Guidelines For The Diagnosis And Treatment Of Chronic Prostatitis/chronic Pelvic Pain Syndrome Ⅱ
Nov 06, 2024
2.6 Differential diagnosis
2.6.1 Differentiation from pain-related diseases
2.6.1.1 Interstitial cystitis
Interstitial cystitis is mainly manifested by characteristic pain and frequent urination. The former is pain that occurs and worsens with bladder filling, and the pain is relieved after urination. Cystoscopy can confirm the diagnosis by finding Hunner ulcers. For patients with frequent urination and characteristic pain, positive erythema on cystoscopic examination is also of diagnostic significance [62].
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2.6.1.2 Cystitis glandularis
The clinical symptoms of cystitis glandularis and CP/CPPS are often similar. The EPS of patients with inflammatory CP/CPPS may show leukocytosis and a significant decrease in lecithin bodies, while the EPS of patients with cystitis glandularis is normal. In addition, cystoscopy of patients with cystitis glandularis can reveal lesions such as triangular follicles in the bladder, and pathological biopsy can confirm the diagnosis [63].
2.6.1. 3. Seminal vesiculitis
Seminal vesiculitis often occurs with CP/CPPS, and may cause pain in the lower abdomen and perineum and discomfort during urination. Patients with seminal vesiculitis may experience hematospermia and pain during ejaculation. Rectal examination can palpate an enlarged seminal vesicle, which may be tender and fluctuating. Routine examination of semen can reveal a large number of red blood cells. Transrectal ultrasonography of the seminal vesicle can assist in diagnosis, and seminal vesiculography can confirm the diagnosis [64].
2.6.1.4 Epididymitis
Physical examination of patients with chronic epididymitis can palpate an enlarged and indurated epididymis with no obvious tenderness. Scrotal ultrasonography can further confirm the diagnosis [65].
2.6.1.5 Digestive system diseases
For example, irritable bowel syndrome is a common functional gastrointestinal disease with abdominal pain and discomfort as the main manifestations, which may be accompanied by extraintestinal symptoms such as frequent urination and urgency. The symptoms of this type of digestive system disease are often related to defecation [66-67].
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2.6.2 Differentiation of diseases related to abnormal urination
2.6.2.1 Benign prostatic hyperplasia (BPH)
The clinical manifestation of BPH is mainly LUTS, and pain is not a typical symptom. It can be differentiated from CP/CPPS through rectal examination, prostate ultrasound, uroflowmetry and other examinations [68-69].
2.6.2.2 OAB
OAB is a syndrome characterized by urgency symptoms, often accompanied by frequent urination and nocturia, and may be accompanied by urge incontinence. It can be differentiated through EPS and urodynamic examinations [70].
2.6.2.3 Neurogenic bladder
It is a general term for a class of diseases caused by bladder and/or urethral dysfunction due to nervous system lesions, which in turn produce a series of LUTS and complications. Therefore, the diagnosis of neurogenic bladder must have a clear history of related nervous system diseases. CP/CPPS can be differentiated from urethral stenosis by medical history, neurological examination and urodynamic examination [71].
2.6.2.4 Reproductive tract infection
CP/CPPS is common in young and middle-aged men, who are also the group with more frequent sexual activities. In addition to LUTS, patients with urethritis may also have redness and swelling of the urethral orifice and urethral discharge, which can be differentiated from CP/CPPS by urethral discharge smear and bacterial culture [72-73].
2.6.2.5 Prostate cancer
Serum prostate-specific antigen (PSA), prostate ultrasound examination, and MRI can be used for differentiation. If necessary, prostate puncture biopsy can be performed [74].
2.6.2. 6 Bladder tumors
Muscle-invasive bladder cancer and carcinoma in situ of the bladder often present with lower abdominal pain and bladder irritation symptoms. Middle-aged and older patients with red blood cells in urine routine examination should undergo urinary system ultrasound, CT and MRI for differentiation. Cystoscopy can be performed if necessary [75].
2.6.2.7 Prostate stones
It can present with different degrees of LUTS. Rectal examination can palpate the prostate with a stone friction sensation.
Prostate ultrasound and CT can confirm the diagnosis [76].
2.6.2.8 Lower ureteral stones
Some patients with lower ureteral stones have atypical clinical symptoms, without obvious symptoms such as renal colic, but only lower urinary tract syndrome such as frequent urination and urgency. Urinalysis, urinary system color Doppler ultrasound and CT can be used for differentiation [77].
