Management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): the studies, the evidence, and the impact

Introduction

The development of an accepted clinical definition, classification system and validated outcome questionnaire for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has led to a flurry of clinical trial activity over the last 15 years.

Methods

Twenty-four of these studies enrolled a homogeneous population of CP/CPPS patients, were prospective randomized placebo or sham controlled, and employed the National Institutes of Health chronic prostatitis symptom index (CPSI) as an outcome parameter.

Results

This review of the evidence and clinical impact from these studies suggests that physician’s strict adherence to a rigid evidence-based approach for the treatment of a CP/CPPS patient will result in disappointed patients as well as disappointed physicians.

Conclusions

There is no one particular treatment that shows significant clinical efficacy to be recommended as a mono-therapy for CP/CPPS. Therefore, the physician must adapt his knowledge and interpretation of the evidence from randomized placebo- and sham-controlled trials to determine what therapy or therapies are best indicated for each individual patient.     

A feasibility trial of a cognitive-behavioural symptom management program for chronic pelvic pain for men with refractory chronic prostatitis/chronic pelvic pain syndrome

Background:

Our objective was to determine the feasibility of a cognitive behavioural symptom management program for the acute improvement of psychosocial risk factors of diminished quality of life (QoL) in men suffering from chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

Materials and Methods:

We assessed CP/CPPS symptoms and impact (i.e., chronic prostatitis symptom index [CPSI] pain, urinary, QoL domains), psychosocial risk factors were assessed at baseline and weekly for 8 weeks. We included the following psychosocial risk factors: catastrophizing (Pain Catastrophizing Scale, PCS), mood (Center for Epidemiological Studies in Depression Scale, CES-D), social support (Multidimensional Scale of Perceived Social Support, MSPSS) and general pain (McGill Pain Questionnaire). Patient sessions dispute and replace pessimistic thinking with health-focused thinking and behaviour.

Results:

Eleven men completed the psychosocial management program (mean age = 51.3, standard deviaton [SD] = 12.49). Mean CPSI baseline total score was 25.2 (SD = 10.21). Repeated measures ANOVAs showed the program was associated with significant linear reductions for pain (p = 0.051), disability (p= 0.020) and catastrophizing (p = 0.005), but no changes in depressive symptoms or social support. The CPSI baseline scores compared to follow-up scores (n = 8) were significantly reduced (p = 0.007), with CPSI pain (p = 0.015) and QoL impact (p = 0.013) reduced, but not for urinary scores. Correlations between change scores at the baseline and at 8 weeks for CPSI and psychosocial risk factors indicated that reductions in catastrophizing were most strongly associated with score reductions for the CPSI; these reductions, however, were not significant.

Conclusions:

The psychosocial management program targets and significantly reduces several empirically supported psychosocial risk factors associated with poorer CP/CPPS outcomes. Psychosocial management for CP/CPPS is feasible, but requires a randomized controlled trial with longitudinal follow-up.     

Immunostimulation in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a one-year prospective,double-blind,placebo-controlled study

Purpose

Inflammation/immunological dysfunction are discussed etiological causes of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). OM-89 is an orally immunostimulating agent. We performed a phase three multicentre, randomized, double-blind, placebo-controlled, long-term (12 months) study with OM-89 produced with a different lysis process in patients with moderate-to-severe CP/CPPS type III.

Methods

Patients were randomized to OM-89 or placebo. Primary efficacy variable was difference of responders at the end of treatment (month 9) in patients receiving OM-89 versus placebo.

Results

Two hundred and three patients were screened, 185 patients (47.8 ± 8.4 years) (90 % of CP/CPPS type IIIb) were enrolled in 30 centers and included in the safety set. Ninety-four were randomized to OM-89, 91 to placebo. One hundred and seventy-six patients were subjected to the full analysis (FAS), 150 to the per protocol set (PPS). Baseline NIH-CPSI score in FAS was 21.8 ± 3.8 (OM-89) and 23.0 ± 5.6 (placebo). At primary efficacy endpoint (month 9), in the OM-89 group, 67.0 % in FAS (PPS 72.7 %) and in the placebo group, 64.3 % in FAS (PPS 64.4 %) were responders [FAS: OR 1.19, p = 0.59; PPS: p = 0.19]. Mean relative decrease in NIH-CPSI was 40.5 and 44.0 % in the FAS. Treatment-related adverse events were low: 8.5 % with OM-89 and 5.5 % with placebo. Because of small numbers, no conclusion could be drawn regarding the potential benefit of OM-89 in CP/CPPS IIIa.

