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INTRODUCTION
Male genital pain can be perceived in bladder, prostate, urethra and male genital organs: penis and scrotum. Bladder pain is discussed in chapter 13. In this chapter we will use the terms that are proposed by the International Association for the Study of Pain (IASP)[1]. The definitions used are from the European Association of Urology guideline on chronic pelvic pain [2]. There is a strong relation between male genital pain and sexual activity because the genital organs are the key parts of the sexual activity. Pain perceived in those will have a strong influence on the performance of sexual tasks. Male genital pain is perceived in the penis or the scrotum. The urethra is part of the penis. It has a function in urinating and in expelling sperm during ejaculation. Scrotal pain is perceived in either the testicles, the epididymis or both. Because they are lying outside the body patients can easily palpate them and feel structures they believe are the cause of their pain. Acute pain in the genital organs is often reported and in most cases based on infection. After treating the acute illness, prevention of chronification is important
BASIC ASPECTS
Terminology
For all pain syndromes in this chapter, the definition states that there is no proven infection or other obvious local pathology. Furthermore, the pain syndrome is often associated with negative cognitive, behavioral, sexual, or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, or bowel dysfunction.
General
The male genital organs consist of the penis and the scrotum. Also included in this chapter is the prostate, a male organ positioned around the most proximal part of the urethra and playing an important role in the ejaculatory process, prostate fluid being the carrier for the sperm cells. The prostate is well known in urology because prostate enlargement is one of the most diagnosed problems in men with voiding symptoms.
The relation between male genital pain and sexual dysfunction is obvious. Sexual dysfunction is the most reported functional complaint in patients with genital pain. Patients with genital pain will also quite often report micturition and defecation problems. One of the central mechanisms that relate pain to dysfunction could be an overactivity of the pelvic floor muscles.
Diagnostic
When a patient presents with male genital pain, it is important to do good diagnostics, starting with a multifunctional history (Lower Urinary Tract, defecation, sexual function, myofascial function, psychological aspects.). Physical examination starts with examining the organ or region where the pain is perceived and is then broadened to every part of the whole pelvic region. Of special importance is the testing of the function of the pelvic floor muscles. The patient as a whole may also need to be examined, especially for musculoskeletal elements and possible neurological signs. Uroflowmetry is helpful in diagnosing the function of the bladder-urethra complex. It also helps in illustrating dysfunctional voiding and thereby clarifying the role of the pelvic floor muscles in voiding and in maintaining the pain.
Treatment
Almost all well known diseases in the field of male genital pain will present as acute problems. Treatment of the acute pain is important to prevent chronification. As with all other chronic pain syndromes a multidisciplinary approach is the way forward. This approach cannot be highlighted too often. Without any delay a patient should be referred for pain management if no well know disease is present. Pain then is a condition in its own right and should be treated as such. In pain management approaching the muscles attached to and surrounding the pelvis is very important. Apart from this myofascial aspect, other functional symptoms need to be addressed as well as the psychological aspects in an early phase of the process. In male genital pain there is often a role for both a sexologist as well as a pain medicine psychologist. Medication can be added to the other treatment options. Tricyclic antidepressants are of value in the first line treatment when symptoms of neuropathic pain are present. The best advice in all pain syndromes is to get a team involved, and to have the first line doctors refer patients early after well know diseases are ruled out.
DESCRIBING THE SUBJECT
Prostate Pain Syndrome
Definition
Prostate pain syndrome is the occurrence of persistent or recurrent episodic pain in the region of the prostate over at least 3 out of the past 6 months, which is convincingly reproduced by prostate palpation.
General
Prostate pain has been one of the first subjects involved in the whole new approach of chronic pelvic pain. Getting rid of the “prostatocentric approach” was a start of looking with a fresh approach into the problems formerly called chronic prostatitis [20]. The problem of these old terms is that they are organ-confined and are based on causal relations between feeling the pain at a certain place and the origin of the pain lying within that place/organ. Nowadays we know that chronic pain is a sensory process and that the central nervous system plays an important role. This is also true for prostate pain syndrome [24]. For the prostate pain patient, this is often quite hard to believe. Especially when a patient also reports LUTS and has an enlarged prostate, the conclusion seems to be inevitable. In daily practice, questionnaires are easy to use and will provide subjective measures that can be used to evaluate symptoms. Both the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) [15] and the International Prostate Symptom Score (I-PSS) [17] can be used for this purpose.
Well Known Diseases
An infection of the prostate can be present but most of the times is a clinical presentation with illness, high fever and abnormal blood tests. Culture of the semen can be done but is of limited information. Prostate cancer is important for the patient but seldom presents with pain.
Treatment
A lot of work has been done on the use of antibiotics, which is not surprising because of the idea of infection. Trying a course of antibiotics for 3–6 weeks is an option that can be used. If there is no effect after 3 weeks treatment should be terminated [4]. When LUTS are present then alpha-blockers can be used. Studies do not have a clear outcome in favor of these drugs [25] but long-term (more than 3 months) treatment can be tried [6]. Alfa blockers show the best results when used in patients with a short history of pain (<1 year), who have not been treated before with these drugs and have a high score on micturition problems in the NIH-CPSI.
Penile Pain
Definition
Penile pain syndrome is the occurrence of pain within the penis that is not primarily in the urethra.
General
The penis has two important aspects. First it is the organ needed for procreation by delivering the semen into the vagina of the female partner. Second it is the most prominent male sex-organ, indispensable for the lust experience of the man. The penis is a somato-neurovascular organ. The nervous innervation is quite unique compared to other organs [5]. The same is true for the vascular aspects. Sensory thresholds for touch and warmth are dependent on the sexual arousal state. Talking about an organ being so ‘sensitive’ it is easy to imagine that it may lead to painful experiences. Add to this its special role in male sexual functioning and the bio-psycho-social model is fully represented. The second aspect of the penis is the close anatomical relationship with the urethra. Penile and urethral pain can therefore be easily mixed up. Patients will talk about pain perceived in the urethra or pain perceived in the penis. Where the pain is perceived depends on the circumstances: pain during voiding will be linked to the urethra, pain during erection and intercourse to the penis.
Well Known Diseases
Looking for skin pathology (especially the foreskin) and change of sensibility are important. Penile pain can be a result from pathology in the bladder or from bladder pain.
Treatment
In cases where no well known diseases are found, no specific management for penile pain syndrome is evidenced based. Patients should than be referred to a specialised pain clinic for pain management.
Urethral Pain Syndrome
Definition
Urethral pain syndrome is the occurrence of chronic or recurrent episodic pain perceived in the urethra. Urethral pain syndrome may occur in men and women.
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