Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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J. Jamnagerwalla and H.H. Kim
suspicious for pelvic floor dysfunction and 22 % had either micturition,
defecation, or sexual complaints [ 79 ]. Patients who have symptoms of
interstitial cystitis often have other disorders of the pelvis, including irritable
bowel syndrome and defecatory dysfunction [ 80 –82 ]. This link may
be explained by cross-sensitization between the bladder and colon via
primary afferent fibers [ 83 , 84 ]. Although interstitial cystitis is classically
associated with bladder pain and urinary symptoms, some men may present
with complaints of isolated groin or genital pain [ 85 ].
Yoshioka et al. reported that noxious stimuli applied to the testes in
rats resulted in significantly decreased bladder capacity compared to
controls [ 86 ]. Rats pretreated with capsaicin had normal bladder function
even after noxious stimuli, suggesting that testicular primary afferent
C-fibers are responsible for the bladder overactivity [ 86 ]. The neural
cross talk between the bladder and the testes may explain why almost
50 % of patients with CP/CPPS endorse symptoms of chronic testicular
discomfort [ 64 ]. Urodynamic studies in men with chronic pelvic pain
(with almost 40 % complaining of primary testicular discomfort)
demonstrated a high percentage of urethral sensitivity, increased sphincter
length and tone, and decreased peak urine flow [ 87 ].
Despite mounting evidence of CSPS as part of a systemic pelvic floor
dysfunction as opposed to a disorder of infectious etiology, men often
receive a course of antibiotics as initial therapy. A survey of Swiss urologists
in 2005 showed that 98 % believed CSPS was secondary to infectious
etiologies [ 5 ]. Despite the belief that CSPS is of bacterial origin,
studies report only 21 % of those who present with CSPS were found to
have a significant bacterial colony count or positive PCR with bacteria
[ 88 ]. Antibiotics should not be considered first-line treatment for CSPS
in the absence of culture proven infection.
NSAIDs may have a limited efficacy for CPPS, but it may be reasonable
to try them, given their minimal potential morbidity. An EAU
update for the treatment of CPPS/CP indicated level 1b evidence that
NSAIDS may be beneficial in symptom reduction [ 2 ]. Alpha-blocker
therapy was also hypothesized to improve CPPS symptoms, but randomized
controlled trials have demonstrated no significant benefit [ 89 ].
Pharmacological treatment may be more beneficial in alleviating associated
symptoms of CPPS such as urinary complaints.
In men with CPPS refractory to analgesia and muscle relaxant therapy,
biofeedback and pelvic floor retraining and relaxation may provide
modest symptom improvement [ 7 , 90 ]. Given that 88 % of CPPS
patients have an increased pelvic floor resting tone [ 79 ], these conservative
therapies may be beneficial .