Conclusions

This placebo-controlled study evaluating OM-89 in patients with CP/CPPS showed a significant and long-lasting (12 months) favorable response with OM-89, but also with placebo. OM-89 was safe and well tolerated.

EudraCT

2007-004609-85.     

Differential expression of immune factor between patients with chronic prostatitis/chronic pelvic pain syndrome and the healthy volunteers

Purpose

Immune mechanisms have been hypothesized to contribute to the development of CP/CPPS. In this study, we investigated the differential expression of immune factors between patients with CP/CPPS and healthy volunteers.

Methods

This study was registered in Australian New Zealand Clinical Trials Registry. Healthy volunteers and patients with CP/CPPS were enrolled in this study. The inclusion criteria for patients were below: (1) aged 18–45 years old; (2) prostatitis-related syndrome longer than 3 months; (3) normal routine urine culture and negative bacterial culture in prostatic fluid. Patients were further classified into two groups: types IIIA and IIIB CP/CPPS according to the results of EPS routine test. Serum immune markers include IgA, IgM, IgG, CD4⁺ and CD8⁺.

Results

There are total 23 CP/CPPS patients, including 12 type IIIB and 11 type IIIA. Relatively, there are 26 healthy volunteers. The serum levels of IgG were higher in CP/CPPS patients compared to healthy volunteers (1141.2 ± 204.3 vs 1031.9 ± 173.7 mg/L, p = 0.045), while the serum levels of CD8⁺ were lower in CP/CPPS patients compared to healthy volunteers (492.8 ± 185.6 vs 640.0 ± 246.8 cells/μL, p = 0.021). Furthermore, serum levels of IgG were higher in patients with IIIA CP/CPPS compared to those with IIIB (1244.3 ± 151.6 vs 1054.3 ± 209.3 mg/L, p = 0.023).

Conclusions

Differential levels of IgG and CD8⁺ between CPPS patients and healthy volunteers suggest a contributing role of immune mechanisms to the development of CP/CPPS; and IgG may play an important role in inflammatory CPPS.Clinical Study registration number ACTRN12613000792729.

     

Alternative therapies in the management of chronic prostatitis/chronic pelvic pain syndrome

Purpose

Standard medical therapy for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) including such agents as nonsteriodal anti-inflammatories, alpha-blockers, antimicrobial therapy, and 5a-reductase inhibitors has not been uniformly effective. The purpose of this review is to focus on the role of alternative therapies available for the management of CP/CPPS.

Methods

We performed a systematic review of the literature for articles published in PubMed up to 2012 pertaining to commonly employed alternative therapies.

Results

The evidence for alternative therapies such as diet and lifestyle modifications, phytotherapy, acupuncture, myofascial physical therapy, and stress management/cognitive behavioral therapy is reviewed.

Conclusion

CP/CPPS often requires a multimodal approach and alternative therapies should be considered as adjuncts in the treatment of refractory CP/CPPS patients.     

A multidisciplinary rehabilitation programme improves disability,kinesiophobia and walking ability in subjects with chronic low back pain: results of a randomised controlled pilot study

Purpose

To evaluate the effect of a multidisciplinary rehabilitation programme on disability, kinesiophobia, catastrophizing, pain, quality of life and gait disturbances in patients with chronic low back pain (CLBP).

Methods

This was a parallel-group, randomised, superiority-controlled pilot study in which 20 patients were randomly assigned to a programme consisting of motor training (spinal stabilising exercises plus usual-care) and cognitive–behavioural therapy (experimental group, 10 subjects) or usual-care alone (control group, 10 subjects). Before treatment, 8 weeks later (post-treatment), and 3 months after the end of treatment, the Oswestry Disability Index, the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a pain numerical rating scale, and the Short-Form Health Survey were assessed. Spatio-temporal gait parameters were also measured by means of an electronic walking mat. A linear mixed model for repeated measures was used for each outcome measure.

