Syndrome of chronic pelvic pain at men
Syndrome of chronic pelvic pain at men (SHTB) - the persistiruyushchy or recurrent local pain in a small basin remaining within 3 months for the last half a year, which is not connected with infectious process. Along with pain symptoms are presented by discomfort to crotches, slackness of a stream of urine, frequent desires on an urination, sexual dysfunction. Clinical inspection includes TRUZI, bladder OUSE scanning, the analysis of a secret, tests for STD, cultural crops, determination of the DOG level. Treatment depends on a pathogenetic factor: the pharmacotherapy, psychotherapy, physical therapy, low-invasive surgery is used.
Syndrome of chronic pelvic pain at men
The syndrome of chronic pelvic pain mainly meets at abacterial chronic prostatitis, patients at the age of 45-50 years are most subject to it. However at a prostate gland biopsy histologic signs of an inflammation are found only in a third of patients that indicates a possible ekstraprostatichesky etiology of a syndrome. Negative influence of SHTB on quality of life is compared to that at a sharp myocardial infarction, stenocardia and a disease Krone. At 92% of men erectile dysfunction develops, from them 56% have a dispareuniya, at 31% - eyakulyatorny dysfunction, at 66% - decrease in a libido. Patients with morbid depression face pathology more often.
The pathophysiological mechanisms connected with a possible etiology of SHTB remain unknown. Scientists believe that clinical manifestations of a syndrome arise because of interaction of psychological incentives with dysfunction of immune, nervous and endocrine systems. As the main reasons consider:
- Not diagnosed inflammation. Some cases of abacterial prostatitis actually are not those as are connected with latentno the proceeding chronic urogenital infection. Hlamidiya, genital mycoplasmas, gonokokk, anaerobe bacterias, trichomonads, Candida, viruses which developed resistance to therapy are found in 47-75% of patients at deeper inspection, i.e. are in a condition of a parabiosis.
- Ischemia and kongestiya. Lack of a regular ejaculation, frequent locks, varicosity of veins of a small pelvis lead to violation of blood supply of a prostate. At ischemia the abacterial inflammation which outcome - prostate fibrosis with an atrophy of its glands develops. The chronic hypoxia - the satellite of ischemia - breaks gland functions: sekretorny, inkretorny, evakuatorny is also followed by a chronic pain syndrome.
- Other reasons. Prostate gland, rectum, bladder operations, injuries, urological manipulations can lead to damage of the nervous fibers innervating bodies of a small pelvis. Neurologic pathology (the compression and ischemic neuropathy, degenerate changes of intervertebral disks, diabetic polyneuropathy, pubic osteit, changes of nerves after radiation therapy) cause the pain typical for SHTB.
Carry irrational food to the promoting factors: alcohol intake, spices, coffee, a surplus in a diet of the greasy food leading to obesity. Overfatigue and stresses strengthen local production of the tsitokin supporting inflammatory process in a prostate gland. Lack of physical activity increases risk of development of a syndrome of chronic pelvic pain in men by 28%.
There are about 50 aspects of pathogenesis anyway explaining development of this pathology in men. A certain role in development of SHTB is carried out by the special alarm molecules called by tsitokina which are produced mainly by leukocytes. Under the influence of some conditions (for example, blood circulation violation, immunosupression) tsitokina stimulate development of inflammatory process. Factors of a necrosis of fabric, an interleykina, an interferona, a neutrophil - the activating factors are only some representatives of tsitokin. The imbalance of pro-inflammatory tsitokin and endogenous inhibitors is connected with development of an inflammation with the accompanying pain at patients with this syndrome. Genetic predisposition - violations in the sequences of DNA on the chromosomal sites responsible for regulation of production and action of various tsitokin, promotes emergence of persistiruyushchy painful manifestations.
Some researchers consider that own immunity is important in development of chronic pelvic pain. The immune system, except bacteria and toxins, begins to reject own healthy body tissues, in this case - a prostate gland. It is proved that testosterone protects a prostate from inflammatory process. Perhaps, its low level or violation of the mechanism at which testosterone inhibits an inflammation in a prostate gland at some men leads to this syndrome. Dysfunctions of nervous system at the local and/or central level can also provoke emergence of pain. The protein known as a factor of growth of nerves, leads to increase in their quantity and hypersensitivity because of what the syndrome becomes more expressed. Above-mentioned factors of pathogenesis can be combined with each other.
Considering variety of manifestations and change of degree of their intensity at SHTB, classification was developed for division of patients into subgroups taking into account the prevailing symptoms. This measure helps to define the most effective tactics of maintaining in each case. Classification of UPOINT includes 6 aspects:
- U - symptoms from urinary tract: dizurichesky frustration (feeling of incomplete depletion, the speeded-up urination), residual urine after an urination (measure by means of ultrasound).
- P - psychosocial manifestations: depression, depression of mood, sleeplessness, feeling of inferiority, fear, refusal of habitual occupations.
- O - the organospetsifichesky symptomatology connected with a prostate gland: reduction of painful manifestations after an urination, morbidity at a prostate palpation.
- I - the symptoms associated with an infection: allocations from an urethra, an itch, burning, painful feelings during an ejaculation.
- N - neurologic/system manifestations: the pain localized outside a basin.
- T - muscular symptoms: tension of pelvic skeletal muscles at a palpation, definition of trigger points.
