pelvic pavement. From January 2005 to January 2007, 20 patients with outlet obstruction underwent STARR. Patients were selected for operation based on a strict diagnostic protocol: anamnesis, clinical examination, coloproctological and urogynaecological examinations, defecography, anorectal manometry, transrectal ultrasonography and peritoneal electromyography. The therapeutic protocol consists of 3 parts: phase I: rehabilitation of the pelvic pavement; phase II: surgical operation; III phase: post-surgical rehabilitation of the pelvic pavement; The clinical result was classified into: excellent (6 patients), when all constipation symptoms disappeared, good (11 patients), when patient has 1 or 2 obstructed defecation episodes treated with a laxative, fairly good (2 patients), more than 2 episodes, and poor (1 patient), when surgical operation doesn't improve any of the symptoms. Our results, confirmed by the literature, suggest that Longo's technique should be considered as gold standard for rectocele treatment.     

Early Identification of Interstitial Cystitis May Avoid Unnecessary Hysterectomy

Background:

Interstitial cystitis is a clinical syndrome characterized by symptoms of pelvic pain, urinary urgency and frequency, and nocturia. It can be difficult to accurately identify interstitial cystitis because the symptoms overlap many other common gynecologic and urologic conditions. Patients with undiagnosed interstitial cystitis may undergo unnecessary procedures, including hysterectomy.

Methods:

A PubMed literature search for articles dating back to 1990 was conducted on the topics of interstitial cystitis and hysterectomy. Further references were identified by cross-referencing the bibliographies in articles of interest.

Results:

The literature review found that hysterectomy is performed more often in patients with undiagnosed interstitial cystitis than in patients with a confirmed diagnosis. Interstitial cystitis often coexists with conditions like endometriosis, for which hysterectomy is indicated. Many patients subsequently diagnosed with interstitial cystitis continue to experience persistent pelvic pain despite having had a hysterectomy for chronic pelvic pain. Careful history and physical examination can identify the majority of interstitial cystitis cases.

Conclusion:

Interstitial cystitis should be considered prior to hysterectomy in women who present with pelvic pain or who experience pelvic pain after a hysterectomy. If interstitial cystitis is diagnosed, appropriate therapy may eliminate the need for hysterectomy.     

一例难治性脊髓损伤痛患者的处理：病例报道及文献综述

慢性疼痛是脊髓损伤众多后遗症之一，它会妨碍患者的基本活动、功能恢复及生活质量。脊髓损伤患者的疼痛常常难以治疗。有限的治疗选择，包括药物治疗和非药物治疗使疼痛的治疗更加困难。我们用检索词“脊髓损伤”或“脊髓损伤和疼痛”或“僵直”或“肌僵直”从Medline数据库查阅1975～2005年的关于脊髓损伤后疼痛的相关文章。我们也手工查阅了国际疼痛研究协会最近出版的关于脊髓损伤痛的书籍以及综述，同时检出参考文献中的相关文章。文中我们报道了一例难治性脊髓损伤痛患者，该患者通过采用综合性治疗措施成功治愈。同时对治疗方式的循证医学证据也进行了回顾。     

Pain management in a patient with intractable spinal cord injury pain: a case report and literature review

Chronic pain is one of the more disturbing sequelae of spinal cord injury, often interfering with the basic activities, effective rehabilitation, and quality of life of the patient. Pain in the cord-injured patient is often recalcitrant to treatment. This dilemma is amplified by the limited availability of effective pharmacological and nonpharmacological treatment options. We identified relevant articles regarding pain after spinal cord injury from the Medline database from 1975 to 2005 using the search terms "spinal cord injury" or "spinal cord injuries" and "pain" or "spasticity or "muscle spasms." We also searched by hand the review articles in a recently published book from the International Association for the Study of Pain Press on spinal cord injury pain, and identified relevant articles through reference lists. We present a patient with intractable spinal cord injury pain who was successfully treated with a pain management plan that addressed the various aspects of spinal cord injury pain. The evidence for treatment options is reviewed.     

Primary care and urology patients with the male pelvic pain syndrome: symptoms and quality of life

PURPOSE: We assessed symptoms and health related quality of life in men who received prostatitis-prostatodynia diagnoses at primary care and urology visits, and compared those in whom pain-discomfort had versus had not resolved approximately 1 month later. MATERIALS AND METHODS: Telephone interviews were done with 357 men an average of 1 month after a prostatitis-prostatodynia diagnosis was made at a health maintenance organization visit. The interview included the National Institutes of Health Chronic Prostatitis Symptom Index, and pain and health related quality of life measures. RESULTS: The most common pain location was the pubic-bladder area. Mean scores on most health related quality of life measures were below average, and higher pelvic pain and urinary symptom scores were associated with worse quality of life. This episode of pelvic pain was the first lifetime episode in fewer urology (22%) than primary care (38%) patients (p = 0.02). Urology patients had longer symptom episodes (p = 0.000), more days with pain in the last month (p = 0.002) and higher National Institutes of Health Chronic Prostatitis Symptom Index pain scores (p = 0.002). Men with pain in the testicles, penis or between the rectum and testicles at the visit, and with longer symptom duration before the visit were significantly more likely to have continued pain between the visit and interview. CONCLUSIONS: Pelvic pain is often a persistent, recurrent condition that can have a significant negative impact on quality of life. The average symptom severity in men with pelvic pain in primary care and urology settings is lower than that in tertiary care samples.     