Results

The programme had significant group (p = 0.027), time (p < 0.001), and time-by-group interaction (p < 0.001) effects on disability, with the experimental group showing an improvement after training of about 61 % (25 % in the control group). The analyses of kinesiophobia, catastrophizing, and the quality of life also revealed significant time, group, and time-by-group interaction effects in favour of the experimental group, and there was a significant effect of time on pain. Both groups showed a general improvement in gait parameters, with the experimental group increasing cadence significantly more.

Conclusion

The multidisciplinary rehabilitation programme including cognitive–behavioural therapy was superior to the exercise programme in reducing disability, kinesiophobia, catastrophizing, and enhancing the quality of life and gait cadence of patients with CLBP.     

Female gender is a risk factor for pain, discomfort, and fatigue after laparoscopic groin hernia repair

Purpose

Female gender is a risk factor for early pain after several specific surgical procedures but has not been studied in detail after laparoscopic groin hernia repair. The aim of this study was to compare early postoperative pain, discomfort, fatigue, and nausea and vomiting between genders undergoing laparoscopic groin hernia repair.

Methods

Prospective consecutive enrollment of women and age-matched (±1 year) and uni-/bilateral hernia-matched male patients undergoing elective transabdominal preperitoneal hernia repair (TAPP). Patients in the two groups received a similar anesthetic, surgical, and analgesic treatment protocol.

Results

Between August 2009 and August 2010, 25 women and 25 men undergoing elective TAPP were prospectively included in the analysis (n = 50) with no significant difference between groups in psychological status regarding anxiety, depression, and catastrophizing. On day 0, women had significantly more pain during rest (p = 0.015) and coughing (p = 0.012), discomfort (p = 0.001), and fatigue (0.020) compared with men. Additionally, cumulative overall postoperative pain during coughing, discomfort, and fatigue on day 0–3 was significantly higher in women compared with men (all p values < 0.05). Women required significantly more opioids (p = 0.015) and had a significantly higher incidence of vomiting on days 0 and 1 (p = 0.002).

Conclusions

Women experienced more pain, discomfort, and fatigue compared with men after laparoscopic groin hernia repair.

Trial registration

Registration number NCT00962338 (www.clinicaltrials.gov).     

Prevalence,symptom impact and predictors of chronic prostatitis‐like symptoms in Canadian males aged 16–19 years

OBJECTIVE

To estimate the prevalence and examine the extent that pain, urinary symptoms, depression and pain catastrophizing predict the quality of life (QoL) in Canadian male adolescents, as the prevalence and impact of chronic prostatitis (CP)‐like symptoms in adolescents is unknown.

SUBJECTS AND METHODS

Participants completed the National Institutes of Health Chronic Prostatitis Symptom Index (NIH‐CPSI), the Patient Health Questionnaire‐depression screen (PHQ‐D), and the Pain Catastrophizing Scale (PCS). CP‐like case identification was based on NIH‐CPSI report of pain/discomfort in perineum and/or with ejaculation and NIH‐CPSI total pain score (0–20) of ≥4 (mild) and ≥8 (moderate‐severe). The point prevalence was estimated and regressions used to examine predictors of diminished QoL gathered from the NIH‐CPSI.

RESULTS

The prevalence of at least mild CP‐like symptoms in 264 Canadian adolescents aged 16–19 years (mean age 17.5, sd 1.1) was 8.3%, with 3% reporting moderate‐severe CP‐like symptoms. Pain, urinary symptoms, depression and catastrophizing were correlated with diminished QoL. Additionally, catastrophizing predicted diminished QoL when the variance of pain, urinary symptoms and depression were simultaneously considered in the analysis.

CONCLUSIONS

Similar to that reported by older cohorts, these data provide the first point‐prevalence estimate of CP‐like symptoms in adolescents. These findings suggest increased vigilance to a potential diagnosis of adolescent CP syndrome and indicate that psychological features (i.e. catastrophizing) are significant in diminished QoL. Adolescent male chronic pelvic pain is an important and understudied area for future investigations.     

Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVE

To examine interactions between demographic, pain, urinary, psychological and environmental predictors of quality of life (QOL) in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

PATIENTS AND METHODS

In all, 253 men previously enrolled in the National Institutes of Health Chronic Prostatitis Cohort study in North American tertiary‐care clinical centres (six in the USA and one in Canada) self‐reported with validated instruments, including the QOL subscales of the Short Form‐12 (physical, SF12‐PCS; and mental, SF12‐MCS), demographics, urinary symptoms, depression, current pain, pain coping, ‘catastrophising’ (catastrophic thinking about pain), pain control, social support and solicitous responses from a partner. Data were collected through a one‐time survey. Covariates determined to be significant were entered into a multivariable regression model predicting SF12‐PCS and SF12‐MCS.

RESULTS

Adjusting for covariates, regression models showed that poorer SF12‐PCS scores were predicted by worse urinary function (P < 0.001) and increased use of pain‐contingent resting as a coping strategy (P = 0.026). Further, poorer SF12‐MCS scores were predicted by greater pain catastrophizing (P = 0.002) and lower perceptions of social support (P< 0.001). In separate follow‐up analyses, helplessness was the significant catastrophizing subscale (P < 0.001), while support from family and friends were the significant social support subscales (P = 0.002 and <0.001).

CONCLUSIONS

These data suggest that specific coping and environmental factors (i.e. catastrophizing, pain‐contingent resting, social support) are significant in understanding how patients with CP/CPPS adjust. These data can be used to develop specific cognitive‐behavioural programmes for men with CP/CPPS who are refractory to standard medical therapy.     

Nerve growth factor level in the prostatic fluid of patients with chronic prostatitis/chronic pelvic pain syndrome is correlated with symptom severity and response to treatment

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To explore whether levels of nerve growth factor (NGF) in expressed prostatic secretions (EPS) are correlated with symptom severity in chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS).

PATIENTS AND METHODS

• ? All patients with CP/CPPS underwent a complete history and physical examination, and were scored according to the National Institutes of Health Chronic Prostatitis Symptom Index (NIH‐CPSI).
• ? Expressed prostatic secretion samples from 20 patients with CP/CPPS and from four asymptomatic control patients were collected and frozen, and NGF levels in EPS were measured by enzyme‐linked immunosorbent assay.
• ? Patients were asked to complete NIH‐CPSI questionnaires at baseline and 8 weeks after treatment and patients with at least a 25% decrease in total NIH‐CPSI score from the baseline values were classified as responders to treatment.

RESULTS

• ? The mean (±sd ) NGF levels in EPS of patients with CP/CPPS and asymptomatic control patients were 7409 (±3788) pg/mL and 4174 (±1349) pg/mL, respectively. The NGF level in patients with CP/CPPS correlated directly with pain severity (P= 0.014, r= 0.541).
• ? There were no significant differences between NGF levels in EPS before and after treatment. However, successful treatment significantly decreased NGF levels in responders (P= 0.001).

CONCLUSION

• ? Nerve growth factor might contribute to the pathophysiology of CP/CPPS as changes in NGF level in EPS occurred in proportion to pain severity. Therefore, these results suggest that NGF could be used as a new biomarker to evaluate the symptoms of CP/CPPS and the effects of treatment.

     

A case-control study on the association between chronic prostatitis/chronic pelvic pain syndrome and erectile dysfunction

Study Type – Symptom prevalence (case control) Level of Evidence 3a What's known on the subject? and What does the study add? In recent years, a number of studies have reported a high prevalence of erectile dysfunction (ED) among patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Several studies have reported that the prevalence of ED ranges from 15.0 to 40.5% in men in China with CP/CPPS; however, the previous studies focusing on the prevalence of ED among patients with CP/CPPS all neglected to explore the magnitude of this association. Our study found an association between ED and previously diagnosed CP/CPPS. The odds of previous CP/CPPS were 3.62 times greater for cases than for controls, after adjusting for patient socio‐demographic characteristics, comorbidities, obesity, and alcohol abuse/alcohol dependence syndrome.

