All about chronic pelvic pain syndrome in men. Human pelvic pain

All men over the age of forty should undergo this examination.. The fact is that in this age group the risk of prostate cancer is significantly increased.

The high mortality from this disease is explained precisely by the fact that it is difficult to diagnose it by conventional methods. If, with their help, cancer becomes noticeable, this indicates that it has already managed to affect not only the prostate, but also nearby organs.

Men need to undergo this type of diagnosis in order to detect pathologies of other organs located in this area. In particular, these are diseases of the bladder, rectum, and lymph nodes.

What does the study show?

Despite the fact that MRI became widespread only a few decades ago, it can detect diseases that are difficult to recognize in these organs. This is especially true for diseases with late onset of symptoms.

With the help of magnetic resonance imaging of the pelvis in men, such diseases can be detected.

Malignant tumors of the bladder.
Malignant tumors of the pelvis or ureter,.
colorectal carcinoma.
carcinoma or adenoma of the prostate.
Osteomyelitis.
Necrotic diseases of the femoral head.
Trauma of the femoral neck.

Note!
With the help of MRI, the smallest foci of the tumor process, as well as other diseases, can be detected. This is because the doctor receives an image in different projections. Tomography can give exactly the number of sections that is needed to detect the disease.

In other words, the doctor not only sees the organ in its entirety, but is also able to examine in detail all the processes taking place inside it. A three-dimensional image is extremely convenient to determine in detail any change in shape, tissue structure.

How should you prepare for the study?

Tell your doctor about the presence of serious renal pathologies: in this case, it is undesirable to conduct an X-ray contrast study.

Please note that all objects foreign to the tomograph must be removed from the body, such as:

jewelry;
watch;
all kinds of zippers, hairpins and other accessories;
glasses;
piercing.

Take note!
If the patient has claustrophobia, it is necessary to warn the doctor about it. He will inject a sedative, and, if possible, conduct a study on.

When is research contraindicated?

If the patient has implants or implanted devices. Here is a list of contraindications.

cochlear implants.
Clips that are used on brain aneurysms.
Stents located in vessels.
implanted pumps.
Built-in defibrillators or pacemakers.
Joint prostheses containing metal.
Nerve stimulators (implanted).
Built-in heart valves.
Pins, plates, stents, staples.
The presence of fragments or other metal objects in the body.

How is an MRI procedure performed?

An MRI machine is a large cylindrical tube that is surrounded by a magnet. During the study, the person is on a table that can move to the center of the magnet.

An open-type tomograph does not completely surround the patient. They are used for patients suffering from fear of closed spaces or being overweight.

However, in some models of open-type tomographs, the magnetic field is not so strong, so in such cases it will be difficult to obtain a normal image.

During an MRI, a coil is placed over the area to be examined. All the time of the procedure (and this is up to 45 minutes), the patient should not move. If a study is performed with a radiopaque substance, then the procedure time increases.

It is administered as a radiopaque substance. It is safe for humans and in very rare cases causes allergies.

A contrast agent is injected into a vein. The study is done immediately after the gadolinium was introduced, until the bloodstream carried it throughout the body.

During the procedure, the patient does not feel pain. At the same time, some patients may feel warmth in the pelvic region. This is the physiological reaction of the human body to a magnetic field.

And although the subject is alone in the control room, he can keep in touch with the doctor via radio. The patient is in the physician's field of vision. After the procedure, he does not need to undergo adaptation.

Are there any risks of this study for the patient?

This procedure is safe for humans. However, in the rarest cases, an allergic reaction to gadolinium is possible. A possible serious complication of the procedure is nephrogenic systemic syndrome.

However, subject to examination of the kidneys, this risk is completely minimized.

It is best to carry out diagnostics in men on an open-type apparatus - this will be much more reliable and safer.

Comparison of MRI machines. Closed MRI on the left, open MRI on the right

Deciphering the analysis and next steps

A person cannot independently understand the analyzes. This is done by a trained professional. After the results of the study are sent to the attending physician.

If necessary, other diagnostic measures are prescribed:

digital rectal examination of the prostate;
ultrasound and;
CT scan;
instrumental research;
biopsy.

Conclusion

Magnetic resonance imaging of the pelvic organs in men can detect many pathologies that are very difficult to detect in other ways. And if your doctor insists on going through it, do not be afraid. After all, it is often recommended to take it for preventive purposes.

Pelvic inflammatory disease is a spectrum of inflammatory conditions in the upper reproductive tract in women and can include any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

ICD-10 code

N74* Inflammatory diseases of the female pelvic organs in diseases classified elsewhere

Causes of pelvic inflammatory disease

In most cases, sexually transmitted microorganisms are involved in the development of the disease, especially N. gonorrhoeae and C. trachomatis; however, pelvic inflammatory disease may be caused by microorganisms that are part of the vaginal microflora, such as anaerobes, G. vaginalis, H. influenzae, gram-negative enterobacteria, and Streptococcus agalactiae. Some experts also believe that M. hominis and U. urealyticum may be the causative agents of pelvic inflammatory disease.

These diseases are caused by gonococci, chlamydia, streptococci, staphylococci, mycoplasmas, Escherichia coli, enterococci, and Proteus. Anaerobic pathogens (bacteroids) play a large role in their occurrence. As a rule, inflammatory processes are caused by a mixed microflora.

The causative agents of inflammatory diseases are most often introduced from the outside (exogenous infection); processes are less often observed, the origin of which is associated with the penetration of microbes from the intestines or other foci of infection in the body of a woman (endogenous infection). Inflammatory diseases of septic etiology occur when the integrity of tissues is violated (the entrance gate of infection).

Forms

Inflammatory diseases of the upper genital organs or inflammatory diseases of the pelvic organs include inflammation of the endometrium (myometrium), fallopian tubes, ovaries, and pelvic peritoneum. Isolated inflammation of these organs of the genital tract is rare in clinical practice, since they all represent a single functional system.

According to the clinical course of the disease and on the basis of pathomorphological studies, two clinical forms of purulent inflammatory diseases of the internal genital organs are distinguished: uncomplicated and complicated, which ultimately determines the choice of management tactics.

Complications and consequences

Any of the forms of inflammatory diseases of the upper part of the female genital organs can be complicated by the development of an acute purulent process.

Diagnosis of inflammatory diseases of the pelvic organs

The diagnosis is established on the basis of the patient's complaints, the history of life and disease, the results of a general examination and gynecological examination. The nature of morphological changes in the internal genital organs (salpingoophoritis, endometritis, endomyometritis, tubo-ovarian abscess, pyosalpinx, inflammatory tubo-ovarian formation, pelvioperitonitis, peritonitis), the course of the inflammatory process (acute, subacute, chronic) are taken into account. The diagnosis must reflect the presence of concomitant gynecological and extragenital diseases.

During the examination, all patients should examine the discharge from the urethra, vagina, cervical canal (if necessary, washings from the rectum) in order to determine the flora and sensitivity of the isolated pathogen to antibiotics, as well as discharge from the fallopian tubes, the contents of the abdominal cavity (effusion), obtained by laparoscopy or abdominal surgery.

