CHRONIC PELVIC PAIN SYNDROME

SEXUAL DYSFUNCTION IN CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME Alberto Trinchieri*, Vittorio Magri§, Lisa Cariani°, Roberto Bonamore°, Antonel...
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SEXUAL DYSFUNCTION IN CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME Alberto Trinchieri*, Vittorio Magri§, Lisa Cariani°, Roberto Bonamore°, Antonella Restelli°, Maria Cristina Garlaschi°, Gianpaolo Perletti # Urology Unit,Ospedale di Lecco * Urology and Sonography Outpatient Clinic, Istituti Clinici di Perfezionamento, Milano §, Microbiology Unit, Istituti Clinici di Perfezionamento, Milano° Department of Anatomy, Embryology, Histology and Medical Physics, Ghent University, Ghent, Belgium #

SEXUAL DYSFUNCTIONS & CP/CPPS  CHRONIC PROSTATITIS DIAGNOSED IN 52% OF THE PATIENTS WITH PREMATURE EJACULATION (SHAMLOUL 2006)  PREMATURE EJACULATION IN 77.3% OF THE PATIENTS WITH CPPS (IN15.2% ERECTILE DYSFUNCTION) (GONEN 2005)  SEXUAL DYSFUNCTIONS IN 49% OF THE PATIENTS WITH CHRONIC PROSTATITIS (PREMATURE EJACULATION IN 26% - ERECTILE DYSFUNCTION 15% (LIANG 2004)  ERECTYLE DYSFUNCTIONS IN 43% AND LOSS OF LIBIDO IN 24% OF MEN WITH PROSTATITIS (SMITH 2006)

SEXUAL DYSFUNCTIONS & CP/CPPS  SEXUAL DYSFUNCTION IN UP TO 92% OF PATIENTS WITH CPPS REFRACTARY TO TREATMENT (EJACULATORY PAIN IN 56%, DECREASED LIBIDO IN 66%, ERECTILE DYSFUNCTION AND EJACULATORY DYSFUNCTION IN 31% (ANDERSON 2006)  HIGHER PREVALENCE OF ERECTILE AND EJACULATORY DYSFUNCION IN MEN WITH LUTS SUGGESTIVE OF BPH ASSOCIATED WITH PROSTATITIS-LIKE SYMPTOMS COMPARED TO MEN WITH LUTS ONLY (BERGER 1999)

AIM OF THE STUDY  THE CORRELATION BETWEEN CP/CPSS AND SEXUAL DYSFUNCTION IS STILL NOT WELL EXPLAINED  THE AIM OF THIS STUDY WAS TO FURTHER ASSESS THE PREVALENCE OF SEXUAL DYSFUNCTION IN MEN WITH CP/CPPS AND EVALUATE THE POSSIBLE RELATIONSHIP BETWEEN SEXUAL DYSFUNCTION AND CP/CPPS

MATERIALS & METHODS  399 PATIENTS WITH SYMPTOMS SUGGESTING PROSTATITIS WITHOUT URETHRAL DISCHARGE  OUTPATIENT PROSTATITIS CLINIC  EVALUATED ACCORDING A PROTOCOL: CLINICAL HISTORY, PHYSICAL EXAMINATION, TRUS AND MICROBIOLOGICAL STUDY

SYMPTOMS EVALUATION  SUBJECTIVE SYMPTOMS SCORED BY CPSI (Chronic Prostatitis Symptom Index) QUESTIONS FOR PAIN (N° 4), URINATION(N°2) AND QOL (N°3)  SEXUAL FUNCTION EVALUATION BY NON VALIDATED GENERAL ASSESSMENT QUESTIONS INQUIRING (LOSS OF LIBIDO, QUALITY OF ERECTION, PREMATURE LOSS OF ERECTION, PAIN ON EJACULATION, HEMOSPERMIA, PYOSPERMIA, PREMATURE EJACULATION, PRESENCE OF SEMEN ABNORMALITIES)

LABORATORY EVALUATION  URETHRAL SWAB FOR BACTERIAL CULTURE  ADDITONIAL SWABS ( C.trachomatis, T.vaginalis, U.urealyticum, M.hominis and Candida spp.)  4-SPECIMEN STUDY ACCORDING MEARESSTAMEY (QUANTITATIVE CULTURE + MICROSCOPY) FIRST VOIDED URINE(VB1), MIDSTREAM URINE (VB2), EXPRESSED PROSTATIC SECRETION (EPS) AND URINE AFTER MASSAGE (VB3)  SEMINAL FLUID CULTURE

RESULTS CLASSIFICATION ACCORDING NIDDK/NIH (National Institute of Diabetes and Digestive and Kidney Disease/ National Institute of Health) CATEGORY II 113 PTS CATEGORY IIIA 156 PTS CATEGORY IIIB 130 PTS

RESULTS  ERECTILE DYSFUNCTION

138 (34%)

 EJACULATORY DYSFUNCTION

220 (55%)

