Non-inflammatory chronic pelvic pain syndrome

Non-inflammatory chronic pelvic pain syndrome (NICPPS, category IIIb according to the NIH classification) is a periodic pain in the lower abdomen, perineum, external genitalia, lumbosacral region observed for more than 3 months, accompanied or not accompanied by urinary disorders.

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Epidemiology

This form of the disease accounts for about 30% of all manifest forms of prostatitis.

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Causes non-inflammatory chronic pelvic pain syndrome.

The causes of non-inflammatory chronic pelvic pain syndrome have not been established. It is possible that autoimmune damage to the prostate gland against the background of the presence of an unidentified antigen is important.

There is an opinion that this disease is simulated by obstructive conditions associated with sclerosis of the bladder neck, detrusor-sphincter dyssynergia, urethral stricture, etc.

There is a hypothesis that non-inflammatory chronic pelvic pain syndrome is not related to the prostate gland. At the same time, neuromuscular dysfunction of the pelvic floor is indicated as the cause of the symptoms.

Pathologically, no changes in the prostate tissue are detected in chronic non-inflammatory bacterial prostatitis.

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Symptoms non-inflammatory chronic pelvic pain syndrome.

Symptoms of non-inflammatory chronic pelvic pain syndrome consist of pain and dysuric phenomena. The described symptoms are of an inconstant nature, and may have different combinations and severity.

Patients with NSCTB complain of periodic pain in the urethra, perineum, rectum, lower abdomen or lumbosacral region, associated or not associated with urination. False urges to urinate occur periodically. Patients note difficulty urinating, weak urine stream, accompanied by a feeling of incomplete emptying of the bladder.

For numerical evaluation and subsequent monitoring of treatment effectiveness, the NIN-CPSI questionnaire is used, as well as the International Prostate Symptom Scale IPSS with the definition of the quality of life index QoL. The latter scale helps to identify obstructive symptoms of urination disorders.

Diagnostics non-inflammatory chronic pelvic pain syndrome.

Laboratory diagnostics of non-inflammatory chronic pelvic pain syndrome is based on multi-portion urine tests. The diagnosis of category IIIb prostatitis when conducting a 4-glass test is established in the absence of an increase in leukocytes and a significant number of bacteria in the urine sample and PM 3. In the case of using a 2-glass test, similar characteristics are noted in the urine portion obtained after prostate massage.

All patients are recommended to undergo examination to exclude sexually transmitted diseases (testing of a smear from the urethra using the polymerase chain reaction method).

An analysis of the ejaculate is necessary (to detect the normal content of leukocytes and bacteria in the seminal fluid).

Instrumental methods

TRUS is not a mandatory diagnostic test for this disease, but its implementation can help identify changes in the prostate gland in the form of heterogeneous echogenicity (areas of increased echo density up to calcifications that produce clear acoustic shadows).

Uroflowmetry with determination of residual urine, voiding ultrasound (or multispiral computer) cystourethroscopy, complex urodynamic examination and optical urethrocystoscopy are necessary for differential diagnosis with obstructive diseases of the lower urinary tract, as shown in the diagnostic algorithm for non-inflammatory chronic pelvic pain syndrome.

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Differential diagnosis

Differential diagnosis is carried out with chronic bacterial prostatitis (category II) and inflammatory syndrome of chronic pelvic pain based on the results of a 4- or 2-glass test.

Non-inflammatory chronic pelvic pain syndrome should be differentiated from chronic urethritis. The diagnostic criterion is the results of the 4-glass test.

Differential diagnosis of non-inflammatory chronic pelvic pain syndrome and urethritis

Disease	4-glass test results (increased leukocytes/presence of bacteria)
	PM 1	PM 2	SPZH	PM 3
NSHTB	-/-	-/-	-/-	-/-
Chronic urethritis	+/+	-/-	-/-	-/-

NIPPS - non-inflammatory chronic pelvic pain syndrome, PM 1 - first portion of urine, PM 2 - second portion of urine, PM 3 - third portion of urine, PPS - prostatic secretion.

It is important to conduct differential diagnostics with obstructive diseases of the lower urinary tract (sclerosis of the bladder neck, detrusor-sphincter dyspergia, urethral stricture). For this purpose, appropriate additional studies are used, the sequence of which is given in the diagnostic algorithm (uroflowmetry with determination of residual urine → micturition ultrasound or multispiral computer cystourethroscopy → complex urodynamic study → optical urethrocystoscopy).

In men over 45 years of age, category IIIb prostatitis must be differentiated from prostate cancer and hyperplasia.

Examples of diagnosis formulation:

• Non-inflammatory chronic pelvic pain syndrome.
• Chronic abacterial non-inflammatory prostatitis.

Treatment non-inflammatory chronic pelvic pain syndrome.

The goal of treatment is to improve the patient's quality of life.

Indications for hospitalization

Treatment of chronic abacterial prostatitis is usually performed on an outpatient basis. If there are indications for surgical treatment, the patient is hospitalized on a planned basis.

Non-drug treatment

An active lifestyle, regular (at least 3 times a week) and protected sexual activity are recommended. Patients should adhere to a diet aimed at eliminating alcohol, carbonated drinks, spicy, pickled, salty and bitter foods.

Drug treatment

The treatment tactics for this disease have not been fully determined. Despite the absence of an infectious basis for NSCTB, it is legitimate to conduct a 14-day trial antibacterial therapy with fluoroquinolones (ofloxacin, ciprofloxacin, levofloxacin, moxifloxacin) or sulfonamides (sulfamethoxazole/trimethoprim). If the symptoms show positive dynamics, the treatment is continued for another 4-6 weeks.

In isolated studies of NSCLS, the effectiveness of alpha-1 blockers (tamsulosin, alfuzosin, doxazosin, terazosin), non-steroidal anti-inflammatory drugs (ibuprofen, diclofenac, indomethacin, celecoxib), muscle relaxants (baclofen, diazepam), and 5a-reductase inhibitors (finasteride, dutosteride) has been demonstrated.

In long-term (months-long) monotherapy of the disease, it is possible to use herbal preparations based on the extract of American fan-leaved (dwarf) palm (Serenoa repens), Cameroon plum (Pygeum qfricanum) or pollen of various plants (Phleum pratense, Seca le cereale, Zea mays).

There is scattered, low-certainty data on the effectiveness of various physical methods of treatment: electrical stimulation, thermal, magnetic, vibration, ultrasound and laser therapy, as well as acupuncture and prostate massage. The latter can be used up to three times a week throughout the treatment period. Prostate massage is contraindicated in the presence of a combination of non-inflammatory chronic pelvic pain syndrome with symptomatic hyperplasia or prostate cancer, true cysts of the organ, and prostatolithiasis (prostate stones).

Recently, the effectiveness of therapy using the negative feedback method has been studied. The method is based on the patient's independent training of the pelvic floor muscles under electromyographic control. Sufficient contraction of the pelvic diaphragm is indicated in the form of clear graphs on the monitor screen or using sound signals.

Surgical treatment

Single publications report the effectiveness of transurethral incision of the bladder neck, subtotal transurethral electroresection of the prostate gland, and radical prostatectomy. These treatment options require detailed indications and cannot be recommended for widespread use in clinical practice.

Prevention

Prevention of non-inflammatory chronic pelvic pain syndrome has not been developed.

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Forecast

Non-inflammatory chronic pelvic pain syndrome has a questionable prognosis in terms of patients' quality of life due to the low effectiveness of existing treatment methods.

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