Symptoms are similar to clinical manifestations at men with chronic bacterial and not bacterial prostatitis. Complaints to discomfort at an urination are typical, frequent desires, urination difficulty. Symptoms of obstruction of the lower urinary tract are followed by moderate or severe pain in the field of a basin, a lower back, a crotch or genitals. Pain can constantly be present or appear during a certain period, intensity of pain is variable: from the exhausting aching - to pronounced. Pain can amplify at the movement or is shown at rest.
Temperature reaction is normal, other speaks about a bacterial infection. The accompanying paresteziya (a penis head sleep, feeling of cold) are typical for neuropathic frustration. Erectile dysfunction at SHTB (weakening of an erection, a painful ejaculation, a premature ejaculation or difficulty in achievement of the culmination, an orgasm stertost) - the main reason for the address to the urologist or the andrologist.
As the syndrome of chronic pelvic pain at men is the diagnosis of an exception, on the basis of assessment of complaints and data of survey the algorithm of inspection is established for each patient individually. Initially the urologist excludes potentially life-endangering states (a prostate cancer and a bladder, an obstructive uropatiya) which can independently proceed or together with a prostatodiniya. Consultations of the neurologist, the oncologist, the psychotherapist and other experts can be useful. Clinical laboratory inspection is based on:
- Visualization methods. TRUZI, ultrasonography of a bladder with control of residual urine, doppler sonography, MRT of bodies of a small pelvis help to specify a condition of a prostate gland, existence of obstruction, feature of blood supply. These researches are directed to an exception of other diseases which are giving in to treatment, but any of them is not universal.
- To laboratory diagnostics. The main objective - STD exception. A prostate secret, eyakulit, sow urine on nutrient mediums for the purpose of identification of the activator and definition of its sensitivity to medicines, estimate by means of microscopy. Reliable correlation between quantity of leukocytes and bacteria with expressiveness of symptomatology is absent. Their increased quantity in a secret demonstrates infectious genesis. Performing PTsR-diagnostics is more preferable to identification of infectious agents. The DOG is investigated at men 45 years are more senior.
- Videourodinamichesky inspection. Assessment of an urodinamika shows symptoms of spastic dysfunction of a bladder and a pro-static part of an urethra. A main objective of a research - identification of the hidden neuropathies and selection of the correct scheme of treatment which will facilitate a state. Incomplete relaxation of a neck and narrowing of pro-static department of an urethra because of a sdavleniye a prostate testify to pathology.
- Tsistoskopiya. To Tsistoskopy carry out for data acquisition about an inflammation in a bladder, tumoral process. The sedation during inspection promotes the best filling that allows to diagnose interstitsialny cystitis. Besides, according to indications capture of a sample of fabric for a biopsy and performance of small interventions - removals of a polyp, treatment of a ring striktura of an urethra is possible.
Differential diagnostics is carried out with proktologichesky diseases: chronic crack of a rectum, syndrome of the angry intestines. From urology stones of a bladder, bacterial prostatitis, urogenital tuberculosis, tumoral processes of the urogenital sphere, prostate fibrosis can have similar manifestations.
Treatment of a syndrome of chronic pelvic pain leans on a pathogenetic factor. The least invasive ways are initially used, in case of their inefficiency performance of surgical intervention is possible. Maintaining tactics mainly conservative, it is extremely rare - quick:
- Medicinal therapy. Antibiotics, antiviral or antifungal medicines are appointed if connection with the infectious agent is established. At a noninfectious form of an inflammation NPVS, antioxidants, hormonal therapy (testosterone), alpha are shown. At the kongestivny and ischemic reasons of SHTB vasoprotectives and dezagregant, FDE-5 inhibitors, androgens, antioxidants appoint. At a neyropatichesky form use antioxidants, vitamins B, D, neuroprotectors. At a miogenny type of chronic pain the main medicines - miorelaksant.
- Physical therapy. Physiotherapeutic influence can promote elimination of different factors of SHTB. The electroacupuncture and chreskozhny stimulation of a nerve reduces a pain syndrome due to removal of a muscular spasm. The electrophoresis, magnetotherapy, laser and thermal influence, vibration, water - and mud cure, strengthen effect of medicines, increase concentration of active ingredient directly in the inflammation center, improve microcirculation that allows to apply physiotherapeutic techniques to treatment and prevention.
- Psychotherapy. Work with the psychologist or the psychotherapist (depending on the mental status of the patient), reception of the corresponding medicines (antidepressants, anksiolitik) promotes improvement of a psychoemotional component of a syndrome of pelvic pain. Use relaksiruyushchy techniques, technology of management of images, self-hypnosis, biological feedback, cognitive behavioural therapy.
- Surgical treatment. Operational ways include a bubble neck section, the TOUR of a prostate, a radical prostatektomiya which is used extremely seldom because of high invasiveness and risk of complications. The surgery at SHTB at men plays very limited role and demands further studying. Introduction of a botulotoksin And through an urethra in lateral shares of a prostate reduces a pain syndrome at 80% of men in 6 months of observation.
Prevention and forecast
The forecast depends on establishment of the fundamental reason and a possibility of its correction. There are no Patognomonichny preventive actions. It is recommended to patient to adhere to a healthy lifestyle, to exclude alcohol, spices and coffee from a diet, if necessary - to reduce body weight, to play sports (the pool, yoga, walking), to avoid stressful situations. Considering that in development of chronic prostatitis causative agents of venereal infections matter, casual sex has to be only with condom use. It is important to man to watch an ejaculation regularity as it provides drainage of a prostate gland, interferes with developments of stagnation of a small pelvis. At all symptoms of trouble from the urogenital sphere it is necessary to register in consultation of the urologist.