To determine the degree of microcirculation disorders, it is advisable to determine the number of erythrocytes, aggregation of erythrocytes, hematocrit, the number of platelets and their aggregation. From the indicators of nonspecific protection, the phagocytic activity of leukocytes should be determined.

To establish the specific etiology of the disease, serological and enzyme immunoassay methods are used. If tuberculosis is suspected, tuberculin reactions should be performed.

Of the additional instrumental methods, ultrasound, computed tomography of small organs, and laparoscopy are used. In the absence of the possibility of performing laparoscopy, the abdominal cavity is punctured through the posterior fornix of the vagina.

Diagnostic notes

Due to the wide range of symptoms and signs, the diagnosis of acute pelvic inflammatory disease in women presents significant challenges. Many women with pelvic inflammatory disease have mild or moderate symptoms that are not always recognized as pelvic inflammatory disease. Therefore, delay in diagnosis and delay in appropriate treatment leads to inflammatory complications in the upper reproductive tract. To obtain a more accurate diagnosis of salpingitis and for a more complete bacteriological diagnosis, laparoscopy can be used. However, this diagnostic technique is often not available in either acute cases or in milder cases where symptoms are mild or vague. Moreover, laparoscopy is unsuitable for detecting endometritis and mild inflammation of the fallopian tubes. Therefore, as a rule, the diagnosis of inflammatory diseases of the pelvic organs is carried out on the basis of clinical signs.

Clinical diagnosis of acute inflammatory diseases of the pelvic organs is also not sufficiently accurate. The data show that in the clinical diagnosis of symptomatic pelvic inflammatory disease, positive predictive values (PPV) for salpingitis are 65-90% compared with laparoscopy as standard. PPVs for the clinical diagnosis of acute pelvic inflammatory disease vary depending on the epidemiological characteristics and type of medical institution; they are higher for sexually active young women (especially adolescents), for patients attending STD clinics, or living in areas with a high prevalence of gonorrhea and chlamydia. However, there is no single history, physical, or laboratory criterion that has the same sensitivity and specificity for diagnosing an acute episode of pelvic inflammatory disease (i.e., a criterion that can be used to detect all cases of PID and to exclude all women without pelvic inflammatory disease). pelvis). When combining diagnostic techniques that improve either sensitivity (find more women with PID) or specificity (exclude more women who do not have PID), this only comes at the expense of the other. For example, requiring two or more criteria excludes more women without pelvic inflammatory disease, but also reduces the number of identified women with PID.

A large number of episodes of pelvic inflammatory disease remain unrecognized. While some women experience PID asymptomatically, others go undiagnosed because a healthcare provider may not correctly interpret mild or nonspecific symptoms and signs such as unusual bleeding, dyspareunia, or vaginal discharge ("atypical PID"). Due to the difficulties of diagnosis and the possibility of a violation of the reproductive health of a woman, even with a mild or atypical course of inflammatory diseases of the pelvic organs, experts recommend that medical workers use the "low threshold" of diagnosis for PID. Even under these circumstances, the impact of early treatment in women with asymptomatic or atypical PID on clinical outcome is unknown. The presented recommendations for the diagnosis of pelvic inflammatory disease are necessary in order to help healthcare professionals to suspect the possibility of pelvic inflammatory disease and to have additional information for the correct diagnosis. These recommendations are based in part on the fact that the diagnosis and management of other common cases of lower abdominal pain (eg, ectopic pregnancy, acute appendicitis, and functional pain) is unlikely to be worsened if a healthcare provider initiates empiric antimicrobial treatment for pelvic inflammatory disease.

Minimum Criteria

Empiric treatment of pelvic inflammatory disease should be considered in sexually active young women and others at risk of STDs if all of the following criteria are met and in the absence of any other cause of the patient's disease:

Pain on palpation in the lower abdomen
Pain in the appendages, and
Painful traction of the cervix.

Additional Criteria

An overestimation of the diagnostic value is often justified, as misdiagnosis and treatment can lead to serious consequences. These additional criteria can be used to increase the specificity of the diagnosis.

The following are additional criteria that support the diagnosis of pelvic inflammatory disease:

Temperature above 38.3°C,
Pathological discharge from the cervix or vagina,
elevated ESR,
Elevated levels of C-reactive protein,
Laboratory confirmation of N. gonorrhoeae or C. trachomatis cervical infection.

Below are the defining criteria for the diagnosis of inflammatory diseases of the pelvic organs, which prove the selected cases of diseases:

Histopathological finding of endometritis on endometrial biopsy,
Ultrasound with a transvaginal probe (or using other technologies) showing thickened, fluid-filled fallopian tubes with or without free fluid in the abdominal cavity or the presence of a tubo-ovarian mass,
Abnormalities found during laparoscopy consistent with PID.

Although the decision to start treatment may be made before a bacteriological diagnosis of N. gonorrhoeae or C. trachomatis infections is made, confirmation of the diagnosis emphasizes the need to treat sexual partners.

Treatment of pelvic inflammatory disease

If acute inflammation is detected, the patient should be hospitalized in a hospital, where she is provided with a therapeutic and protective regimen with strict observance of physical and emotional rest. Assign bed rest, ice on the hypogastric region (2 hours with breaks of 30 minutes - 1 hour for 1-2 days), sparing diet. Carefully monitor the activity of the intestines, if necessary, prescribe warm cleansing enemas. Patients benefit from bromine preparations, valerian, sedatives.

Etiopathogenetic treatment of patients with inflammatory diseases of the pelvic organs involves the use of both conservative therapy and timely surgical treatment.

Conservative treatment of acute inflammatory diseases of the upper genital organs is carried out in a complex manner and includes:

antibacterial therapy;
detoxification therapy and correction of metabolic disorders;
anticoagulant therapy;
immunotherapy;
symptomatic therapy.

Antibacterial therapy

Since the microbial factor plays a decisive role in the acute stage of inflammation, antibiotic therapy is the determining factor during this period of the disease. On the first day of the patient's stay in the hospital, when there are still no laboratory data on the nature of the pathogen and its sensitivity to a particular antibiotic, the presumptive etiology of the disease is taken into account when prescribing drugs.

In recent years, the effectiveness of the treatment of severe forms of purulent-inflammatory complications has increased with the use of beta-lactam antibiotics (augmentin, meronem, thienam). The "gold" standard is the use of clindamycin with gentamicin. It is recommended to change antibiotics after 7-10 days with repeated determination of antibiograms. In connection with the possible development of local and generalized candidiasis during antibiotic therapy, it is necessary to study hemo- and urocultures, as well as prescribe antifungal drugs.

If oligoanuria occurs, an immediate review of the doses of antibiotics used is indicated, taking into account their half-life.

Treatment regimens for pelvic inflammatory disease should empirically eliminate a wide range of possible pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. Although some antimicrobial regimens have been shown to be effective in achieving clinical and microbiological cure in a clinical randomized trial with short-term follow-up, there are few studies evaluating and comparing the elimination of endometrial and fallopian tube infection or the incidence of long-term complications such as tubal infertility and ectopic pregnancy.