OBJECTIVE

• ? To examine the association between erectile dysfunction (ED) and a previous diagnosis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) using a population‐based dataset.

PATIENTS AND METHODS

• ? The data for this case–control study was obtained from the National Health Insurance database.
• ? A total of 3194 males, who were ≥18 years of age when they first received a diagnosis of ED, were identified and 15 970 controls were randomly selected.
• ? The prevalence and risk of CP/CPPS among cases and controls were calculated by using conditional logistic regression analysis.

RESULTS

• ? In total, 667 (3.5%) of the 19 164 sampled subjects had been diagnosed with CP/CPPS before the index date; CP/CPPS was found in 276 (8.6%) cases and in 391 (2.5%) controls (P < 0.001).
• ? Regression analysis indicated that cases were more likely to have had previous CP/CPPS (odd ratio 3.62, 95% confidence interval 3.07–4.26) after adjusting for patient monthly income, geographical location and urbanization level, as well as hypertension, diabetes, coronary heart disease, renal disease, obesity and alcohol abuse/alcohol dependence syndrome status, when compared with controls.

CONCLUSIONS

• ? We conclude that there was an association between ED and having been previously diagnosed with CP/CPPS.
• ? Urologists should be alert to the association between CP/CPPS and ED, and assess the erectile function of patients suffering from CP/CPPS.

     

Prevalence of sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis

Purpose

This study aims to estimate the prevalence of sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) by conducting a meta-analysis.

Methods

Relevant publications were searched using PubMed, Embase, CBM, China National Knowledge Infrastructure, VIP and Wanfang databases up to August 2015. Studies that reported the prevalence of erectile dysfunction, premature ejaculation and total sexual dysfunction in men with CP/CPPS were included.

Results

A total of 24 studies involving 11,189 men were included. Overall prevalence of sexual dysfunction in men with CP/CPPS was 0.62 (95 % CI 0.48–0.75), while the prevalence of erectile dysfunction and premature ejaculation was 0.29 (95 % CI 0.24–0.33) and 0.40 (95 % CI 0.30–0.50), respectively. From 1999 to 2010, the prevalence of sexual dysfunction, erectile dysfunction and premature ejaculation was 0.65 (95 % CI 0.45–0.83), 0.27 (95 % CI 0.22–0.33) and 0.41 (95 % CI 0.27–0.55), respectively. From 2011 to 2014, the prevalence of sexual dysfunction, erectile dysfunction and premature ejaculation was 0.50 (95 % CI 0.22–0.75), 0.35 (95 % CI 0.29– 0.40) and 0.39 (95 % CI 0.37–0.41), respectively.

Conclusion

The prevalence of sexual dysfunction in men with CP/CPPS was high, even though overall sexual dysfunction demonstrated a slightly decreasing trend. Furthermore, erectile dysfunction prevalence rate had an increasing trend in recent years. More prospective studies are needed to evaluate sexual dysfunction improvement with better management of CP/CPPS.

     

A case-control study of chronic prostatitis/chronic pelvic pain syndrome and colorectal cancer

Study Type – Symptom prevalence (case control) Level of Evidence 2b What's known on the subject? and What does the study add? Associations are well established between intestinal infection/inflammation or inflammatory bowel diseases and colorectal cancer (CRC). Our study found an association between CRC and previously diagnosed chronic prostatitis/chronic pelvic pain syndrome. Patients with CRC had a 1.45‐fold higher risk of having a previous diagnosis of chronic prostatitis/chronic pelvic pain syndrome than controls. This phenomenon was found to be more prominent in subjects younger than 60 years.

OBJECTIVE

• ? To estimate the association between chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and colorectal cancer (CRC) using a nationwide population‐based data set.

PATIENTS AND METHODS

• ? This case–control study used data sourced from the Taiwan Longitudinal Health Insurance Database.
• ? The cases comprised 2899 patients with CRC and 14 995 randomly selected subjects as controls.
• ? We used conditional logistic regression to examine the association between CRC and previous diagnosis of CP/CPPS.

