Traditional therapy for chronic pelvic pain does not work: what do we do now?

The dilemma of managing patients with chronic pelvic pain syndromes continues to frustrate physicians confronted with these complaints. Multiple diagnoses traditionally label this condition in men and women and, typically, implicate a pelvic-organ system when, in fact, very little objective evidence for a pathophysiologic process exists. Traditional therapies, consisting of antibiotics, anti-inflammatories, and muscle relaxants, simply do not work, and their lack of efficacy compared with placebo has been documented by randomized clinical trials in the US that were sponsored by the NIH. What do we do now? This review article attempts to describe the clinical efforts of several investigators and to put their patients' outcomes in perspective, and thereby suggest alternative therapies to help these patients. Key Points - Traditional therapy for chronic pelvic pain (CPP) relies on conventional oral agents that have been used for many years without substantial evidence for efficacy - Carefully conducted, randomized, placebo-controlled trials show no efficacy for antibiotic therapy in nonbacterial pelvic pain syndromes - There is clear evidence that α-blocker therapy could be beneficial in male CPP syndrome - There is very little published evidence that CPP implies an inflammatory process, although emerging studies have demonstrated the upregulation of proinflammatory and inflammatory cytokines as well as neurotransmitters - Pilot exploration of therapeutic trials designed to inhibit neuromuscular transmission of painful stimuli seem promising, but randomized, controlled studies are necessary - CPP, like other chronic pain syndromes, seems to occur as a biopsychosocial phenomenon This is a preview of subscription content, access via your institution Access options Subscribe to this journal Receive 12 print issues and online access 176,64 € per year only 14,72 € per issue Buy this article - Purchase on SpringerLink - Instant access to the full article PDF. 39,95 € Prices may be subject to local taxes which are calculated during checkout Similar content being viewed by others

Schaeffer AJ et al. (2002) Overview summary statement, diagnosis, management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Urology 60: 1–4 Nickel JC et al. (2003) Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial. Urology 62: 614–617 Weidner W (2004) Treating chronic prostatitis: antibiotics no, α-blockers maybe. Ann Intern Med 141: 639–640 Alexander RB et al. (2004) Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann Intern Med 141: 581–589 Theodorou C et al. (1999) The urodynamic profile of prostadynia. BJU Int 84: 461–463 Cheah PY et al. (2003) Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized, placebo controlled trial. J Urol 169: 592–596 Mehik A et al. (2003) Alfuzosin treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, double-blind, placebo-controlled, pilot study. Urology 62: 425–429 Nickel JC et al. (2004) Treatment of chronic prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomized, double blind trial. J Urol 171: 1594–1597 Nickel JC et al. (2003) Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol 170: 818–822 Nickel JC et al. (2003) A randomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis. J Urol 169: 1401–1405 Bresalier RS et al. (2005) Cardiovascular events associated with rofecoxib in a colorectal chemoprevention trial. N Engl J Med 17: 1092–1102 Rugendorff EW et al. (1993) Results of treatment with pollen extract (Cernilton N) in chronic prostatitis and prostatodynia. Br J Urol 71: 433–438 Hwang P et al. (1997) Efficacy of pentosan polysulfate in the treatment of interstitial cystitis: a meta-analysis. Urology 50: 39–43 Nickel JC et al. (2005) Randomized, double-blind, dose-ranging study of pentosan polysulfate sodium for interstitial cystitis. Urology 65: 654–658 Nickel JC et al. (2005) Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicenter, randomized, placebo