All regimens should be effective against N. gonorrhoeae and C. trachomatis, as negative tests for these infections in the endocervix do not rule out infection in the upper reproductive tract. While the need for anaerobic eradication in women with PID is still controversial, there is evidence that it may be important. Anaerobic bacteria isolated from the upper reproductive tract of women with PID and those obtained in vitro clearly show that anaerobes such as B. fragilis can cause tubal and epithelial destruction. In addition, many women with PID are also diagnosed with bacterial vaginosis. In order to prevent complications, the recommended regimens should include drugs that act on anaerobes. Treatment should be started immediately upon establishing a preliminary diagnosis, since the prevention of long-term consequences is directly related to the timing of the appointment of appropriate antibiotics. When choosing a treatment regimen, the physician should consider its availability, cost, patient acceptability, and sensitivity of pathogens to antibiotics.

In the past, many experts have recommended that all patients with PID be hospitalized so that parenteral antibiotic treatment can be administered under medical supervision under bed rest. However, hospitalization is no longer synonymous with parenteral therapy. There are currently no data available that would show the comparative efficacy of parenteral and oral treatment, or inpatient or outpatient treatment. Until data from ongoing studies comparing parenteral inpatient versus oral outpatient treatment in women with PID become available, clinical observational data should be considered. The doctor makes a decision on the need for hospitalization based on the following recommendations, based on observational data and theoretical developments:

Conditions requiring urgent surgical intervention, such as appendicitis,
The patient is pregnant
Unsuccessful treatment with oral antimicrobials,
Inability to comply with or tolerate outpatient oral regimen,
Severe illness, nausea and vomiting, or high fever.
tubo-ovarian abscess
The presence of immunodeficiency (HIV infection with a low CD4 count, immunosuppressive therapy or other diseases).

Most clinicians conduct at least 24 hours of direct observation in the hospital of patients with tubo-ovarian abscesses, after which adequate parenteral treatment should be given at home.

There are no convincing data comparing parenteral and oral regimens. A lot of experience has been accumulated in the application of the following schemes. Also, there are multiple randomized trials demonstrating the effectiveness of each regimen. Although most of the studies used parenteral treatment for at least 48 hours after the patient showed significant clinical improvement, this regimen was administered arbitrarily. Clinical experience should guide the decision to switch to oral treatment, which can be made within 24 hours of the onset of clinical improvement.

Scheme A for parenteral treatment

Cefotetan 2 g IV every 12 hours
or Cefoxitin 2 g IV every 6 hours
plus doxycycline 100 mg IV or po q 12 hours.

NOTE. Given that intravenous administration of drugs is associated with pain, doxycycline should be administered orally whenever possible, even if the patient is in the hospital. Oral and intravenous treatment with doxycycline has similar bioavailability. If intravenous administration is required, the use of lidocaine or other fast-acting local anesthetics, heparin, or steroids, or prolongation of the infusion time may reduce infusion complications. Parenteral treatment may be discontinued 24 hours after the patient is clinically improved, and oral doxycycline 100 mg twice daily should be continued for up to 14 days. In the presence of a tubo-ovarian abscess, many physicians use clindamycin or metronidazole with doxycycline to continue treatment, rather than doxycycline alone, as this contributes to a more effective overlap of the entire spectrum of pathogens, including anaerobes.

Clinical data on second- or third-generation cephalosporins (eg, ceftizoxime, cefotaxime, or ceftriaxone) that can replace cefoxitin or cefotetan are limited, although many authors believe that they are also effective in PID. However, they are less active against anaerobic bacteria than cefoxitin or cefotetan.

Scheme B for parenteral treatment

Clindamycin 900 mg IV every 8 hours
plus Gentamicin - IV or IM loading dose (2 mg/kg body weight) followed by maintenance dose (1.5 mg/kg) every 8 hours.

NOTE. Although the use of a single dose of gentamicin has not been studied in the treatment of pelvic inflammatory disease, its effectiveness in other similar situations is well established. Parenteral treatment may be interrupted 24 hours after the patient has clinical improvement, and then switched to oral treatment with doxycycline 100 mg 2 times a day or clindamycin 450 mg orally 4 times a day. The total duration of treatment should be 14 days.

For tubo-ovarian abscess, many health care providers use clindamycin rather than doxycycline to continue treatment because it is more effective against anaerobic organisms.

Alternative parenteral regimens

There is limited data on the use of other parenteral regimens, but the following three regimens have been in at least one clinical trial and shown to be effective against a wide range of organisms.

Ofloxacin 400 mg IV every 12 hours
or Ampicillin/sulbactam 3 g IV every 6 hours
or Ciprofloxacin 200 mg IV every 12 hours
plus doxycycline 100 mg orally or IV every 12 hours.
plus Metronidazole 500 mg IV every 8 hours.

The ampicillin/sulbactam with doxycycline regimen was effective against N. gonorrhoeae, C. trachomatis, and anaerobes and was effective in patients with tubo-ovarian abscess. Both intravenous drugs, ofloxacin and ciprofloxacin, have been studied as monotherapy drugs. Given the data obtained on the ineffective effect of ciprofloxacin on C. trachomatis, it is recommended to routinely add doxycycline to treatment. Since these quinolones are active only against a subset of anaerobes, metronidazole should be added to each regimen.

oral treatment

There are few data on the immediate and long-term outcomes of treatment, both in the parenteral regimen and in the outpatient regimen. The following regimens provide antimicrobial activity against the most common causative agents of PID, but clinical trial data on their use are very limited. Patients who do not improve with oral treatment within 72 hours should be re-examined to confirm the diagnosis and receive parenteral treatment on an outpatient or inpatient basis.

Scheme A

Ofloxacin 400 mg twice daily for 14 days
plus Metronidazole 500 mg orally twice a day for 14 days

Oral ofloxacin, used as monotherapy, has been studied in two well-designed clinical trials and has been shown to be effective against N. gonorrhoeae and C. trachomatis. However, given that ofloxacin is still not sufficiently effective against anaerobes, the addition of metronidazole is necessary.

Scheme B

Ceftriaxone 250 mg IM once
or Cefoxitin 2 g IM plus Probenecid 1 g orally once at a time
or Other third-generation parenteral cephalosporin (eg, ceftizoxime, cefotaxime),
plus doxycycline 100 mg orally twice a day for 14 days. (Use this circuit with one of the above circuits)

The optimal choice of cephalosporin for this regimen has not been determined; while cefoxitin is active against more anaerobic species, ceftriaxone is more effective against N. gonorrhoeae. Clinical trials have shown that a single dose of cefoxitin is effective in obtaining a rapid clinical response in women with PID, however, theoretical data indicate the need to add metronidazole. Metronidazole will also effectively treat bacterial vaginosis, which is often associated with PID. No data have been published on the use of oral cephalosporins for the treatment of PID.

Alternative outpatient regimens

Information on the use of other outpatient regimens is limited, but one regimen has received at least one clinical trial showing efficacy against a wide range of pathogens in pelvic inflammatory disease. When amoxicillin/clavulanic acid was combined with doxycycline, a rapid clinical effect was obtained, however, many patients were forced to interrupt the course of treatment due to undesirable symptoms from the gastrointestinal tract. Several studies have evaluated azithromycin in the treatment of upper reproductive tract infections, however, these data are not sufficient to recommend this drug for the treatment of pelvic inflammatory disease.

