Prostatodynia

Prostatodynia 

Prostatodynia is an uncommon cause of perineal pain in men. Also known as chronic nonbacterial prostatitis and chronic pelvic pain syndrome, prostatodynia probably is not a single clinical entity, but rather the conglomeration of a variety of disorders that can cause pain in this anatomical region. Included in these disorders are chronic infections of the prostate, chronic inflammation of the prostate without demonstrable infection, bladder outflow abnormalities, pelvic floor muscle disorders, reflex sympathetic dystrophy, and psychogenic causes. All have in common the ability to cause chronic, ill-defined perineal pain, which is the hallmark of prostatodynia.

The pain of prostatodynia is characterized by dull, aching, or burning pain of the perineum and underlying structures. The intensity of pain is mild to moderate and may worsen with urination or sexual activity. The pain may be referred to the penis, testicles, scrotum, or inner thigh. Irritative urinary outflow symptoms and sexual dysfunction often coexist with the pain of prostatodynia. 

Signs and Symptoms

Physical examination of patients with acute prostatodynia is directed at identifying acute bacterial infection of the prostate, urinary tract, or both. Patients with acute orchitis secondary to infections, including sexually transmitted diseases, have a prostate that is exquisitely tender to palpation. For patients with chronic prostatodynia, the physical findings are often nonspecific, with the prostate mildly tender to palpation, unless specific pathological processes are present. Allodynia of the perineum also often is present. Prostate malignancy always should be considered in any patient presenting with prostatodynia. Physical findings in this setting vary, but prostate enlargement is often an early finding.

Extraprostate pathological processes can occur with the primary symptom of prostatodynia. One of the most common causes of prostatodynia of extraprostate origin is malignancy involving pelvic contents other than the prostate. Tumor involving the lumbar plexus, cauda equina, or hypogastric plexus rarely can manifest as pain localized to the prostate and perineum. Postradiation neuropathy can occur after radiation therapy for the treatment of malignancy of the prostate and rectum and can mimic the pain of prostatodynia.

Testing

Digital examination of the prostate is the cornerstone of the diagnosis of patients with prostatodynia. Careful examination for tenderness, nodules, or tumor is crucial to avoid overlooking prostatic malignancy. Ultrasound examination of the prostate is indicated in all patients with prostatodynia. If any question of occult malignancy of the prostate or pelvic contents exists, magnetic resonance imaging (MRI), ultrasound imaging, or computed tomography (CT) of the pelvis is mandatory, as is laboratory determination of prostate-specific antigen (PSA) level. Positron emission tomography (PET) may help identify occult pelvic malignancy in selected cases. Acute infection of the prostate can elevate the PSA level. Urinalysis to rule out urinary tract infection is indicated in all patients with prostatodynia. The role of laboratory examination of postprostatic massage prostatic fluid in the evaluation of prostatodynia is unclear, as leukocyte elevation may be present in the absence of bacterial prostatitis, although anecdotal reports exist of the consistent finding of an elevated uric acid level in the prostatic fluid of patients with prostatodynia.

Electromyography helps distinguish radiation neuropathy from lumbar plexopathy or lumbar radiculopathy. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, uric acid, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. MRI of the lumbar plexus is indicated if tumor or hematoma is suspected.

Differential Diagnosis

Extraprostate pathology, including reflex sympathetic dystrophy and lesions of the lumbar plexus, nerve roots, and spinal cord, can mimic the pain of prostatodynia and must be included in the differential diagnosis. As mentioned earlier, because of the disastrous results of missing a diagnosis of prostatic malignancy when evaluating and treating patients thought to have prostatodynia, it is mandatory that malignancy be high on the list of differential diagnostic possibilities. It is also important to correctly diagnose any underlying causes of prostatitis because some are readily amenable to treatment with antibiotics

Distinguishing Features of Prostate Syndromes

SyndromeConfirmed UtiProstate ExaminationProstatic FluidResponse to AntibioticsImpaired Urinary Flow
White Blood CellCulture
Acute bacterial prostatitisYesTender, warmYesYesYesYes
Chronic bacterial prostatitisUsuallyVariedYesYesSlow±
Nonbacterial prostatitisNoVariedYesNoPoor±
ProstatodyniaNoUsually normalNoNoNoYes

UTI, Urinary tract infection. From Lummus WE, Thompson I. Prostatitis. Emerg Med Clin North Am . 2001;19:691–707.

Treatment

Initial treatment of the pain associated with prostatodynia should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors. The local application of heat and cold with sitz baths also may be beneficial. An arbitrary treatment course of antibiotics, such as doxycycline 100 mg twice daily for 2 weeks, may be worth trying, even though urine cultures are negative.

Anecdotal reports of decreased pain after treatment with allopurinol make this drug a consideration for patients who continue to have pain. For patients who do not respond to these treatment modalities, caudal epidural nerve blocks with a local anesthetic and steroid may be a reasonable next step.

Psychological evaluation and interventions should occur concurrently with the aforementioned treatment modalities, given the high incidence of coexistent psychological issues associated with all pelvic pain syndromes.

Complications and Pitfalls

The major pitfalls in the care of a patient with prostatodynia are threefold: (1) the misdiagnosis of extraprostate pathological processes responsible for the patient’s pain, (2) the failure to identify prostate malignancy, and (3) the failure to address the psychological issues surrounding the patient’s pain.

Clinical Pearls

The clinician should be aware that the relationship of the genitalia to the male psyche presents some unique challenges for the clinician treating patients with prostatodynia.

The behavioral and psychological issues must be addressed concurrently with the medical issues if treatment is to be successful.

The possibility for prostate malignancy is ever present and should be carefully sought in all patients with prostatodynia.


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