Non-inflammatory syndrome of chronic pelvic pain

Non-inflammatory syndrome of chronic pelvic pain (NSHTB, category IIIb according to the NIH classification) - observed more than 3 months. Periodic pain in the lower abdomen, in the perineum, external genitalia, lumbosacral region, accompanied or not accompanied by impaired urination.

[1], [2], [3], [4], [5], [6]

Epidemiology

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

[7], [8], [9], [10], [11]

Causes of the noninflammatory syndrome of chronic pelvic pain

The causes of non-inflammatory syndrome of chronic pelvic pain have not been established. Perhaps the significance is an autoimmune lesion of the prostate gland against the background of the presence of an unidentified antigen.

There is an opinion that this disease simulates obstructive conditions associated with sclerosis of the neck of the bladder, detrusor-sphincter dissynergy, stricture of the urethra,

There is a hypothesis that non-inflammatory syndrome of chronic pelvic pain is not associated with the prostate gland. In this case, as reasons for the onset of symptoms indicate neuromuscular dysfunction of the pelvic floor.

Pathomorphologically, with chronic non-inflammatory bacterial prostatitis, no changes in prostate tissue are detected.

[12], [13], [14], [15]

Symptoms of the noninflammatory syndrome of chronic pelvic pain

Symptoms of noninflammatory syndrome of chronic pelvic pain consist of pain and dysuric phenomena. The described symptoms are of a non-permanent nature, can have different combination and severity.

Patients of the NSHTB complain of periodic pain in the urethra, perineum, rectum, lower abdominal areas or in the lumbosacral region, whether or not associated with urination. Periodically, there are false desires for the lecture. Patients report difficulty with urination, lethargy of the urine stream, accompanied by a feeling of incomplete emptying of the bladder.

For the numerical evaluation and subsequent monitoring of the effectiveness of treatment, the NIH-CPSI questionnaire is used, as well as the International Symptom Scope of Prostate Gland IBSS with the QoL Quality of Life Index. The last scale helps to identify obstructive symptoms of urination disorders.

Diagnostics of the noninflammatory syndrome of chronic pelvic pain

Laboratory diagnosis of noninflammatory syndrome of chronic pelvic pain is based on multiport  urinalysis. Diagnosis of prostatitis of category IIIb in the 4-sample sample is established in the absence of an increase in leukocytes and a significant number of bacteria in the SPL and PM 3. In the case of a 2-cup sample, similar characteristics are noted in the portion of urine obtained after the massage of the prostate gland.

All patients are shown a survey aimed at eliminating sexually transmitted diseases (smear examination from the urethra by polymerase chain reaction).

It is necessary to  analyze the ejaculate  (reveal the normal content of leukocytes and bacteria in the seminal fluid).

Instrumental methods

TRUS is not an obligatory diagnostic test for this disease, but its implementation can help to identify changes in the prostate gland in the form of heterogeneous echogenicity (areas of high echoltenance up to calcifications giving clear acoustic shadows).

Uroflowmetry with determination of residual urine, mixed ultrasound (or multispiral computer) cystourethroscopy, complex urodynamic examination and optical urethrocystoscopy are necessary for differential diagnosis with obstructive diseases of the lower urine of excretory pathways, as shown in the algorithm for diagnosis of noninflammatory syndrome of chronic pelvic pain.

[16], [17]

Differential diagnosis

Differential diagnostics is performed with chronic bacterial prostatitis (category II) and inflammatory syndrome of chronic pelvic pain but results of a 4 or 2-glass sample.

Non-inflammatory syndrome of chronic pelvic pain should be differentiated from chronic urethritis. Criterion of diagnosis - the results of a 4-glass sample.

 Differential diagnosis of noninflammatory syndrome of chronic pelvic pain and urethritis

Disease	The results of a 4-glass sample (increase of leukocytes / presence of bacteria)
	PM 1	PM 2	SPL	PM 3
NSHTB	- / -	- / -	- / -	- / -
Chronic urethritis	+ / +	- / -	- / -	- / -

NSHTB - non-inflammatory syndrome of chronic pelvic pain, PM 1 - the first portion of urine, PM 2 - the second portion of urine, PM 3 - the third portion of urine, SPL - the secretion of the prostate.

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

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

Examples of the diagnosis:

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

Treatment of the noninflammatory syndrome of chronic pelvic pain

The goal of the 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 prompt treatment, the patient is hospitalized in a hospital in a planned manner.

Non-drug treatment

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

Medication

The therapeutic tactics in this disease are not fully determined. Despite the absence of an infectious basis of NSHTB, it is legal to conduct 14-day trial antibacterial therapy with fluoroquinolones (ofloxacip, ciprofloxacin, levofloxacia, moxifloxacin) or sulfonamides (sulfamethoxazole / trimethoprim). With a positive dynamics of symptoms, treatment continues for another 4-6 weeks.

In single studies with NSXT, the effectiveness of a1-adrsposoblokatorov (tamsulosin, alfuzozin, doxazosin, terazosin), non-steroidal anti-inflammatory drugs (ibuprofen, diclofenac, indomethacin, celecoxib), muscular relaxants (baclofen, diazepam), 5a-reductase inhibitors (finasteride, dutosteride) .

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

There are scattered data of low degree of reliability about the effectiveness of various physical methods of influence: electrostimulation, thermal, magnetic, vibration, ultrasound and laser therapy, as well as acupuncture and massage of the prostate. The latter can be used up to three times a week throughout the treatment period. Massage of the prostate is contraindicated in the combination of noninflammatory syndrome of chronic pelvic pain with symptomatic hyperplasia or prostate cancer, the true cysts of the organ, and also in prostatolithiasis (prostate stones).

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

Surgery

In single publications, the effectiveness of the transurethral incision of the bladder neck, subtotal transurethral electroresection of the prostate and radical prostatectomy is reported. These treatment options require detailed indication and can not be recommended for wide application in clinical practice.

Prevention

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

[18], [19], [20], [21]

Forecast

The noninflammatory syndrome of chronic pelvic pain in relation to the quality of life of patients has a doubtful prognosis due to the low effectiveness of existing methods of treatment.

[22], [23], [24], [25]