Clinical images. Atypical midcycle pain

A 16-year-old female presented with acute-onset abdominal pain and an initial diagnosis of midcycle pain. Subsequent pelvic ultrasound and diagnostic laparoscopy showed a large mass in the pouch of Douglas. The patient underwent a laparotomy and excision of a mass from a loop of jejunum. This case highlights the difficulties in diagnostic differentiation relating to large pelvic masses in young females.     

Atypical midcycle pain

A 16-year-old female presented with acute-onset abdominal pain and an initial diagnosis of midcycle pain. Subsequent pelvic ultrasound and diagnostic laparoscopy showed a large mass in the pouch of Douglas. The patient underwent a laparotomy and excision of a mass from a loop of jejunum. This case highlights the difficulties in diagnostic differentiation relating to large pelvic masses in young females.     

Prevalence of prostatitis-like symptoms in a managed care population

PURPOSE: We calculated the prevalence of symptoms typically associated with chronic prostatitis/chronic pelvic pain syndrome in men in a managed care population in the Pacific Northwest. MATERIALS AND METHODS: A questionnaire mailing to 5,000 male enrollees 25 to 80 years old in the Kaiser Permanente Northwest (Portland, Oregon) health plan was performed. The questionnaires included screening questions about the presence, duration and severity of pelvic pain, and the National Institutes of Health Chronic Prostatitis Symptom Index. Chronic prostatitis/chronic pelvic pain syndrome symptoms were defined in 2 ways: 1) presence of any of the following for a duration of 3 or more months: pain in the perineum, testicles, tip of penis, pubic or bladder area, dysuria, ejaculatory pain; and 2) perineal and/or ejaculatory pain, and a National Institutes of Health Chronic Prostatitis Symptom Index total pain score of 4 or more. Prevalence estimates were age adjusted to the total Kaiser Permanente Northwest male population. RESULTS: A total of 1,550 questionnaires were returned. The prevalence of chronic prostatitis/chronic pelvic pain syndrome symptoms was 7.5% for definition 1 and 5.9% for definition 2. Mean National Institutes of Health Chronic Prostatitis Symptom Index scores were 17 for definitions 1 and 2. Of those with prostatitis-like symptoms, 30% met criteria for having both definitions present. The prevalence of prostatitis-like symptoms using either of the 2 diagnoses was 11.2%. CONCLUSIONS: This population based study indicates that approximately 1 in 9 men have prostatitis-like symptoms. Application of 2 different definitions for prostatitis-like symptoms identified unique groups of men, with limited overlap in the groups.     

Percutaneous posterior tibial nerve stimulation in patients with chronic pelvic pain: a preliminary study

BACKGROUND: We evaluated the clinical effect of intermittent percutaneous posterior tibial nerve stimulation (PTNS) in patients with chronic pelvic pain (CPP). METHODS: A total of 15 patients (10 women and 5 men, mean age 60.0 years, range 41-78) with CPP were enrolled in an open prospective clinical trial. The patients had 12 weekly outpatient treatment sessions, each lasting 30 min. All patients were evaluated by history, physical as well as urological examination, the Visual Analogue Scale (VAS) for pain and urgency, the International Prostate Symptom Score, and a 3-day frequency-volume chart. RESULTS: After 12 weeks of PTNS, 9 (60%) and 3 patients (30%) had an improvement of >50% and 25-50% in the VAS score for pain, respectively. Six patients (40%) ended up with a mean VAS <3. Mean VAS for pain changed from 8.1 +/- 0.2 at baseline to 4.1 +/- 0.6 after 12 weeks of treatment (p < 0.01). Mean VAS for urgency changed from 4.5 +/- 1.0 at baseline to 2.7 +/- 0.7 after 12 weeks of treatment (p < 0.05). However, there was no statistically significant improvement in the International Prostate Symptom Score. There was no statistically significant difference in the number of voids and bladder volumes either. CONCLUSIONS: Our findings suggest that PTNS may improve pain symptoms for over half of the patients with CPP. Long-term follow-up studies are needed to verify these preliminary results.     

Delayed Diagnosis of Charcot Foot: A Systematic Review

This study aims to examine the duration and rate of delayed diagnosis in Charcot foot. We systematically reviewed articles published in Medline, SCOPUS, and Cumulative Index of Nursing and Allied Health Literature to identify articles discussing delayed or misdiagnosis of Charcot foot. Random-effects models were generated to determine the average time from symptom onset to correct diagnosis (diagnostic delay duration) and proportion of patients misdiagnosed prior to being correctly diagnosed (delayed diagnosis rate). Our search identified 142 articles, 7 of which are included in this review. The review found that 53.2% of cases of Charcot osteoarthropathy experienced a delay in diagnosis (95% CI: 28.9%-77.4%). Overall, the duration of diagnostic delay was determined to be 86.9 days (95% CI: 10.5-162.1). We found that patients with Charcot foot experienced prolonged delays from symptom onset to correct diagnosis, and a majority of patients are misdiagnosed. These delays in diagnosis contribute to worse patient outcomes.