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New names for pelvic pain could advance treatments


Baltimore—What's in a name? Would chronic prostatitis or interstitial cystitis by any other names be as treatable?

Andrew Baranowski, MD, thinks so. In fact, he believes that applying better terminology will make these conditions even more treatable because they can turn patients and physicians away from therapies that don't work and toward helpful therapies and the specialists who need to be involved in their management.

Care of both men and women with these and other pelvic pain conditions requires a multidisciplinary approach, which new terminology implies, he told attendees at the NIDDK-sponsored Chronic Pelvic Pain/Chronic Prostatitis Scientific Workshop. Dr. Baranowski is a pain management specialist who heads the Urogenital Pain Clinic at University College London Hospitals, UK. He has been involved with a number of organizations that have tried to improve concepts of just what chronic prostatitis, IC, and other pelvic pain conditions are.

The International Continence Society, the International Society for Study of Vulvar Disease, and various other groups all have tried to tackle the terminology problem. The evolution of terminology in these efforts has shifted the focus from end-organ pathology to a much broader view, one that recognizes the many similarities of pelvic pain syndromes in men and women.

Past terminology has held management back, he argued. The "itis" of prostatitis, for example, has encouraged patients to seek anti-inflammatory or long-term antibiotic therapies that often don't help. The 1987 NIDDK definition of IC, intended only for research, became widely used in practice, but excluded groups of patients who clearly had IC. One of the exclusions he pointed to as questionable was age under 18 years.

"That's a bit crazy," Dr. Baranowski said. "I'm sure no one in this room would say we can't have IC in people less than 18."

But with even broader implications, experts have concluded that many, if not most, patients with the condition don't show glomerulations or Hunner's ulcers on cystoscopy with hydrodistension under anesthesia.

Old conditions, new names.

The International Continence Society's term "painful bladder syndrome" (PBS) was a more inclusive term that pointed to pain as well as the bladder as important treatment targets. The new definition now proposed by Dr. Baranowski and the European Association of Urology Committee for Guidelines on Chronic Pelvic Pain is a dual one. It applies the term "pelvic pain syndrome" (PPS) to "the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction." "There is no proven infection or obvious pathology," he explained. That reserves the term "chronic pelvic pain" (CPP) for conditions where pathologies are well defined, such as endometriosis-associated pain or localized vulvar pain.

A system like this does have problems, he admitted. First, pain often doesn't stem from the site where it's perceived. For example, pelvic floor muscle dysfunction can be perceived as pain in the bladder. Also, secondary symptoms suggesting an organ may be misleading. The system seemingly involved might suggest a specific diagnosis when none exists, and in fact, multiple organ systems can be involved.

Workshop participants also saw potential problems. David Wise, PhD, pointed out that the term "chronic" can condemn patients to a prognosis. Dr. Wise is the Stanford (CA) University psychologist who developed a combined physical therapy and psychological therapy approach to chronic prostatitis. Leroy Nyberg, MD, PhD, director of urology programs at the NIDDK in Bethesda, MD, said that patients don't like losing the identity of the old labels, which have also become integral to patient associations and support groups. In addition, urologists may fear that renaming the syndromes may take patients from their practices.

But more important than the specific term was Dr. Baranowski's conviction that management has to be a team effort. The urologists don't have all the answers, nor do the pelvic muscle specialists, the pudendal neuralgia experts, the psychologists, and the neurologists, he emphasized.

So to urologists who have asked, "How can I as a urologist manage these patients?" Dr. Baranowski replies, "It's simple: teamwork."


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Chronic pain: It's time to think outside the box


Multidisciplinary meetings, such as the 2005 Chronic Pelvic Pain/Chronic Prostatitis Scientific Workshop in Baltimore, have taken a significant, important step toward broadening our understanding of pain syndromes such as chronic prostatitis and interstitial cystitis.

Specifically, pain researchers have introduced the concept that all pain syndromes may share a common central pathway, suggesting that those patients who have these syndromes have a reduced ability to cope with them (see "Clinicians urged to adapt new model of chronic pain" ). At the same time, researchers have not abandoned the concept that pain syndromes may be in part associated with a specific target organ, such as the prostate, bladder, pelvic side wall, or bowel.

For urologists and other specialists, this new model changes how the problem of chronic pelvic pain is perceived, and eventually may change how it is managed. It may lead to goal-directed therapy, which is now used in many men with erectile dysfunction. In the past, urologists focused on pinpointing the cause of ED as vasculogenic, neurogenic, or another etiology. Now, with the availability of effective oral treatments, we are less concerned about a specific cause, as long as the patient is satisfied with his treatment.

Nevertheless, we must not neglect the primary problem associated with a pain syndrome for two important reasons. First, successfully treating the primary problem, such as a slipped disk in a patient with back pain, often also solves the central problem. Second, treating symptoms without investigating their cause may result in the physician's missing a more serious underlying disorder. Some patients with symptoms suggestive of IC have, in fact, been shown to have bladder cancer, for example. Remember that the diagnosis of IC or chronic pelvic pain syndrome remains a diagnosis of exclusion.

Because of the Chronic Pelvic Pain/Chronic Prostatitis Workshop and other conferences, researchers are taking a broader view of chronic pain that will allow development of new treatment strategies. It's clear that novel ways of treating central pain, including drug therapies currently under study, are part of the evolving strategy for dealing with all pain syndromes, including prostatitis and IC.

This is good news for clinicians managing chronic pelvic pain, a field that has little good news to report in recent years. It's time to think, literally and figuratively, outside the box, whether that "box" is the prostate, the bladder, or another pelvic organ. Although we must not abandon our search for specific causes of pain, we should make an effort to understand how the central nervous system plays a role in chronic pelvic pain syndromes.

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