The American Urological Association annual meeting is often the highlight of the year for researchers and clinicians working with interstitial cystitis. This year the conversations/lectures/research focused to a great degree on pelvic pain syndrome. One highlight was Drs. J. Curtis Nickel, Dan Shoskes and Michel Pontari who presented the cases of two men struggling with pelvic pain. Their key point was that urologists should not assume that all men with pelvic pain have prostate infection nor should every case be treated with antibiotics. Rather, they showed that if a physician assesses then treats ALL of the conditions contributing to pelvic pain (i.e. pelvic floor dysfunction, other neurological related conditions, etc. etc.) using the UPOINT Diagnostic System, 77% of patients have symptom improvement and, for some, a complete resolution of their symptoms.
When it was released several years ago, UPOINT revolutionized the diagnosis of IC and pelvic pain in men and women. It asks doctors to survey six potential areas of concern: (1) urological symptoms, (2) the presence of bacteria, (3) the health of the pelvic floor, (4) the presence of other related conditions (IBS, etc.), (5) the presence of depression or catastrophizing and (6) any organ specific changes .. i.e. such as Hunner’s lesions. Based upon those results, it then builds a “phenotype” of the patient that is used to create an individualized treatment plan.
For the IC patient community, UPOINT is a confirmation that we often have other conditions that appear linked to our IC. It’s a system which doesn’t minimize our struggles with pelvic floor dysfunction, IBS or depression. Rather, it encourages compassionate treatment.
For physicians, however, this represents a very significant change in the way they treat patients. Gone are the days when antibiotics are recommended to all men struggling with urinary symptoms. Dr. Shoskes said “Please don’t treat with antibiotics long term without positive cultures or symptom resolution. We’ve seen patients who have been on them for months or years and they are doing great harm to their nervous system and biome.” In fact, they said that only 7% of men who visit the doctor for prostatitis have evidence of infection.
So what’s wrong with the 93% of men who don’t have infection? It could be any number of things. Symptoms can begin after an STD, a bacterial infection, pelvic floor dysfunction, sexual trauma and, for many men, repetitive perineal trauma (i.e. long distance truck drives, long haul airline pilots, etc.). But there are also factors which can exacerbate symptoms such as: stress, autoimmune disease, endocrine abnormalities, nerve sensitization and even catastrophizing or depression.
They encouraged urologists to look beyond the prostate and the bladder to the pelvic floor muscles. Dr. Shoskes said “When you do the rectal exam the key point is to palpate the pelvic floor muscles for spasm and tenderness. If its not the prostate and you push on it and it reproduces their symptoms, that’s key information.” Pre and post prostate massage urine should be tested to rule out the small minority of patients who could have infection. Clearly, if PFD is found, treatment is vital. Dr. Pontari said ” One of the biggest advances in the past ten years is the use of pelvic floor physical therapy… it not only helps pelvic pain but ejaculatory and testicular dysfunction.”
Dr. Nickel ended the presentation by encouraging doctors to treat pelvic pain patients. He said “Do not be afraid to see these patients. They can be very simple to deal with the simple algorithmic approach that we gave you examples of…. Most patients will do very well.”
Watch the webcast here: http://www.aua2015.org/webcasts/webcast_play.cfm?videoID=1815&agendaid=7239