RESULTS

• ? Of the sampled patients, 531(3.05%) had been diagnosed with CP/CPPS before the index date, with 123 (4.24% of the patients with CRC) coming from the cases and 408 individuals (2.81% of patients without CRC) coming from the controls.
• ? Conditional logistic regression analysis revealed that cases were more likely to have CP/CPPS than controls (odds ratio 1.45, 95% CI 1.17–1.79, P < 0.001) after adjusting for the monthly income, geographic location, urbanization level, hypertension, diabetes, renal disease, obesity and cystic kidney disease.
• ? In subgroup analysis, we found the magnitude of the association to be higher in subjects younger than 60 years (age 40–49, odds ratio 2.01; 95% CI 2.04–3.58 and aged 50–59, 2.40, 95% CI 1.48–3.87, both P < 0.001) than among other age groups.

CONCLUSION

• ? We conclude that CP/CPPS patients are at higher risk for CRC, especially in males under 60 years of age.

     

Development of an evidence-based cognitive behavioral treatment program for men with chronic prostatitis/chronic pelvic pain syndrome

Objectives Psychosocial factors reported by patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) promote greater pain, disability, and ultimately poorer quality of life (QOL). We targeted those parameters in the development of a cognitive-behavioral (CB) program designed specifically for CP/CPPS. Methods and materials Five NIH sponsored biopsychosocial studies examined predictors of pain, disability, and QOL in CP/CPPS men. Pain, urinary symptoms, QOL, depressive symptoms, catastrophic thinking about pain, perceived control over pain, pain-contingent resting as a pain coping measure, social support and interaction, sexual functioning, and relationship issues were assessed. These data showed that CB intervention for pain catastrophizing, pain contingent rest, social support and depressive symptoms is warranted for men with CP/CPPS Results An evidence based 8-week CB program was developed. The content of the CB sessions are defined in an instructional patient workbook for each of the weekly 1-h sessions. The CB program guides patients in examining the relationship between their symptom-based distress, their thinking at such times and the emotions linked with those thoughts, and their behavioral responses to their particular thinking style (e.g., illness vs. wellness focused). Patients complete such analyses by using a Reaction Record format, which also delineates new thinking/behavioral responses. Conclusions The CB program developed for CP/CPPS is the first comprehensive attempt to target specific evidence supported biopsychosocial variables for both symptom and QOL improvement in CP/CPPS and is expected to provide a useful tool for the clinical management of this chronic condition.     

An increased response to experimental muscle pain is related to psychological status in women with chronic non-traumatic neck-shoulder pain

Background

Neck-shoulder pain conditions, e.g., chronic trapezius myalgia, have been associated with sensory disturbances such as increased sensitivity to experimentally induced pain. This study investigated pain sensitivity in terms of bilateral pressure pain thresholds over the trapezius and tibialis anterior muscles and pain responses after a unilateral hypertonic saline infusion into the right legs tibialis anterior muscle and related those parameters to intensity and area size of the clinical pain and to psychological factors (sleeping problems, depression, anxiety, catastrophizing and fear-avoidance).

Methods

Nineteen women with chronic non-traumatic neck-shoulder pain but without simultaneous anatomically widespread clinical pain (NSP) and 30 age-matched pain-free female control subjects (CON) participated in the study.

Results

NSP had lower pressure pain thresholds over the trapezius and over the tibialis anterior muscles and experienced hypertonic saline-evoked pain in the tibialis anterior muscle to be significantly more intense and locally more widespread than CON. More intense symptoms of anxiety and depression together with a higher disability level were associated with increased pain responses to experimental pain induction and a larger area size of the clinical neck-shoulder pain at its worst.

Conclusion

These results indicate that central mechanisms e.g., central sensitization and altered descending control, are involved in chronic neck-shoulder pain since sensory hypersensitivity was found in areas distant to the site of clinical pain. Psychological status was found to interact with the perception, intensity, duration and distribution of induced pain (hypertonic saline) together with the spreading of clinical pain. The duration and intensity of pain correlated negatively with pressure pain thresholds.

