Urologic pelvic pain: Diagnosis and management

August 1, 2008

Urologic pelvic pain is a debilitating condition that affects significant numbers of men and women during their lifetime. Diverse disease states, physiologic conditions, and lifestyle factors may cause or exacerbate pain, challenging diagnosis and treatment efforts. We outline the fundamentals of a multimodal approach to managing urologic pelvic pain.

Key Points

Chronic pelvic pain (CPP) is a problem of significant magnitude, and has many causes. Up to 33% of female patients report having had CPP in their lifetime,1 and a poll of 5,263 women revealed that 14.7% complained of CPP at the time of one study.2

Evaluation

An accurate history is the single most important part of the patient's evaluation. The specific nature, location, and radiation of the pain, as well as its temporal relationship to any inciting event or cyclic pattern must be noted. For reasons not entirely clear, chronic pain often encompasses a progressively larger anatomic area.5

During the physical examination, great attention should be paid to identifying the specific site of pain. Often overlooked during physical examination are the muscles of the pelvic floor, which are frequently quite tender in both CP and IC patients.

A voiding diary is recommended for those patients with irritative voiding symptoms accompanying their pelvic pain. The social and psychological causes and effects of the pain must be explored. Ultimately, the issues discussed may help guide therapy and facilitate rapport, and the discussion itself may prove therapeutic.5

Diagnostic testing should be performed on the basis of suspected pathology. All patients should be asked to provide a urine sample for analysis and culture. Urine cytology is recommended for patients at higher risk for bladder cancer. Uroflowmetry and postvoid residual volume assessment are simple screening tests for underlying voiding dysfunction. Valsalva voiding and interrupted flow patterns, with or without elevations of the postvoid residual volume, are frequently associated with pelvic floor tenderness. Many clinicians also include urodynamics in their evaluation of CPP, although the results may be difficult to interpret in the setting of such subjective complaints.

Further diagnostic evaluation to demonstrate the bladder as a pain generator can include flexible cystoscopy. This procedure can be helpful in eliminating the pathologic processes of the bladder/urethra as a cause of pain. In our series of 90 patients with Hunner's ulcer disease of the bladder, approximately 50% of patients had abnormalities found on urinalysis. In addition, the clinician can use the tip of the flexible instrument to "palpate" specific regions of discomfort within the urethra or bladder.

Hydrodistention of the urinary bladder to 80 or 100 cc/H2O under anesthesia may reveal glomerulations (ie, punctate submucosal hemorrhages), mucosal tears, and/or a subnormal bladder capacity in IC patients. Bladder biopsies are taken if mucosal lesions are identified. The utility of hydrodistention has been questioned, however, since many younger IC patients have few of these diagnostic features.

The potassium chloride test can also be used to evaluate the bladder or prostate as sources of pain. This test entails intravesical administration of 40 MEq KCl solution in 100 cc/H2O, which may exacerbate IC.6

We have also used the loss of pain with an intravesical anesthetic challenge to help establish that bladder-based pain is present. The challenge is usually accomplished at the completion of office flexible cystoscopy. At that time, the bladder is emptied through the cystoscope and 30 cc of a 1:1 solution of 0.5% bupivacaine and 2% lidocaine jelly is introduced through the inflow port, then the scope is removed. Of 80 IC patients studied, 77% had >50% reduction of pain within 15 minutes of instillation.7 Uncommon side effects included transient urinary retention and post-treatment symptom flare. No patient suffered any stigma of sodium channel blocker overdose.

Orchalgia may be primary or referred. Differentiation may be made on the basis of physical exam and confirmed by a spermatic cord block. Scrotal ultrasonography is recommended in cases of primary orchalgia to exclude underlying neoplasia.