Detoxification therapy and correction of metabolic disorders

This is one of the most important components of treatment aimed at breaking the pathological circle of cause-and-effect relationships that occur in purulent-inflammatory diseases. It is known that these diseases are accompanied by a violation of all types of metabolism, the excretion of a large amount of fluid; there is an imbalance of electrolytes, metabolic acidosis, renal and hepatic insufficiency. Adequate correction of the identified violations is carried out jointly with resuscitators. When carrying out detoxification and correction of water-electrolyte metabolism, two extreme conditions should be avoided: insufficient fluid intake and overhydration of the body.

In order to eliminate these errors, it is necessary to control the amount of fluid introduced from the outside (drink, food, medicinal solutions) and excreted in the urine and other ways. The calculation of the introduced risk should be individual, taking into account the indicated parameters and the patient's condition. Correct infusion therapy in the treatment of acute inflammatory and purulent-inflammatory diseases is no less important than the appointment of antibiotics. Clinical experience shows that a patient with stable hemodynamics with adequate replenishment of BCC is less susceptible to the development of circulatory disorders and the occurrence of septic shock.

The main clinical signs of the restoration of BCC, the elimination of hypovolemia are CVP (60-100 mm of water column), diuresis (more than 30 ml / h without the use of diuretics), improvement of microcirculation (skin color, etc.).

Pelvioperitonitis is observed quite often with the development of inflammatory diseases of the pelvic organs. Because peritoneal inflammation increases extrarenal fluid and electrolyte losses, the basic principles of fluid and protein replacement must be considered. According to modern concepts, both colloidal solutions (plasma, albumin, low molecular weight dextrans) and crystalloid solutions (0.9% sodium chloride solution) should be administered per 1 kg of the patient's body weight.

From crystalloid solutions, isotonic sodium chloride solution, 10% and 5% glucose solution, Ringer-Locke solution, polyionic solutions are used. From colloidal solutions, low molecular weight dextrans are used. It should be emphasized that the total amount of dextrans should not exceed 800-1200 ml / day, since their excessive administration can contribute to the development of hemorrhagic diathesis.

Patients with septic complications of community-acquired abortion lose a significant amount of electrolytes along with fluid. In the process of treatment, it becomes necessary to quantify the introduction of the main electrolytes - sodium, potassium, calcium and chlorine. When introducing corrective doses of electrolyte solutions, the following should be observed:

Compensation for electrolyte deficiency should be done slowly, drip method, avoiding the use of concentrated solutions.
Periodic monitoring of the acid-base state and electrolytes of blood serum is indicated, since corrective doses are calculated only for extracellular fluid.
You should not strive to bring their performance to the absolute norm.
After reaching a stable normal level of serum electrolytes, only their maintenance dose is administered.
With deterioration of kidney function, it is necessary to reduce the amount of fluid administered, reduce the amount of sodium administered, and completely eliminate the introduction of potassium. For detoxification therapy, the method of fractional forced diuresis is widely used with the production of 3000-4000 ml of urine per day.

Since hypoproteinemia is always observed in septic conditions due to impaired protein synthesis, as well as due to increased protein breakdown and blood loss, the administration of protein preparations is mandatory (plasma, albumin, protein).

Anticoagulant therapy

With widespread inflammatory processes, pelvioperitone, peritonitis, thromboembolic complications are possible in patients, as well as the development of disseminated intravascular coagulation (DIC).

Currently, one of the first signs of DIC is thrombocytopenia. Reducing the number of platelets to 150 x 10 3 /l is the minimum that does not lead to hypocoagulable bleeding.

In practice, the determination of the prothrombin index, platelet count, fibrinogen level, fibrin monomers, and blood clotting time is sufficient for the timely diagnosis of DIC. For the prevention of DIC and with a slight change in these tests, heparin is prescribed at 5000 IU every 6 hours under the control of blood clotting time within 8-12 minutes (according to Lee White). The duration of heparin therapy depends on the speed of improvement of laboratory data and is usually 3-5 days. Heparin should be given before clotting factors are significantly reduced. Treatment of DIC, especially in severe cases, is extremely difficult.

Immunotherapy

Along with antibacterial therapy in conditions of low sensitivity of pathogens to antibiotics, agents that increase the general and specific reactivity of the patient's body are of particular importance, since generalization of infection is accompanied by a decrease in cellular and humoral immunity. Based on this, complex therapy includes substances that increase immunological reactivity: antistaphylococcal gamma globulin and hyperimmune antistaphylococcal plasma. Gamma globulin is used to increase nonspecific reactivity. An increase in cellular immunity is facilitated by drugs such as levamisole, taktivin, thymogen, cycloferon. In order to stimulate the immune system, efferent therapy methods (plasmapheresis, ultraviolet and laser blood irradiation) are also used.

Symptomatic treatment

An essential condition for the treatment of patients with inflammatory diseases of the upper genital organs is effective pain relief using both analgesics and antispasmodics, and inhibitors of prostaglandin synthesis.

It is mandatory to introduce vitamins based on the daily requirement: thiamine bromide - 10 mg, riboflavin - 10 mg, pyridoxine - 50 mg, nicotinic acid - 100 mg, cyanocobalamin - 4 mg, ascorbic acid - 300 mg, retinol acetate - 5000 units.

The appointment of antihistamines (suprastin, tavegil, diphenhydramine, etc.) is shown.

Rehabilitation of patients with inflammatory diseases of the upper genital organs

Treatment of inflammatory diseases of the genital organs in a woman necessarily includes a set of rehabilitation measures aimed at restoring the specific functions of the female body.

To normalize menstrual function after acute inflammation, medications are prescribed, the action of which is aimed at preventing the development of algomenorrhea (antispasmodics, non-steroidal anti-inflammatory drugs). The most acceptable form of administration of these drugs are rectal suppositories. Restoration of the ovarian cycle is carried out by the appointment of combined oral contraceptives.

Physiotherapeutic methods in the treatment of inflammatory diseases of the pelvic organs are prescribed differentially, depending on the stage of the process, the duration of the disease and the effectiveness of the previous treatment, the presence of concomitant extragenital pathology, the state of the central and autonomic nervous system and the age characteristics of the patient. The use of hormonal contraception is recommended.

In the acute stage of the disease, at a body temperature below 38 ° C, UHF is prescribed for the hypogastric region and the lumbosacral plexus according to the transverse method in a non-thermal dosage. With a pronounced edematous component, combined exposure to ultraviolet light on the panty zone in 4 fields is prescribed.

With a subacute onset of the disease, the appointment of a microwave electromagnetic field is preferable.

With the transition of the disease to the stage of residual phenomena, the task of physiotherapy is to normalize the trophism of suffering organs by changing vascular tone, the final relief of edematous phenomena and pain syndrome. For this purpose, reflex methods of exposure to currents of supratonal frequency are used. D "Arsonval, ultrasound therapy.

When the disease passes into the remission stage, heat and mud therapy procedures (paraffin, ozocerite) are prescribed for the area of the panty zone, balneotherapy, aerotherapy, helio- and thalassotherapy.

