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Chronic pelvic pain syndromes (CPPS) with special focus on chronic prostatitis (CP) and painful bladder syndrome / interstitial cystitis (PBS/IC)

“Impact on the Life of the Family”

 

ESU Course 8 at the EAU Annual Congress 2006

Published in EAU Congress News, Biermann Verlag GmbH; D-50997 Cologne(Germany), April 7, 2006, Paris

Thiscourse can be followed on EAU webcasts: www.uroweb.org/webcastseau2006 (ESU courses)
 

Chronic pain is a condition that often destroys life for the unfortunate patient suffering from this condition. In the worst cases, life becomes so unbearable, chronic pain can even result in suicide. A patient describes the impact on family life as follows:

 “PBS/IC has an impact on the life of the whole family. This gives the patient a feeling of intense guilt. The feeling that you are ruining everyone’s life around you because you cannot do all the things you used to be able to do.”  

We see patients with chronic pain in many areas of urology. These patients are difficult to treat and many feel insecure in how to handle the situation.

 

The course focuses on the two most frequent conditions in chronic pelvic pain: chronic prostatitis in the male and painful bladder syndrome predominant in the female.

The course covers diagnostic procedures and treatment strategy, so as to ensure that course participants can handle these patients in the future in the best possible way.

 
Prostate Pain Syndrome
Prostatitis is a poorly defined condition that encompasses the three elements of lower urinary tract symptoms, evidence of inflammation and prostate involvement. These features may exhibit varying degrees of involvement since the term primarily portrays a symptom set. The NIDDK system is the preferred classification and identifies four major subtypes of disease.

 

NIDDK system of classification of prostate pain syndrome
I Acute bacterial prostatitis    
II Chronic bacterial prostatitis    
III Chronic abacterial    
  A: Inflammatory (semen, secretion, urine)    
  B: Non-inflammatory    
IV Asymptomatic inflammatory prostatitis (histological)    
 
Diagnosis

In this educational course on CPPS, focus is placed on the diagnosis of CP type IIIB. Such a diagnosis is quite clearly a diagnosis of exclusion, with laboratory investigation of urine, secretion and semen being an important aspect in differentiating between bacterial, inflammatory and non-inflammatory prostatitis.

A specific test is the four-glass test where four aliquots of urine are obtained. These aliquots have been designated Voided Bladder 1 (VB1), Voided Bladder 2 (VB2), Expressed Prostatic Secretions (EPS), and Voided Bladder 3 (VB3). The VB1 is the initial 5-10 ml of urine voided (urethral portion), whereas VB2 is the midstream urine. The EPS is the secretions obtained after gentle prostatic massage, and the VB3 specimen is the initial 2-3 ml of urine obtained after prostatic massage. The value of these cultures for localization of UTIs is that the VB1 sample represents urethral flora , the VB2 bladder flora , and the EPS and VB3 samples prostatic flora. The VB3 sample is particularly helpful when there is little or no prostatic fluid obtained by massage. Although the four-glass test remains the gold standard, clinicians have more or less abandoned this time-consuming and expensive rigorous evaluation.

The premassage and postmassage test (or two-glass test), originally suggested by Weidner and Ebner (1985) and popularized by Nickel, is a simple, cost-effective screen to categorize CP patients. The patient provides a midstream premassage urine specimen and a urine specimen (initial 10 ml) after prostatic massage. Microscopy (sediment) and culturing of these two screening urine specimens allows categorization of the majority of patients presenting with CP.

 
Treatment
The treatment of patients with symptoms of CP has generally initially been based on the use of antimicrobial agents, although 90% of cases with CP were believed to be of non-bacterial aetiology. Interestingly, new randomized, placebo-controlled studies have found that 6 weeks of treatment with levofloxacin or ciprofloxacin were no better than placebo in ameliorating symptoms in patients with CP type II and especially type IIIA. Most patients in these studies were heavily pre-treated and results in naive patients have not been reported.

Adrenergic alpha-1-blockers have gained widespread acceptance especially in the treatment of patients with type III prostatitis. This is today confirmed by several, prospective, randomized, placebo-controlled studies showing their superiority to placebo in amelioration of symptoms. Treatment must be long-term, at least more than 6 weeks. Effects were better in patients with moderate to severe symptoms and naive to alpha-1-blockers.
 

Painful bladder syndrome / interstitial cystitis

The collective term painful bladder syndrome / interstitial cystitis (PBS/IC) includes a variety of conditions most commonly identified by symptoms. The pain, which is sometimes extreme, typically increases with bladder filling, is located suprapubically and may radiate to the groins, vagina, clitoris, penis, rectum or sacrum; it is relieved by voiding although it soon returns. Since symptoms invariably define the clinical condition, the term “bladder pain syndrome” or “painful bladder syndrome” is more apposite.

The genuine inflammatory form, the classical IC ulcer disease (Hunner’s lesion) is found in as few as 10% and up to 50% of cases. It represents a well-defined subset of IC, with special features concerning age, endoscopic and histological presentation, response to various treatments, neurobiological findings and mast cell expression compared to other presentations of IC.
 
 

webmaster's notes:

for definitions of painful bladder syndrome and interstitial cystitis: see the website of the European Society for the Study of IC/PBS (ESSIC)

the picture on the left shows the bladder mucosa with glomerulations: see the ESSIC consensus report for definitions

Interstitial cystitis

 
Treatment

Recommendations for treatment are difficult due to the lack of well-designed, prospective, controlled, randomized studies. Some recommendations can be derived from the ICI consultation 2004 and ESSIC group conclusions.
When a patient is diagnosed with PBS/IC, the next step is to determine whether treatment is needed. Some patients with minor symptoms may only need watchful waiting, while others will need oral treatment, bladder installations or even surgery. If a patient’s symptoms are tolerable with little impact on quality of life, waiting is reasonable.

Patient information, education and empowerment are important initial steps in treatment. The role of self-help groups may be important, but needs to be further evaluated.

 

Prof. Jørgen Nordling, Prof. Magnus Fall, Prof. Jean-Jacques Wyndaele

 
updated 29.05.2007 14:05 © 2006-2018 International Painful Bladder Foundation (IPBF). All rights reserved.