2.6.2. 9 Posterior urethral stones
Posterior urethral stones with incomplete obstruction often present with symptoms such as frequent urination, urgency, pain, and dysuria, which are similar to CP/CPPS. Urinalysis, urinary ultrasound, and CT can be used to differentiate them [78].
2.6.2.10 Pelvic floor muscle dysfunction
Because the pelvic floor muscles are involved in male urination and reproductive system activities, pelvic floor muscle dysfunction often coexists with a variety of diseases including ED and CP/CPPS. EPS routine examinations can be performed to differentiate them [79].
2. 6. 3 Identification of other related diseases
2. 6. 3. 1 Prostate and seminal vesicle tuberculosis
Prostate and seminal vesicle tuberculosis have no obvious clinical symptoms, but may cause occasional discomfort in the rectum and perineum. In severe cases, patients may experience hematospermia, decreased semen volume, sexual dysfunction, and infertility. Rectal examination may palpate prostate and seminal vesicle nodules, which are usually painless. Patients often have a history of urinary tuberculosis or tuberculosis in other parts of the body: pulmonary CT can confirm the presence of pulmonary tuberculosis lesions, urinary CT can confirm the presence of urinary tuberculosis lesions, EPS acid-fast staining can find acid-fast bacilli, and Mycobacterium tuberculosis culture can confirm the diagnosis.
2. 6. 3. 2 Lumbar sacral spine, hip joint and sports medicine related diseases
Diseases such as lumbar disc herniation, lumbar spondylolisthesis and lumbar muscle strain may also manifest as discomfort in the lumbar sacral region, and hip joint diseases may manifest as ipsilateral groin pain. If necessary, X-ray films, CT, MRI and other related examinations can be performed for differentiation.
2.6.3.3 Mental and psychological diseases
CP/CPPS patients often have symptoms such as anxiety and depression, and there is a clear correlation between symptoms and severity; and some patients with anxiety and mood disorders may have abnormal urination symptoms, which currently have certain difficulties in differential diagnosis. If necessary, a psychiatrist can be consulted to assist in diagnosis, supplemented with appropriate drug treatment.
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3 Treatment of CP/CPPS
3.1 Treatment principles
① Actively seek the cause, try to treat the cause, and adopt symptomatic treatment plans at the same time.
② For most patients with no clear cause and significant symptoms, symptomatic treatment is used to control symptoms and improve the patient's quality of life.
③ Combined use of multiple treatment plans, and if necessary, a multidisciplinary treatment model (multiple disciplinary treatment, MDT) can be adopted [80-81].
3.2 General treatment of CP/CPPS
3.2.1 Improve lifestyle
A good lifestyle can play a positive role in the treatment of CP/CPPS patients [82]. Long-term urinary retention, staying up late or working at night, smoking, drinking, dietary preferences, and excessive sexual activity are all potential risk factors for CP/CPPS [83]. Therefore, correcting the above factors can reduce the occurrence of CP/CPPS and alleviate the various symptoms induced by the above factors.
3. 2.2 Psychological counseling
The symptoms of CP/CPPS can seriously affect the patient's psychological state, causing psychological problems such as anxiety, depression, and pain catastrophizing [84]. Therefore, urologists should pay attention to the mental and psychological state of CP/CPPS patients and provide appropriate psychological counseling based on the actual clinical situation; they can also conduct MDT diagnosis and treatment in conjunction with relevant departments such as the Department of Psychology. The patient's spouse should be advised to actively cooperate with the patient's daily activities and maintain a harmonious relationship [84]. Effective psychological counseling can often benefit patients more from treatment.
3.2.3 Formulate a self-management plan
Physical activity is an important self-management content for CP/CPPS patients. Studies have shown that physical activity is negatively correlated with the risk of CP/CPPS, suggesting that moderate physical activity can reduce the risk of CP/CPPS [85]. In addition, regular sex can also help CP/CPPS patients improve their symptoms; regular sex can promote the discharge of inflammatory substances in the prostate gland and relieve pain and abnormal urination in the prostate area [86].
3.2. 4 Physical therapy at home
Including hot water sitting bath, hot compress on the lower abdomen, etc.［87-88］.
3.3 CP/CPPS
Chemical drug treatment CP/CPPS has various causes and heterogeneous clinical manifestations. Individualized comprehensive treatment should be adopted to improve efficacy and quality of life. Commonly used drugs are as follows.