In the presence of chronic inflammation of the uterus and its appendages in the period of remission, it is necessary to prescribe resolving therapy using biogenic stimulants and proteolytic enzymes. The duration of rehabilitation measures after acute inflammation of the internal genital organs is usually 2-3 menstrual cycles. A pronounced positive effect and a decrease in the number of exacerbations of chronic inflammatory processes are observed after spa treatment.

Surgical treatment of purulent-inflammatory diseases of the internal genital organs

Indications for surgical treatment of purulent-inflammatory diseases of the female genital organs are currently:

Lack of effect during conservative complex therapy for 24-48 hours.
Deterioration of the patient's condition during a conservative course, which can be caused by perforation of a purulent formation into the abdominal cavity with the development of diffuse peritonitis.
Development of symptoms of bacterial toxic shock. The volume of surgical intervention in patients with inflammatory diseases of the uterine appendages depends on the following main points:
1. the nature of the process;
2. concomitant pathology of the genital organs;
3. the age of the patients.

It is the young age of patients that is one of the main points that determine the adherence of gynecologists to sparing operations. In the presence of concomitant acute pelvioperitonitis With purulent lesions of the uterine appendages, the uterus is extirpated, since only such an operation can ensure the complete elimination of the infection and good drainage. One of the important points in the surgical treatment of purulent inflammatory diseases of the uterine appendages is the complete restoration of normal anatomical relationships between the organs of the small pelvis, abdominal cavity and surrounding tissues. It is necessary to make an audit of the abdominal cavity, determine the condition of the appendix and exclude interintestinal abscesses with a purulent nature of the inflammatory process in the uterine appendages.

In all cases, when performing an operation for inflammatory diseases of the uterine appendages, especially with a purulent process, one of the main principles should be the principle of mandatory complete removal of the focus of destruction, i.e., inflammatory formation. No matter how gentle the operation is, it is always necessary to completely remove all tissues of the inflammatory formation. Preservation of even a small portion of the capsule often leads to severe complications in the postoperative period, recurrence of the inflammatory process, and the formation of fistulas. During surgical intervention, drainage of the abdominal cavity (colyutomy) is mandatory.

The condition for reconstructive surgery with preservation of the uterus is primarily the absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the pelvis and abdominal cavity, as well as concomitant severe genital pathology (adenomyosis, fibroids) established before or during surgery.

In women of reproductive age, if there are conditions, it is necessary to perform extirpation of the uterus with the preservation, if possible, of at least part of the unchanged ovary.

In the postoperative period, complex conservative therapy continues.

Follow-up

In patients receiving oral or parenteral treatment, significant clinical improvement (eg, reduction in temperature, reduction in abdominal wall muscle tension, reduction in pain on palpation during examination of the uterus, appendages, and cervix) should be observed within 3 days from the start of treatment. Patients in whom such improvement is not observed require clarification of the diagnosis or surgical intervention.

If the clinician has opted for outpatient oral or parenteral treatment, follow-up and evaluation of the patient should be carried out within 72 hours using the above criteria for clinical improvement. Some experts also recommend repeat screening for C. trachomatis and N. gonorrhoeae 4–6 weeks after completion of therapy. If PCR or LCR is used to control cure, then a second study should be carried out one month after the end of treatment.

Management of sexual partners

Examination and treatment of sexual partners (who were in contact in the previous 60 days before the onset of symptoms) of women with PID is necessary because of the risk of reinfection and the high probability of detecting gonococcal or chlamydial urethritis in them. Male sexual partners of women with PID caused by gonorrhea or chlamydia often do not have symptoms.

Sexual partners should be treated empirically according to the treatment regimen for both infections, regardless of whether the causative agent for pelvic inflammatory disease has been identified.

Even in clinics where only women are seen, health care providers should ensure that men who are sexual partners of women with PID are treated. If this is not possible, the health worker treating a woman with PID needs to be sure that her partners have received appropriate treatment.

Special remarks

Pregnancy. Given the high risk of adverse pregnancy outcomes, pregnant women with suspected PID should be hospitalized and treated with parenteral antibiotics.

HIV infection. Differences in the clinical manifestations of PID in HIV-infected and uninfected women are not described in detail. Based on early observational data, it was assumed that HIV-infected women with PID were more likely to need surgery. Subsequent, more comprehensive review studies of HIV-infected women with PID noted that even with more severe symptoms than HIV-negative women, parenteral antibiotic treatment of these patients was successful. In another trial, the results of microbiological studies in HIV-infected and uninfected women were similar, except for a higher incidence of concomitant chlamydial infection and HPV infection, as well as cellular changes caused by HPV. Immunocompromised HIV-infected women with PID require more extensive therapy using one of the parenteral antimicrobial regimens described in this guideline.

Let us consider in detail the syndrome of chronic pelvic pain that is often encountered in everyday life. Women often turn to the doctor with complaints of prolonged, periodically increasing pelvic pain. These pains are localized in the lower abdomen. Many diseases of the pelvic organs (eg, gynecological, urological, proctological) may be accompanied by similar complaints. Therefore, the concept of chronic pelvic pain is quite diverse and diverse.

What are the symptoms of chronic pelvic pain?

As a diagnostic criterion for chronic pelvic pain syndrome, there must be the presence in the clinical symptoms of at least one of the following symptoms:

the presence of pain in the lower back, inguinal regions, lower abdomen, which are present almost constantly, with a tendency to increase with hypothermia, physical and psycho-emotional stress, forced long position of the body, and also associated with certain days of the menstrual cycle. All of the above we will refer to the actual pelvic pain
dysmenorrhea - pain during menstruation
signs deep dyspareunia- pain during deep insertion (intromission) of the male penis into the vagina during intercourse. Quite often, the quality of sexual life suffers significantly, a dilemma arises - to refuse intimacy or to endure pain.

As mentioned above, prolonged pain leads to adverse consequences, causes constant psycho-emotional discomfort in a person, upsets the normal functioning of all organs and systems, disrupts personal and social adaptation.

How common is the phenomenon of pelvic pain?

According to international research organizations, including WHO, more than 60% of women who annually seek the advice of a gynecologist complain of pelvic pain. It is not uncommon for women with these complaints to alternately visit a neurologist, urologist, gynecologist and chiropractor for years. Often it is necessary to resort to expensive and rather difficult examinations, and the presence of gynecological pathology is far from always confirmed, moreover, the reasons for the existence of pain syndrome are not revealed at all. This category of women with pelvic pain often has fears of an oncological disease. From some doctors, this category of patients receives advice to consult with relevant specialists. However, the vast majority of cases are still a consequence of gynecological diseases, less often - diseases of other organs and systems (21-22%), and even less often - mental illness (about 1%).

