Perineal/pelvic pain in the male relates to either a well-defined pathology or one of the pain syndromes. Well-defined pathologies would include the cancers and infectious diseases that may produce pain; the management of such pathologic process will not be discussed in this chapter as treatment of the primary cause is described in numerous texts and is the treatment of choice when possible.
The pain syndromes, by definition, are poorly defined in terms of classical pathology; in particular, there is no evidence of tumor, infection or inflammation as a cause of pain. Over the past few years a number of mechanisms have been suggested that would explain some of the features of these conditions. In certain cases, most notably the pelvic neuralgias and myalgias, "classical pathological processes"
Evidence-Based Chronic Pain Management. Edited by C. Stannard, E. Kalso and J. Ballantyne. © 2010 Blackwell Publishing.
are being used to explain the mechanisms for the pain syndrome; in other cases "chronic pain mechanisms" are being invoked. Some of the pain syndromes will thus be recategorized, with time, into the well-defined pathology group.
Historically the perineal/pelvic pain syndromes were classified by a terminology that implied a pathologic process that could not be confirmed. For instance, testicular pain was referred to as "chronic orchitis" despite there being no evidence of infection or even inflammation. Other spurious terms used include "chronic prostatitis" for pain perceived to arise from the "prostate" and "interstitial cystitis" for pain perceived in the "bladder." The European Association for Urology (EAU) modified the axial taxonomy of the International Association for the Study of Pain in 2003, publishing a pain syndrome classification based on perceived site of pain. Pain perceived to be in the prostate, from the clinical history and examination, according to that taxonomy is to be known as prostate pain syndrome, pain perceived in the testis as testicular pain syndrome and in the bladder as bladder pain syndrome. This classification does not imply any pathologic process; in particular, it is not meant to imply a pain source in the organ, only that the perceived sensation appears associated with that organ. There may be associated symptoms such as swelling, urinary frequency or urgency and the mechanisms for these are beginning to be understood.
Most of the recent emphasis on classification has been in the fields of prostate pain and bladder pain. The NIH in 1990 included chronic prostate pain under its classification of "prostatitis." This is now considered by many to have been a mistake. However, it did allow clinicians to divide the chronic prostate pains into those with inflammation on examination of the prostatic secretions and those without evidence of inflammation (in both of these groups, by definition, there was no evidence of infection). Recent experience suggests that the mechanisms in both groups may be similar and that the presence of inflammatory cells has no therapeutic implications and does not affect prognosis. Recently, the European Association for the Study of Interstitial Cystitis (ESSIC) agreed that the term "interstitial cystitis" should be abandoned for the term bladder pain syndrome. It further subdivided the condition according to changes in the bladder seen on cystoscopy and biopsy.
The new taxonomy has had a number of consequences. First, patient groups and some clinicians have raised concerns about the implications of the name changes for "the sake of name change." These groups raise concerns about costs, particularly in those countries where a specific named diagnosis is necessary to obtain treatment. Second, there is a move away from an organ-based taxonomy and towards a mechanism-based approach. For the purpose of this chapter, we shall discuss evidence-based treatments as appropriate for both mechanism-based and organ-specific diagnoses.
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