     

Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks for chronic pain after inguinal hernia repair

Purpose

The aim of this study was to evaluate the outcome of ilioinguinal and iliohypogastric nerve blocks in patients with chronic pain after herniorrhaphy, by comparing nerve stimulator and ultrasound guidance to administer the block.

Methods

A total of 43 patients who received nerve blocks for chronic inguinal post-herniorrhaphy pain received standardized questionnaires. Nerve stimulator–guided blocks were performed prior to January 2009, and thereafter, ultrasound-guided blocks were performed using a local anaesthetic solution and a corticosteroid.

Results

The questionnaire was completed by 38 patients (88 %). The inguinal hernia repair was performed for a median 16 months (range 3–219) ahead of the nerve blocks. A median of 2 pain treatments (range 1–7) was calculated. Median follow-up was 21 months (range 3–68). According to the DN4, 21 patients (55.3 %) no longer reported neuropathic pain. Subjectively, 32 % no longer reported moderate-to-severe pain. After ultrasound-guided blocks, a higher VAS score (at rest and during activities), a higher proportion of daily pain and more anxiety and depression are reported compared to blocks performed after nerve stimulator guidance.

Conclusions

Ilioinguinal/iliohypogastric nerve blocks can be effective to treat chronic inguinal pain following surgery of the groin. The use of ultrasound was not superior to nerve stimulator–guided blocks. These blocks could be considered prior to more invasive procedures such as neurectomy.     

Prognosis of chronic low back pain in patients presenting to a private community-based group exercise program

Purpose

To examine the prognosis and prognostic factors for patients with chronic low back pain presenting to a private, community-based, group exercise program.

Methods

A total of 118 consecutive patients with chronic LBP were recruited. Baseline assessments included socio-demographic characteristics, back pain history and clinical examination findings. Primary outcome measures were pain intensity and disability at 3, 6 and 12 months. Potential prognostic factors to predict pain intensity and disability at 12 months were assessed using a multivariate regression model.

Results

112 (95 %) participants were followed up at 12 months. The majority of participants were female (73 %), had high educational levels (82 %) and resided in suburbs with a high socio-economic status (99 %). Pain intensity improved markedly during the first 6 months (35 %) with further minimal reductions up to 12 months (39 %). Interestingly, disability improved to a greater degree than pain (48 % improvement at 6 months) and continued to improve throughout the 12 months (60 %). Baseline pain intensity accounted for 10 % of the variance in the 1 year pain outcomes. Duration of current episode, baseline disability and educational level accounted for 15 % of the variation in disability at 12 months.

Conclusions

During a period of 12 months, patients with chronic LBP presenting to a private, community-based, group exercise program improved markedly, with greater improvements in disability than pain. The predictors investigated accounted for only 10 and 15 % of pain and disability outcomes, respectively.     

Long-term follow-up after mesh removal and selective neurectomy for persistent inguinal postherniorrhaphy pain

Purpose

Persistent inguinal pain, influencing daily activities, is seen in about 5 % of patients following inguinal herniorrhaphy. Surgical treatment of patients with persistent postherniorrhaphy pain has been associated with pain relief and improvement in functional status. However, the detailed long-term outcome effects remain to be clarified. The aim of this study was to determine the long-term effects of mesh removal and selective neurectomy in patients with persistent postherniorrhaphy pain after previous open repair.

Methods

The study consecutively included 54 inguinal postherniorrhaphy pain patients treated with mesh removal and aimed neurectomy. Patients completed questionnaires evaluating pain intensity with a numerical rating scale (NRS) and pain-related functional impairment preoperatively, and, 3, 6, 12, 24, and 36 months postoperatively. Endpoints were changes in pain intensity and functional ability when comparing preoperative and postoperative assessments.

Results

Pain intensities (average, maximum, and during activity) were significantly lower at all time points during follow-up compared to preoperative values (p < 0.01 for all) with a reduction in median (IQR) average pain intensity from 6.0 (5.0–7.0) preoperatively to 3.0 (1.0–5.5) at 36-month follow-up. There was no association between positive pain outcome and intraoperative nerve identification (p = 0.47). The number of patients who reported a long-term negative effect of the operation (≥25 % increase in average pain intensity at 36-month follow-up) was 1 of 8. The functional ability was improved at 3 months after the operation (p < 0.01), but the improvement was not statistically significant in the follow-up period. Preoperative signs of depression, anxiety, and catastrophizing had no influence on outcome.