controlled study. J Urol 173: 1252–1255 Sairanen J et al. (2005) Cyclosporine A and pentosan polysulfate sodium for the treatment of interstitial cystitis: a randomized comparative study. J Urol 174: 2235–2238 Nickel JC et al. (2004) A randomized placebo-controlled multicentre study to evaluate the safety and efficacy of finasteride for male chronic pelvic pain syndrome (category IIIA chronic nonbacterial prostatitis). BJU Int 93: 991–995 Kaplan SA et al. (2004) A prospective, 1-year trial using saw palmetto versus finasteride in the treatment of category III prostatitis/chronic pelvic pain syndrome. J Urol 171: 284–288 van Ophoven A et al. (2004) A prospective, randomized, placebo controlled, double-blind study of amitriptyline for the treatment of interstitial cystitis. J Urol 172: 533–536 De Rose AF et al. (2004) Role of mepartricin in category III chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized prospective placebo-controlled trial. Urology 63: 13–16 Shoskes DA et al. (1999) Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology 54: 960–963 Payne CK et al. (2005) Intravesical resiniferatoxin for the treatment of interstitial cystitis: a randomized, double-blind, placebo controlled trial. J Urol 173: 1590–1594 Doggweiler-Wiygul R and Sellhorn E (2002) Role of behavioral changes and biofeedback in urology. World J Urol 20: 302–305 Glazer HI et al. (1995) Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 40: 282–290 McKay E et al. (2001) Treating vulvar vestibulitis with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 46: 337–342 Glazer HI et al. (1999) Pelvic floor muscle surface electromyography. J Reprod Med 44: 779–782 Clemens JQ et al. (2000) Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology 56: 951–955 Cornel EB et al. (2005) The effect of biofeedback physical therapy in men with chronic pelvic pain syndrome type III. Eur Urol 47: 607–611 Kaplan SA et al. (1994) Urodynamic evidence of vesical neck obstruction in men with misdiagnosed chronic nonbacterial prostatitis and the therapeutic role of endoscopic incision of the bladder neck. Urol Neurol Urodyn 152: 2063–2065 Nickel JC and Sorensen R (1996) Transurethral microwave thermotherapy for nonbacterial prostatitis: a randomized double-blind sham controlled study using new prostatitis specific assessment questionnaires. J Urol 155: 1950–1955 Serel TA et al. (1997) Treatment with neodymium:YAG laser in patients with chr onic prostatitis: a preliminary report. Intl Urol Nephrol 29: 53–58 Leskinen MJ et al. (2002) Transurethral needle ablation for the treatment of chronic pelvic pain syndrome (category III prostatitis): a randomized sham-controlled study. Urology 60: 300–304 Chiang PH and Chiang CP (2004) Therapeutic effect of transurethral needle ablation in non-bacterial prostatitis: chronic pelvic pain syndrome type IIIa. Intl J Urol 11: 97–102 Ripoll E and Mahowald D (2002) Hatha yoga therapy management of urologic disorders. World J Urol 20: 306–309 Jacobson E (1929) Progressive Relaxation. Chicago and London: The University of Chicago Wise D and Anderson RU (2005) A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes, edn 3, 19–170. Occidental, CA: National Center for Pelvic Pain Research Anderson RU et al. (2005) Integration of myofascial trigger point release and paradoxical relaxation training for treatment of chronic pelvic pain. J Urol 174: 155–160 Savidge CJ and Slade P (1997) Psychological aspects of chronic pelvic pain. J Psychosom Res 42: 433–444 Miller HC (1988) Stress prostatitis. Urology 32: 507–510 Gatenbeck L et al. (1987) Stress stimuli-induced histopathological changes in the prostate: an experimental study in the rat. Prostate 11: 69–75 Chen R and Nickel JC (2003) Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 61: 1156–1159 Honjo H et al. (2004) Effects of acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion: preliminary results. Int J Urol 11: 607–612 Maan Z et al. (2004) Alternative use of botulinum toxin