Causes of the development of pelvic pain syndrome in women

Consider the main causes of chronic pelvic pain in women.
Among gynecological reasons distinguish the following:

adhesions due to inflammation of the internal genital organs in the past
various chronic diseases of the small pelvis with a long course
adenomyosis - endometriosis of the uterus
intrauterine contraception (eg, intrauterine device)
tuberculosis of the female genital organs
painful period syndrome
malignant tumors of the uterus and cervix
adhesive process after operations in the small pelvis (urological, gynecological, proctological)
various anomalies in the development of the genital organs, when the rejection of the uterine mucosa is impaired
Alain-Masters syndrome

In Group non-gynecological reasons distinguish the following:

Pathology of the musculoskeletal system

osteochondrosis (usually lumbosacral)
arthrosis of the sacrococcygeal joint
herniated discs
tumors of the pelvic bones, metastases to the spine and pelvic bones
damage to the pubic joint
tuberculous lesions of the musculoskeletal system

Neoplasms of the retroperitoneal space

Ganglioneuroma
kidney tumors

Diseases of the peripheral nervous system

inflammatory or other damage to the pelvic or sacral ganglions or plexuses

Pathology of the gastrointestinal tract

adhesive disease
chronic colitis
appendicular-genital syndrome

Diseases of the urinary system

nephroptosis of various degrees of severity
malposition of the kidney, dystopia
anomaly of kidney development (doubling and others)
chronic cystitis

What moments play a major role in the formation of chronic pain syndrome?

Let's try to highlight some of the most significant components of the formation of chronic pelvic pain.

First, pathological changes in receptors and nerve pathways, nerve ganglions, ganglia, and plexuses are of paramount importance. Secondly, the vascular component is extremely important, namely, circulatory disorders in the organs of the small pelvis, local parts of the small pelvis, primarily the formation of venous congestion, varicose veins and venous plexuses of the organs and walls of the small pelvis. Chronic venous plethora of blood vessels leads to irritation of the receptors of the serous integument of the internal genital organs and peritoneum, which is perceived as pain. Omission, both complete and partial, of the internal organs of the abdominal cavity, the presence of tumor-like formations in the small pelvis, enlarged lymph nodes, dilatation of the veins of the rectum and posterior deviation of the uterus, together with the mobility of the uterus, are also the causes of overflow of the pelvic venous vessels.

Research data of recent years have shown that a persistent, long-term absence (the duration is calculated in months and years) of orgasm causes chronic overflow of venous and lymphatic vessels, which leads to the development of congestive (congestive) metritis, structural changes in the ligamentous apparatus of the uterus and even ovaries. Cases are described when prolonged use of coitus interruptus as a method of contraception also led to the formation of pelvic pain syndrome.

Regardless of the reasons causing it, plethora and overflow of the venous and vascular plexuses of the small pelvis ultimately leads to violations of capillary blood flow, insufficient supply of oxygen and necessary substances to cells, and difficulty in the removal of waste products of cells. Atrophic processes, once started, continue to progress, involving more and more nerve plexuses, nodes and conductors. Thus, it does not matter whether the chain of pathological changes is caused by endometriosis, uterine fibroids, chronic inflammatory process of the pelvic organs or anything else. The sequence is almost the same - this is a violation of hemodynamics, both pelvic and organ, a violation of tissue and cellular respiration, "slagging" with waste products, various changes in the nervous apparatus of the small pelvis.

How the further development of the pain syndrome will go, namely its perception and awareness, directly depends on many factors. The main role among these factors belongs to the psychological type of a particular woman, the genetically determined threshold of pain sensitivity, the presence or absence of concomitant somatic diseases, and finally, the lifestyle, intelligence and marital status of a woman.

What are the stages in the development of pain syndrome in pelvic pain syndrome?

Organ or first stage. At this stage, the appearance of episodes of local pain in the pelvic area is typical, which may be accompanied by violations from neighboring organs, however, the degree of manifestation of painful sensations at this moment depends on the severity of local hemodynamic disorders (the degree of venous plethora). If at this stage a gynecological examination is performed, then the medical manipulation causes a definite discomfort in the woman.

Supraorgan or second stage. During this stage, the appearance of radiating pain in the upper abdomen is characteristic. In a significant proportion of patients, pain can generally migrate to the upper abdomen. During the second stage, the peri-aortic and paravertebral nerve formations are involved in the pathological process. If at this stage of development a gynecological examination is performed, then the doctor will find the compliance of complaints with the stage of development of pelvic pain syndrome and clinical examination data. However, at this stage, especially with the displacement of pain in the upper abdomen, diagnostic errors are also possible.

Polysystemic or third stage. This is the final stage in the formation of pelvic pain syndrome. At this stage, pathological processes are widespread in breadth and depth, metabolic and atrophic processes have covered various parts of the tissues and organs of the small pelvis, different parts of the nerve transmission were involved in the process. During this stage, disorders of sexual, menstrual function, metabolic disorders, disorders of the intestines and other pelvic organs gradually join the already described disorders. At this systemic stage, the intensity of pain sharply increases, absolutely any reason, any irritant can provoke an increase in the pain syndrome. As they say, the ends are finally tangled. Thus, it is already practically impossible, given the multisystem nature of the pathological process, to identify the cause of the underlying disease only on the basis of the history of the development of the disease, complaints and gynecological examination.

Features of the anatomy of the female pelvis. The role of the nervous system in the formation of pain.

For a better understanding of why in the formation and development of the pelvic pain syndrome it happens exactly this way and not otherwise, we will briefly consider the features of the neuroanatomy of the pelvic organs.

The pelvic organs are provided with somatic and autonomic nervous innervation. The somatic department of nervous innervation accounts for the skin, pelvic bones and periosteum, peritoneum, enveloping the walls of the pelvis. On the vegetative part - the bladder, ureters, rectum and caecum, internal genital organs and appendix.

Sensitive fibers of the somatic nervous system, along with pain conductors, pass through the pudendal, sacral, and lumbar nerve plexuses. These nerve conductors provide the appearance of pain immediately immediately after the irritating effect, while the woman is able to localize and indicate the painful point or area. So, for example, pain during intercourse and local pain in endometrioid lesions of the cervix and uterine ligaments are explained. However, the main role in the conduction and amplification of pain impulses still belongs to the autonomic nervous system. The fibers of the autonomic nervous system have a slightly different structure, and therefore a lower speed of the pain impulse. This means that excitation in the area of responsibility of the sensitive receptors of the autonomic nervous system will be perceived as a diffuse pain sensation, of indistinct localization, with blurred boundaries. It is known that the autonomic nervous system is divided into sympathetic and parasympathetic divisions.

Sensitive nerve fibers as part of the parasympathetic nerves divert impulses from the following organs: uterine ligaments (except round and wide), lower uterus, cervix, upper vagina, rectum and sigmoid colon, urethra, bladder area. Passing through the pelvic plexus, the sensory nerves enter the spinal cord at the level of II-III sacral segments. This means that pain impulses that have arisen somewhere in the above organs can “give” to the sacrum, gluteal regions, and lower limbs. The sympathetic division of the autonomic nervous system provides sensitive innervation of the fundus of the uterus, the parts of the fallopian tubes adjacent to the uterus, the tubal mesentery, the appendix, the dome of the caecum, part of the final section of the small intestine, the bottom of the bladder. Nerve conductors, passing through the solar and mesenteric plexuses, continue into the spinal cord. Consequently, pain impulses formed in one or more of the listed anatomical formations will be subjectively felt as painful sensations in the lower abdomen.