3.3.1 Antibiotics
Although there is no clear evidence of bacterial infection in inflammatory CP/CPPS［89］, empirical use of antibiotics can improve clinical symptoms in some patients, such as levofloxacin, ciprofloxacin, prulifloxacin, and moxifloxacin and other fluoroquinolone drugs［90-91］, macrolide drugs (such as azithromycin) or tetracycline drugs (such as minocycline)［92］. Antibiotics are not recommended for non-inflammatory CP/CPPS.
3.5 Treatment by Traditional Chinese Medicine Traditional Chinese Medicine advocates syndrome differentiation and treatment combined with comprehensive treatment, and pays attention to lifestyle and diet adjustment.
The onset of CP/CPPS is often attributed to the six causes of dampness, heat, cold, stasis, depression, and deficiency [110], among which "stasis" is the key to the pathogenesis [111]. The basic treatment principles are to clear away the dampness, nourish the kidney, soothe the liver, and remove stasis and turbidity. However, the primary and secondary should be distinguished, and the use of drugs should be weighed. Do not blindly clear away the dampness or overuse warming and nourishing [112].
3.5.1 Damp-heat and stasis syndrome
If dampness and heat are prevalent, the symptoms of abnormal urination are obvious, such as frequent urination, urgency, pain, burning sensation in the urethra, dripping after urination, occasional white turbidity at the end of urination or during defecation, damp scrotum, dry mouth and bitter taste. Red tongue coating yellow or yellow greasy, slippery and rapid pulse or stringy and rapid pulse. Treatment: Clear away heat and dampness, and assist with blood circulation. Recommended prescriptions: Cheng's Radix Dihuangqingyin, Bazhengsan, Longdanxiegan Decoction with modifications. Recommended Chinese patent medicines: Longjintonglin Capsules [113], Ningmitai Capsules [114], Niuqingshu Granules [115], Xueniaoan Capsules [116], Qianlieshutong Capsules [117], Huangbai Bawei Tablets [118].
If the stasis is severe, the pelvic pain is obvious, and the perineum, lumbar sacral area, testicles, lower abdomen, and groin are heavy and painful or painful like needles, sometimes light and sometimes heavy, and aggravated by sitting for a long time. The tongue is dark or has petechiae and ecchymosis, the tongue coating is thin and yellow, and the pulse is often deep and sluggish. Treatment: Promote blood circulation and remove blood stasis, and clear away dampness and heat. Recommended prescriptions: Prostate Decoction, Xuefu Zhuyu Decoction with modifications. Recommended Chinese patent medicines: dicheng kangka tablets, Qianlie Beixi capsules [119], Qingzhuo Qudu pills [120], Shuangshi Tonglin capsules [121], Qianlie Xin capsules [122].
3.5.2 Liver qi stagnation syndrome
Discomfort and distension in the perineum, lower abdomen, external genitalia, lumbar sacral area or perianal area, pain-like but not painful, dribbling and difficult urination; accompanied by chest tightness, sighing, irritability, anxiety and depression, etc., and symptoms worsen with mood swings. Pale red tongue, thin white fur, stringy pulse. Treatment: Soothe the liver and relieve depression, regulate qi and relieve pain. Recommended prescriptions: Chaihu Shugan San, Xiaoyao San, Jinlingzi San with modifications.
Recommended Chinese patent medicine: Xiaoyao Wan.
3.5.3 Cold stagnation in the liver pulse syndrome
The main symptoms are cold pain in the lower abdomen, testicles, perineum, etc., which is more severe when cold and less painful when warm. The patient also has frequent urination, residual dripping, cold body and limbs, pale tongue with white coating, and deep, slow or stringy pulse. Treatment: Warming the meridians and unblocking the collaterals, warming the liver and dispersing cold. Recommended prescriptions: Tiantai Wuyao Powder, Shaofu Zhuyu Decoction [123]. Recommended Chinese patent medicine: Shaofu Zhuyu Capsule.
3.5.4 Kidney deficiency and blood stasis syndrome
If the patient is more prone to kidney yin deficiency, symptoms include residual dripping after urination, sluggish urination, or discomfort in the perineum, accompanied by soreness of the waist and knees, dizziness, insomnia, premature ejaculation, fever in the five hearts, dry mouth and throat.
The tongue is red with little coating, and the pulse is deep, thin or fine. Treatment: Nourish the kidney yin and clear the fire of the kidney. Recommended prescriptions: Zhibai Dihuang Pills, Dabuyin Pills with modifications. Recommended Chinese patent medicine: Zhibai Dihuang Wan [124].