in urology. Expert Opin Pharmacother 5: 1015–1021 Mense S (2004) Neurobiological basis for the use of botulinum toxin in pain therapy. J Neurol 251 (Suppl 1): 11–17 Zermann D et al. (2000) Perisphincteric injection of botulinum toxin type A: a treatment option for patients with chronic prostatic pain? Eur Urol 38: 393–399 Jarvis SK et al. (2004) Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles. Aust NZ J Obstet Gynaecol 44: 46–50 Smith CP et al. (2004) Botulinum toxin A has antinocioceptive effects in treating interstitial cystitis. Urology 64: 871–875 Cui M et al. (2004) Subcutaneous administration of botulinum toxin type A reduces formalin-induced pain. Pain 107: 125–133 Leippold T et al. (2003) Botulinum toxin as a new therapy option for voiding disorders: current state of art. Eur Urology 44: 165–174 Goschel H et al. (1997) Botulinum A toxin therapy: neutralizing and nonneutralizing antibodies-therapeutic consequences. Exp Neurol 147: 96–102 Comiter CV (2003) Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol 169: 1369–1373 Chai TC et al. (2000) Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis. Urology 55: 643–646 Fitzwater JB et al. (2003) Electrical stimulation in the treatment of pelvic pain due to levator ani spasm. J Reprod Med 48: 573–577 Nappi RE et al. (2003) Electrical stimulation (ES) in the management of sexual pain disorders. J Sex Marital Ther 29: 103–110 Peters KM and Konstandt D (2004) Sacral neuromodulation decreases narcotic requirements in refractory interstitial cystitis. BJU Int 93: 777–779 Siegel S et al. (2001) Sacral nerve stimulation in patients with chronic intractable pelvic pain. J Urol 166: 1742–1745 John H et al. (2003) A new high frequency electrostimulation device to treat chronic prostatitis. J Urol 170: 1275–1277 Schmidt RA et al. (1999) Sacral nerve stimulation for treatment of refractory urinary urge incontinence. J Urol 162: 352–357 Deer TR (2001) Current and future trends in spinal cord stimulation. Curr Pain Headache Rep 5: 503–509 Rowe E et al. (2005) A prospective, randomized, placebo controlled, double-blind study of pelvic electromagnetic therapy for the treatment of chronic pelvic pain syndrome with 1 year of follow-up. J Urol 173: 2044–2047 Ramsden CE et al. (2003) Pudendal nerve entrapment as source of intractable pain. Am J Phys Med Rehabil 82: 479–484 Robert R et al. (1998) Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat 20: 93–98 Amarenco G et al. (1997) Treatments of perineal neuralgia caused by involvement of the pudendal nerve. Rev Neurol (Paris) 153: 331–334 Shafik A (1998) Pudendal canal syndrome as a cause of vulvodynia and its treatment by pudendal nerve decompression. Eur J Obstet Gynecol Reprod Biol 80: 215–220 Bautrant E et al. (2003) Modern algorithm for treating pudendal neuralgia: 212 cases and 104 decompressions. J Gynecol Obstet Biol Reprod (Paris) 32: 705–712 Magni G et al. (1986) Psychological findings in chronic anal pain. Psychopharmacology 1: 170–174 Henry C et al. (1991) Chronic anogenital and perineal pain. Clinical and psychopathological characteristics of a syndrome. Rev Med Suisse Romande [French] 111: 27–32 Mauillon J et al. (1999) Results of pudendal nerve neurolysis-transposition in twelve patients suffering from pudendal neuralgia. Dis Colon Rectum 42: 186–192 Author information Authors and Affiliations Corresponding author Ethics declarations Competing interests The author declares no competing financial interests. Rights and permissions About this article Cite this article Anderson, R. Traditional therapy for chronic pelvic pain does not work: what do we do now?. Nat Rev Urol 3, 145–156 (2006). https://doi.org/10.1038/ncpuro0438 Received: Accepted: Issue date: DOI: https://doi.org/10.1038/ncpuro0438 This article is cited by - The role of pelvic floor therapies in chronic pelvic pain syndromes Current Prostate Reports (2008) - Frequency, urgency, and pelvic pain: Treating the pelvic floor versus the epithelium Current Urology Reports (2006)