Localization of pain in the umbilical region may indicate that the source of pathological pain impulses is the ovaries, part of the fallopian tubes, ureters, and the tissue surrounding the described organs.

What is Chronic Pelvic Pain Syndrome?

pelvic pain- this is a feeling of discomfort in the area below the navel, above and central to the inguinal ligaments, as well as behind the pubic joint and in the lumbosacral region. The anatomical and physiological features of a woman's body determine the fact that chronic pelvic pain, on the one hand, may be the result of some organic gynecological, mental or somatic disease, on the other hand, be an independent part of the symptom complex, which in modern medical literature appears as a pelvic pain syndrome.

Why is it difficult to identify the causes of pelvic pain syndrome?
What is the reason for the complexity of the diagnostic search for the causes of chronic pelvic pain in females? This complexity is associated with the proximity of the location, the peculiarities of innervation and the general embryonic development of the pelvic organs.

For simplicity of presentation, we will omit the long chains of differential diagnostic research by a specialist doctor on the path of his diagnostic search. We confine ourselves to the fact that as a result of special gynecological examinations, vaginal examination, if necessary, and rectovaginal examination, two groups of patients are formed.

To the first group includes women who, already at the initial stages of the examination, are diagnosed with various types of gynecological pathologies that can, alone or in combination with each other, cause the appearance and further development of symptoms of chronic pelvic pain involving the mental sphere (with the progression of the disease).

To the second group those women will be included in whose body various detectable pathological changes are not determined or the degree of their severity is rather insignificant, so that these changes do not explain the causes of chronic pelvic pain. Naturally, this group of women should not have other diseases not related to the sexual sphere or any mental disorders that occur with severe pain. In this case, we can assume the presence of a state of pain - disease (pain as a disease). It is logical that this conclusion should be confirmed by a number of instrumental, clinical, laboratory, and, if necessary, histological studies.

Diagnosis of chronic pelvic pain syndrome

There is currently no concise and universal algorithm for examining patients with chronic pelvic pain. And its creation due to various reasons is currently problematic. It was shown above that the causes of pelvic pain are multifactorial and quite diverse. However, the current state of affairs dictates the need to act consistently and step by step, to use various laboratory and clinical methods, instrumental and hardware research methods in order to achieve a result - to find out the cause of pelvic pain.

On first and second stage examinations, anamnestic data are collected, at the second, general clinical and special gynecological examinations are carried out, the threshold of individual pain sensitivity is determined, consultations of related specialists are applied - urologists, neurologists, therapists, surgeons.

On third stage patients undergo a more in-depth clinical and laboratory examination - a clinical urinalysis, a clinical blood test, a virological and bacteriological examination of the vaginal discharge and cervical canal (for chlamydia, ureaplasma, herpes virus and others), ultrasonographic studies are performed: ultrasound of the abdominal cavity and retroperitoneal space, pelvic organs, Doppler examination of the renal and pelvic vessels, a complex of X-ray studies: radiography of the pelvic bones and spine, excretory urography and metrosalpingography, irrigoscopy. Endoscopic studies of the third stage of examination for chronic pelvic pain include diagnostic laparoscopy, hysteroscopy, cystoscopy and colonoscopy. After carrying out invasive diagnostic measures, when material for histological examination is obtained, biopsy examination or cytological examination of aspirates obtained from the abdominal cavity is carried out.

It should be emphasized that the indispensable components of a comprehensive survey are:

examination to detect herpetic, mycoplasmal and chlamydial infections in the body (these pathogens cause damage to the nerve conductors and pelvic nodes)
Ultrasound screening of the pelvic organs with Doppler examination of the renal and pelvic vessels
x-ray examination of the pelvic bones, spinal column, irrigoscopy
endoscopic research methods, namely: colonoscopy, cystoscopy, sigmoidoscopy, proctoscopy
diagnostic laparoscopy

It should be said that the performance of diagnostic laparoscopy, according to various authors, should be considered a reasonable and necessary diagnostic manipulation. This circumstance is explained by the fact that this procedure is necessary to detect endometriosis, various adhesive processes in the small pelvis, chronic inflammatory and volumetric inflammatory formations of the small pelvis (serozocele, hydrosalpinx, pyosalpinx and others), varicose veins of the walls of the pelvis and pelvic organs, Alain-Masters syndrome. All of the above are among the leading causes of chronic pelvic pain.

The role of the mental factor in the pelvic pain syndrome

However, despite a thorough comprehensive examination, in 1.5-3% of cases, the cause of chronic pelvic pain remains undisclosed. What should be done in this situation? It is most preferable to consider the question of the relationship of pain with various diseases of a neuropsychic nature. We are talking about epilepsy, sometimes more serious disorders, as well as depressive disorders or neurotic conditions.

Nevertheless, it is worth noting that at present the psychogenic factor in the conditions of existing realities manifests itself much more often than most doctors and their patients or patients suggest. This is quite eloquently evidenced by the increase in the frequency of depressive and affective (emotional) disorders encountered in the practice of doctors of various profiles.

Treatment of chronic pelvic pain

The essence of the methods of treatment of chronic pelvic pain is the implementation of measures aimed at minimizing the activity of pain pathway neurons. To achieve the goal can be applied:

method of medicinal or surgical elimination of the source of pain impulses
interruption of the spread of pain impulses along the paths of pain sensitivity
increased productivity of the anti-pain system
change in pain perception threshold

It must be emphasized that the treatment of such patients is an extremely difficult task.
With the aim of elimination of the cause pain sensations are used:

antiviral and antibacterial, antichlamydial or other treatment aimed at eliminating a specific pathogen
antispasmodics, non-steroidal anti-inflammatory drugs (for example, from the indomethacin group)

A set of measures for correction of biochemical and neurotrophic processes provides for the following activities:

hormone replacement therapy (in order to correct the functioning of the ovaries and the hypothalamus-pituitary system, progestogen preparations are used - duphaston, utrozhestan; as well as estrogen-gestagenic preparations - logest, novinet). The use of hormonal drugs is decided individually, taking into account indications and contraindications, age, weight, concomitant diseases and the identified underlying cause, pelvic pain
enzyme and antioxidant therapy (Wobenzym - a complex enzyme preparation that improves tissue nutrition and metabolism. Antioxidant drugs - instenon, cocarboxylase, calcium gluconate. These antioxidant drugs improve tissue and cellular metabolism, tissue respiration at various levels - the brain and other body structures ). The duration of the course of treatment, dosages and combinations of drugs are prescribed taking into account all the characteristics of each individual person.
vitamin therapy (ascorbic acid, folic acid, complex multivitamin preparations - undevit, dekavit, gendevit. Vitamin preparations are used to normalize biochemical enzymatic reactions in tissues)
physiotherapy (percutaneous electrical nerve stimulation, diadynamic, fluctuating and sinus-modeled currents are used for chronic pelvic pain of inflammatory origin. Appointment is carried out taking into account individual tolerance)
hormone therapy for endometriosis
the use of drugs that improve tissue microcirculation (such drugs include trental, chimes, pentoxifylline, orocetam, etc.)

