Chronic pelvic pain syndrome – causes and treatment

Definition

Chronic pelvic pain syndrome, abacterial, non-inflammatory type, is not just “chronic prostatitis”. It is a set of symptoms associated with inflammatory processes in the seminal tracts (seminal vesicles and seminal ducts), dysfunction of the seminal tracts. The mechanism of occurrence and development of the disease is complex, mainly consisting in the reflux of urine that occurs during urination.

Symptoms

• Pain in the groin area, which may extend to the testicle, inner thighs, coccyx, anus
• Pain may increase after ejaculation or urination
• Increased urges to urinate
• Difficulty in urination, reduced intensity of urination, splashing and interruption of the stream, especially in the morning. The presence of a small residual amount of urine, which flows from the urethra 15-30 seconds after stopping the act of urination.
• Presence of yellow mucus in the ejaculate
• Decreased erection

The essence of the disease

There is reactive swelling and sometimes a so-called proliferative inflammation around the seminal vesicles. It is not the seminal duct or the seminal vesicle itself that is inflamed, but the tissue around it. Infiltrates are formed – dense formations, something like fibrosis. They are very difficult to see with standard hardware diagnostic methods. You can see them on the latest ultrasound machine with a certain methodology, as well as on an MRI with special image processing.

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These dense masses are usually in the area of the neurovascular bundles in the projection of the seminal vesicle and ampulla of the seminal duct, at some distance from the prostate contour.

On the basis of examination of hundreds of patients, infiltrates were detected in 93% of patients initially diagnosed with CPPS (chronic pelvic pain syndrome).

Occurrence of chronic pain syndrome

Swelling develops, squeezes nearby tissues, the blood circulation in small nerve structures is disrupted, and severe pain begins. Often the nerve structures are also inflamed. 

Therefore, this process is often accompanied by pain of different nature and localization.

Why can the pain be concentrated in the area of the prostate gland, and not in the seminal vesicles or ducts?

The two seminal ducts, which approach the prostate, pass through the thickness of the prostate gland. When there is irritation and swelling in them, there is innervation of the same area as the prostate, so there is often pain over the pubis and burning there.

Causes

• Pelvic vegetative neurosis, dysfunction of the seminal vesicles and vas deferens, prostate
• Reflux of urine into the prostatic exit ducts and common vas deferens

Pelvic vegetative neurosis

Pelvic vegetative neurosis is a dysregulation of the local nervous system. 

The consequences of pelvic vegetative neurosis

Dysfunctions of the seminal vesicles and the seminal duct cause abnormal secretory and evacuatory functions, poor liquefaction and emptying disorders. Impaired emptying, in turn, causes an accumulation of secretion and its decomposition, which strongly irritates the walls of the seminal tract.

Destruction of the urothelium

Sometimes disorders lead to the destruction of the urothelium (the cells lining the vas deferens), disrupting its ability to resist both seminal fluid with sperm and urine. This also leads to irritation of the vas deferens.

Causes of pelvic pelvic vegetative neurosis

• severe or prolonged stress, psychological problems, neurosis, anxiety, depression (causing unconscious pelvic tension, increased muscle and sympathetic nerve tone)
• peculiarities of vegetative system
• defective sexual process
• traumas
• past infections
• pinched pudendal nerve

Urinary reflux

Reflux is the backflow of urine into the prostate exit ducts and common vas deferens during urination.

Causes of reflux

There can be many causes:

• Forced urinary retention
• Spasm of the urogenital diaphragm and the external sphincter of the bladder
• Vegetative neurosis – expressed in the fact that as soon as urination begins, the external sphincter reacts to the passage of urine itself and spasm occurs.

Consequences of reflux

The encounter between the prostate secretion and the seminal tract which is sharply alkaline and the urine which has an acidic pH causes a neutralization reaction with the formation of salt and water.

Salt is a strong irritant and destroys the membrane of the urothelium. Inflammation develops in the walls of the seminal vesicles, the outlet ducts of the prostate, with subsequent reactive inflammation of the surrounding tissues, but without signs of a leading role of infection in the mechanism of inflammation.

Diagnosis

1. Finger examination of seminal vesicles and vas deferens
2. Uroflowmetry
3. Pappenheim microscopic examination of the seminal tract secretion

Finger examination

Be sure to ask your urologist to perform a thorough rectal finger examination in the projection area of the seminal vesicles and vas deferens, which allows you to detect painful masses.

Normally, if there is no inflammation, this area is not palpated at all and it is impossible to distinguish palpatorily between the ampullary section of the seminal duct and the seminal vesicle itself.

However, with prolonged inflammation, especially with pain syndrome and frequent exacerbations, this area becomes hard and well visualized by palpation.  And, as a rule, a painful and dense common seminal duct running to the posterior urethra through the prostate is palpable.

These seals can be from 5 mm to several centimeters in size.

Important fact: often patients note the identity of his own pain, with the pain resulting from palpation of these masses.

How to conduct the study correctly?

In the classic knee-elbow position position it will not be possible to palpate these masses: the pelvic diaphragm is strained, the finger does not go deep.

But if you put the patient on the stomach (the pelvic diaphragm is relaxed), with your left hand you press on the wing of the left iliac bone, and with your right hand your finger goes in rectally. Then you can go deep and feel these masses.

Uroflowmetry

Uroflowmetry helps to obtain information about the deviation of the urination process from the norm, about the functional state of the bladder detrusor and the patency of the urinary tract.

But it is important to consider that the uroflowmetry performed may give contradictory results for bladder neck resistance every time: from no signs at one examination, to pronounced signs at the next examination literally the next day.

Microscopic analysis of seminal tract secretions with Pappenheim staining

The analysis must be done with digital photographs, with Pappenheim staining. The doctor or lab technician processing the analysis must be good at interpreting the results. This is very important because the tests are often done automatically, superficially, without going into detail.

What is characteristic of the tests?

The analysis should be done with digital photographs and Pappenheim staining. The doctor or lab technician performing the test must be good at interpreting the results. This is very important because the tests are often done automatically, superficially, without diving into the details.

What is characteristic in the tests?

• Colloidal mucus forms with prolonged inflammation. Mucous plugs from the conduits are quite visible under the microscope with some staining.
• Most patients show no signs of inflammation in the prostate secretion: no or scanty white blood cell count. Although the secretion itself is altered, does not have a classical shape, does not have the proper number of lecithin grains, the phenomenon of crystallization of the secretion, one of the main indicators, is disturbed. The secretion often loses its normal consistency and upon fixation with subsequent staining some phenomenon of amorphous crystallization in the form of “cracked earth” pattern is noted.
• The secretion often contains a large amount of desquamated epithelium lining the seminal ducts from the inside.
• Presence of spermatozoa in colloidal viscous mucus
• Presence of urine salt crystals

Treatment

The treatment method is described in detail in our Facebook group.