Neurourological insights into the etiology of genitourinary pain in men

Purpose: Pelvic pain remains a challenging urological problem. Because anti microbial therapy is often unsuccessful for relieving symptoms, it is reaso nable to question whether pelvic pain is the result of microbiological vers us functional pelvic disease. We analyzed clinical and urodynamic findings to evaluate the role of pelvic floor dysfunction in patients with pelvic pa in. Materials and Methods: We retrospectively evaluated history, physical exami nation and urodynamic studies in 103 men with an average age of 47 years wh o presented with pelvic pain between August 1994 and August 1997. In all pa tients microbiological tests were negative before study entry. Results: The reported locations of pain mere the prostate and/or perineal r egion in 45.6% of cases, scrotum and/or testis in 38.8%, penis in 5.8%, bla dder in 5.8%, and lower abdomen and lower back in 1.9% each. Previous treat ment consisted of 1 to 12 courses of antibiotics in the preceding 6 to 36 m onths. In 88.3% of the patients there was pathological tenderness of the st riated muscle with poor to absent pelvic floor function. Urodynamics were p erformed in 84 cases. Cystometry was normal except for decreased compliance in 5 patients. Abnormal findings were mostly evident in the coordination o f voiding and in dynamic sphincter-pelvic floor activity. Average sphincter pressure was increased to 104.9 cm. water in 72.6% of the patients, averag e peak urine flow was decreased to 9.9 ml. per second in 61.9% and function al urethral length was increased to greater than 35 mm. in 79.8%. Urethral profile pattern was dysfunctional, obstructed, and combined dysfunctional a nd obstructed in 52.4, 11.9 and 21.4% of the cases, respectively, while in 88.1% urethral sensitivity was minimally or markedly increased. Conclusions: Since activity is a reflection of neural control, the apparent association of pelvic floor dysfunction with pelvic pain raises the probab ility of a primary or secondary central nervous system breakdown in the reg ulation of pelvic floor function. This hypothesis is supported by the impro vement in symptoms caused by therapy aimed at modulating the pelvic floor, such as biofeedback, medication and sacral anterior root stimulation.