PREVALENCE RATE OF SEXUAL DISORDERS IN CP/CPPS PATIENTS 10

SEMEN ABNORMALITIES

27,5

PREMATURE EJAC

1,7

PYOSPERMIA

24,8

HEMOSPERMIA

48,1

EJACUATORY PAIN

34,3

PREMATURE LOSS OF ERECTION

8,5

ERECTILE IMPAIRMENT

3

LOSS OF LIBIDO

0

10

20

30 CP/CPPS

40

50

60

SEXUAL DISORDERS IN CP/CPPS IN RELATION TO AGE 32,8

35 30 25 20 15 10 5 0

21,5 12,7 6,9

4,7 1 LOSS OF LIBIDO

PREMATURE EJACULATION < 50 YRS

> 50 YRS

SEMEN ABNORMALITIES

LIBIDO & ERECTILE FUNCTION IN RELATION TO NIH CLASSIFICATION OF CP/CPPS PREMATURE LOSS OF ERECTION ERECTILE IMPAIRMENT

IIIB IIIA II

P=0.000

LOSS OF LIBIDO 0

10

20

30

40

EJACULATORY DYSFUNCTIONS IN RELATION TO NIH CLASSIFICATION OF CP/CPPS 6,9 5,1

SEMEN ABNORMALITIES

P=0.000

20 21

PREMATURE EJACULATION

29

33

0,8 3,2 0,8

PYOSPERMIA

23 27 23

HEMOSPERMIA

44

EJACULATORY PAIN

0

10

20

30 II

IIIA

40 IIIB

47 50

55 60

ERECTILE DYSFUNCTION IN RELATION TO CPSI-SCORE P=0.001 25

22,8

20,6

20 15 10

P=0.001 10,8

P=0.007

9,7

8,3 7,5 3,6 3,3

5 0 CPSI-PAIN

CPSI-LUTS

CPSI-QOL

ERECTILE DYSFUNCTION

CPSI-TOTAL NO

EJACULATORY DYSFUNCTION IN RELATION TO CPSI-SCORE P=0.000 25 20 15 10

23,3 19,1

P=0.000

P=0.000

11,3 8,6

8,4

7,1

3,5 3,4

5 0 CPSI-PAIN

CPSI-LUTS

CPSI-QOL

EJACULATORY DYSFUNCTION

CPSI-TOTAL NO

SEXUAL DYSFUNCTION IN RELATION TO PAIN AND QOL CPSI-PAIN

CPSI-QOL

ERECTILE IMPAIRMENT LOSS OF ERECTION

p = 0.006 p = 0.001

p = 0.021 p = 0.010

EJACULATORY PAIN HEMOSPERMIA PREMATURE EJACULATION ABNORMALITIES OF SEMEN

p = 0.000 p = 0.000 p = 0.000 p = 0.000

p = 0.000 p = 0.002 p = 0.000 p = 0.001

N° LEUKOCYTES AT MICROSCOPIC EXAMINATION (VB3) P=0.02 40

36

35

32

30 25

22

20 15 10 5 0 PREMATURE EJACULATION

< 10 10 to 30 > 30

TRUS OF THE PROSTATE AND SEMINAL VESCICLES  ENLARGMENT (38%), ASYMMETRY (37%) AND INFLAMMATORY CHANGES (37.3%) OF SEMINAL VESICLES  PAINFUL EJACULATION ASSOCIATED TO ASYMMETRY (P = 0.001), TO INFLAMMATORY CHANGES (P = 0.013) AND TO ENLARGMENT (P=0.000)  HEMOSPERMIA ASSOCIATED TO ASYMMETRY (P = 0.000) AND TO INFLAMMATORY CHANGES (P = 0.013)  NO RELATION TO ERECTYLE DYSFUNCTION

PSYCOLOGICAL AND SOCIAL DYSFUNCTION SYMPTOMS OF PROSTATITIS

IMPAIRED QUALITY OF LIFE & MENTAL DISTRESS (MULLER 2005)

METICULOUS ATTITUDE & ANXIOUSNESS

ERECTYLE DYSFUNCTION

MARITAL DIFFICULTIES FEAR OF SEXUALLY TRANSMITTED DISEASE SUICIDAL THINKING (MEHIK 2001) SEXUAL DISTURBANCES OF PARTNERS (PAIN UPON INTERCOURSE OR VAGINISMUS) (SMITH 2006)

RELAXATION TRAINING

TRIGGER POINT RELEASE/ PARADOXICAL RELAXATION TRAINING

PAIN & LUTS IMPROVEMENT

LIBIDO, EJACULATORY PAIN, ERECTILE AND EJACULATORY DYSFUNCTION

ACUPUNCTURE

IMPROVEMENT OF SYMPTOMS & QOL

ORGANIC DYSFUNCTION  PROSTATE INFLAMMATION MEDIATED THROUGH CYTOKINE-INDUCED EXPRESSION OF CHEMOKINES, INDUCIBLE NITRIC OXIDE SYNTHETASE AND CYCLOOHYGENASE-2  IMBALANCE OF PRO-INFLAMMATORY AND ANTI-INFLAMMATORY CYTOKINES (JANG 2003, PONTARI 2004)

LOW-GRADE CHRONIC SYSTEMIC INFECTION

INFECTION-INDUCED INFLAMMATION

IMPAIRED NITRIC OXIDE AVAILABILITY

ENDHOTELIAL DYSFUNCTION ERECTILE DYSFUNCTION VLACHOPOULOS 2006 (CORONARY ARTERY DISEASE) KARADAG 2007 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) BLANS 2006 (DIABETES) GIUGLIANO 2004 (OBESITY)

PRESENT STUDY  ERECTYLE AND EJACULATORY DISORDERS MORE FREQUENT IN CP THAN IN CPPS (III A-B)  SIGNIFICANTLY CORRELATED TO SYMPTOMS AND IMAGING SUGGESTIVE OF A SEVERE INFLAMMATION OF THE GENITAL TRACT

CONCLUSION SEXUAL DYSFUNCTION RELATED TO CP/CPPS APPEAR TO RESULT FROM AN INTERPLAY BETWEEN PSYCHOLOGICAL FACTORS AND DYSFUNCTION IN THE IMMUNE, NEUROLOGICAL AND ENDOCRINE SYSTEMS

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