Conclusions

Mesh removal and attempted neurectomy may provide long-lasting analgesic effects in most patients and with a small proportion being worse, without relation to pain history and operative findings. Detailed multicenter collaboration is required to define preoperative diagnostics and the indication for mesh removal and neurectomy, the exact surgical procedure (type of neurectomy) and with detailed follow-up.     

Prevalence of low back pain and factors associated with chronic disabling back pain in Japan

Purpose

This study aimed to report lifetime and 4-week low back pain (LBP) prevalence and examine factors associated with chronic LBP and back pain disability over a lifetime in a Japanese adult population.

Methods

In February 2011, 1,063,083 adults aged 20–79 years registered as internet research volunteers were randomly selected to participate in a questionnaire survey. The data from 65,496 respondents were analyzed to calculate age-standardized lifetime and 4-week prevalence. Chronic LBP and back pain disability were defined as LBP lasting for ≥3 months and a consecutive ≥4-day-long absence, respectively. Factors associated with chronic disabling back pain over a lifetime were examined by multiple logistic regression modeling.

Results

The lifetime LBP prevalence was 83 % and 4-week prevalence was 36 %; majority of the respondents had disability-free LBP. Smoking [adjusted odds ratio (aOR): 1.17; 95 % CI: 1.05, 1.30], lower educational level (aOR: 1.21; 95 % CI: 1.09, 1.34), history of disabling back pain among family members and/or significant others (aOR: 1.46; 95 % CI: 1.27, 1.67), occupational LBP (aOR: 1.34; 95 % CI: 1.16, 1.55), traffic injury (aOR: 2.81; 95 % CI: 2.07, 3.81), compensated work injury (aOR: 2.42; 95 % CI: 1.92, 3.05), radiating pain (aOR: 4.94; 95 % CI: 4.45, 5.48), low back surgery (aOR: 10.69; 95 % CI: 9.02, 12.68), and advice to rest upon back pain consultation (aOR: 3.84; 95 % CI: 3.36, 4.40) were associated with chronic disabling back pain over a lifetime.

Conclusions

LBP is common in Japan as in other industrialized countries. The association between the advice to rest and chronic disabling back pain supports recent treatment guidelines emphasizing continuation of daily activities.     

Brain structural and psychometric alterations in chronic low back pain

Purpose

Chronic low back pain (CLBP) is one of the most important pain disorders with increasing social and economic implications. Given that CLBP is a multidimensional process associated with comorbidities such as anxiety and depression, treatment of chronic low back pain is still a challenge. Advancement of in vivo brain imaging technologies has revealed increasing insights into the etiology and pathogenesis of chronic pain; however, the exact mechanisms of chronification of LBP remain still unclear. The purpose of the present study was to analyse the neurostructural alterations in CLBP and to evaluate the role of comorbidities and their neurostructural underpinnings.

Methods

In the present study we investigated a well-characterized group of 14 patients with CLBP and 14 healthy controls applying structural MRI and psychometric measures. Using an improved algorithm for brain normalization (DARTEL) we performed a voxel-based morphometry (VBM) approach. Correlation analyses were performed to evaluate the role of anxiety and depression in neurostructural alterations observed in CLBP.

Results

The psychometric measures revealed significantly higher scores on depression and anxiety in the patient population. VBM analysis showed significant decreases in grey matter density in areas associated with pain processing and modulation, i.e. the dorsolateral prefrontal cortex, the thalamus and the middle cingulate cortex. With respect to anxiety and depression scores, we did not observe any correlations to the structural data.

Conclusions

In the present study we found compelling evidence for alterations of grey matter architecture in CLBP in brain regions playing a major role in pain modulation and control. Our results fit the hypothesis of a “brain signature” in chronic pain conditions. The results of the psychometric assessment underline the importance of an interdisciplinary therapeutic approach including orthopedic, neurological and psychological evaluation and treatment.