If the patient is suffering from kidney yang deficiency, symptoms include frequent and long urination, dripping, impotence, turbid semen leakage due to exertion, low libido, lumbar pain, fatigue, listlessness, cold hands and feet. Pale tongue with white coating, deep and weak pulse. Treatment: Warm and tonify the lower abdomen, tonify the kidney and strengthen yang. Recommended prescriptions: Jisheng Shenqi Wan and Yougui Wan with modifications. Recommended patent medicine: Guifu Dihuang Wan and Yougui Wan.
3.5.5 Qi deficiency and blood stasis syndrome
With a long course of disease, the patient may experience obvious anal distension, dull or continuous pain in the lower abdomen and perineum, heavy exertion and weak breathing, weak urination, lack of energy, fatigue, and lack of energy. Pale tongue with thin white coating and deep and thin pulse. Treatment: Invigorate qi and strengthen the spleen, activate blood circulation and relieve pain. Recommended prescription: Buzhong Yiqi Decoction with modifications [125]. Recommended Chinese patent medicine: Buzhong Yiqi Pills.
3.5.6 Others
Many traditional Chinese medicine treatments, such as rectal administration of Qianliean suppositories [126], acupuncture [127], and acupoint application [128], also have certain effects on CP/CPPS and deserve further clinical research.
3.6 Physical therapy
3.6.1 Biofeedback
Biofeedback can improve the contraction function of the pelvic floor muscles to increase or decrease muscle tension to relieve pain. Biofeedback treatment of CP/CPPS has certain effects and can significantly improve pelvic pain and urination symptoms [88, 129]. Biofeedback training requires a long consolidation period to achieve long-term successful treatment of CP/CPPS, and the degree of short-term symptom improvement is small [130].
3． 6. 2 Electrophysiological therapy
Electrophysiological therapy can improve pain and urinary symptoms in patients with CP/CPPS [50, 131-132].
3． 6. 3 magnet therapy
CP/CPPS patients were treated with extracorporeal magnetic stimulation (EMS), and their symptoms were significantly improved compared with before treatment [133-134]; the efficacy of magnetic resonance magnetoelectric therapy combined with Chinese patent medicines was significantly higher than that of drug treatment alone [135].
3． 6. 4 Microwave hyperthermia
Transrectal microwave hyperthermia relieves the patient's symptoms in the short term, but has a certain impact on sperm quality, which gradually recovers after the treatment is completed [136].
3． 6. 5 Low-intensity extracorporeal shock wave and low-intensity pulsed ultrasound therapy
Low-intensity extracorporeal shock waves and low-intensity pulsed ultrasound can significantly improve the pain and quality of life of patients with CP/CPPS [137-141], but further clinical and basic research is still needed to explore their specific mechanisms of action.
3． 7 Psychotherapy
In clinical practice, some CP/CPPS patients have certain psychological problems. Conventional drugs and physical therapy sometimes fail to achieve the best results. On this basis, psychological intervention can not only effectively improve the patients' psychological problems, but also reduce the physical symptoms of the patients. severity of symptoms [142]. Anti-anxiety and antidepressant drugs can improve the negative emotions of patients with CP/CPPS, but they are often less effective for patients with catastrophizing cognition. Therefore, such patients can be treated comprehensively with psychological intervention [143-144]. Psychological treatment for patients with CP/CPPS mainly includes the following aspects.
3． 7． 1 Psychological support
This includes patiently answering doubts, guiding patients to comprehensively and correctly understand CP/CPPS diseases, and reducing unnecessary psychological pressure on patients.
3． 7． 2 Relaxation training
The main purpose is to train patients to consciously control their own psychological and physiological activities, reduce their arousal level, and thereby improve body dysfunction.
3． 7． 3 Cognitive Behavioral Therapy
It is mainly used to change patients' abnormal cognitive patterns and help them deal with abnormal emotions correctly; at the same time, it corrects patients' bad cognition of the disease, reduces their negative thinking, and reduces their emotional response to physical diseases, thereby effectively improving the patient's condition. physical discomfort, urinary symptoms, and psychological problems, and improve quality of life.
3． 7． 4 Social/Family Support
Promote communication between patients and their families, guide family members to understand, encourage, and comfort patients, provide them with certain psychological support, and guide the release of negative emotions.