Reducing the intensity of the flow of painful pathological impulses and correction of the balance of nervous processes in the central nervous system contribute to:

acupuncture (acupuncture methods, acupressure, su-jok, shiatsu)
local anesthetic blockades (alcoholization of the nerve, nerve blockade - intrapelvic blockades)
the use of sedatives (valerian tincture, sedasen, persen, novo-passit, corvalol, as well as anti-anxiety drugs - diazepam are used)
psychotherapeutic methods of influence (First of all, it is rational to use various relaxation techniques - hypnosis, autogenic training. They also conduct behavioral psychotherapy, the essence of which is to teach a person a certain set of psychological methods by which pain can be reduced)
the use of painkillers (non-narcotic painkillers - nurofen, ibuclin, ibuprofen, aspirin, naklofen, orthofen, nimesulide, indomethacin. It is also possible to use combined drugs - sedalgin, baralgin, pentalgin)
surgical reduction of pain sensitivity (methods of laser neurosurgery, separation of existing adhesions, surgical treatment of genital prolapse)

Specific dosages, duration of use, combinations of drugs are determined by the attending physician in each case individually.

In the treatment of pelvic pain syndrome, it is important to adhere to the following principles:

remember the old rule: “treat the patient, not just the disease”, give the patient the opportunity to realize what is the causal factor in pain
it is rational to use drug methods of exposure, given that the treatment will last a long time. It is necessary to choose the minimum effective dose with the minimum side effect.
maximize the use of the forces of rehabilitation medicine
to maintain and maintain the quality of life to carry out personal correction

In conclusion, it should be emphasized that this article is informational in nature and is intended to improve orientation in the complex problem of pain. Also, it cannot be a manual for self-diagnosis and self-treatment. BOOKING AN APPOINTMENT TO A UROLOGIST IN VOLGOGRAD

What is prostatitis, what are prostatitis? What is Chronic Pelvic Pain Syndrome (CPPS)?

Prostatitis is an inflammation of the prostate gland. It can be acute or chronic, infectious (bacterial) or non-infectious (abacterial). Chronic abacterial (non-infectious) prostatitis is also called chronic pelvic pain syndrome. If the patient has symptoms of prostatitis (primarily pain in the perineum), but signs of inflammation of the prostate are present, then this is an inflammatory syndrome of chronic pelvic pain (category IIIA). If the patient does not have inflammation, then this is a non-inflammatory chronic pelvic pain syndrome (category IIIB). So far, the question of the cause and development of this pathology has not been fully studied.

What can cause prostatitis and what predisposes to the development of chronic prostatitis and CPPS?

All causes of the disease can be divided into two large groups - external and internal. Among non-infectious factors, the leading role in recent years has been assigned by most researchers to chronic spasm of the prostatic urethra, which leads to the reflux of urine from the urethra into the prostate, disruption of the normal emptying of the prostate and seminal vesicles. Violations of the venous outflow from the pelvic organs, neuromuscular dysfunction of the pelvic floor muscles, disorders of local immunological resistance, and a lack of concentration of zinc-containing prostatic antibacterial factor in the prostate are also important. The reasons for the emergence and development of CPPS are not well understood. It is quite possible that this diagnosis hides a whole gamut of different conditions, including those when the prostate gland is involved in the pathological process only indirectly or not at all.

What are the predisposing factors for the development of prostatitis?

Predisposing factors are: irregular sex life, sedentary lifestyle, wearing tight underwear, alcohol abuse, reduced body defenses, hormonal disorders, untreated foci of infection (sinusitis, tonsillitis, caries, cholecystitis and others), urinary tract infections, promiscuity with different sexual partners without using a condom.

How is prostatitis and chronic pelvic pain syndrome most often manifested?

The most common symptom of prostatitis is pain in the perineum, scrotum, suprapubic region and lower abdomen, groin and sacrum. With prostatitis, there is often frequent and painful urination, decreased libido and premature ejaculation. The appearance of these symptoms is a reason to consult a doctor and undergo a special examination.

What is the treatment for chronic pelvic pain syndrome?

Today we can say with confidence that there is no single approach to the treatment of CPPS, modern medicine still cannot finally solve the problem of prostatitis. For its treatment, methods such as antibiotic therapy, prostate massage, physiotherapy, immunocorrective therapy and lifestyle correction are used. The main thing is that treatment should be started as early as possible, strictly following the recommendations of the doctor. Prostatitis is treated in a complex manner, with each patient the doctor selects an individual set of therapeutic measures. With prostatitis, the treatment is so difficult that one cannot afford to neglect any of the mentioned methods of influence. It is impossible to cure prostatitis once in a lifetime. Prostatitis is treated for a while. The quality of treatment can be determined by the timing of remission (the period from the end of treatment to the need for re-treatment). But modern medicine can eliminate the symptoms of prostatitis and cause a stable long-term remission. If the patient will clearly and carefully follow all the doctor's recommendations, it is very likely that the unpleasant and annoying symptoms of prostatitis will disappear for life. But in the absence of treatment and prevention, the disease returns. But not everyone has the money and time for permanent treatment. How can you help each person? This has always been a sore point for doctors.

Dear patients with chronic pelvic pain syndrome! Solving your problem is very difficult! Sometimes it takes a month to heal, or it may take years to get better. Paradoxically, it is a fact that antibiotics are most effective in the treatment of abacterial, non-infectious. In complex therapy, drugs are used that improve microcirculation (phlebodia), anticholinergics, modulators and stimulants of immunity, peptides, epeleptic drugs, xanthine genase inhibitors, antidepressants and tranquilizers, muscle relaxants and antispasmodics, 5L-reductase inhibitors, adrenoblockers, non-steroidal anti-inflammatory drugs, vitamin complexes and trace elements. Phytotherapy (so-palmetto, pro formula) is becoming increasingly important for the treatment of prostatitis - treatment with medicinal plants, which is associated with an increase in complications when prescribing synthetic drugs and a change in the pharmacological effect when they are used together, especially in the treatment of elderly and senile people. The advantage of herbal preparations is their low toxicity and the possibility of long-term use without significant side effects. Sometimes intracutaneous autohemotherapy and lymphotropic therapy are performed.

Retains its value and prostate massage. For the treatment of chronic abacterial prostatitis and CPPS, a large number of various drugs and methods have been proposed, the use of which is based on information about their effect on various stages of the development of the disease. Hopes for improving the results of treatment of patients with pelvic pain are associated with progress in the field of diagnosis and differential diagnosis of these conditions, improvement of the clinical classification of diseases, and the accumulation of reliable clinical results characterizing the efficacy and safety of drugs.

Treatment Methods	Priority (0-5)
Antibiotics	4,4
L-blockers	3,7
Prostate massage course	3,3
Anti-inflammatory therapy (NSAIDs and others)	3,3
Pain therapy (analgesics, amitriptyline, gabapenti)	3,1
Biofeedback Treatment	2,7
Phytotherapy	2,5
5L reductase inhibitors	2,5
Muscle relaxants	2,2
Thermotherapy (transurethral thermotherapy, laser therapy)	2,2
Physiotherapy	2,1
Psychotherapy	2,1
Alternative therapy (meditation, acupuncture and others)	2,0
Anticoagulants, capsacin	1,8
Surgery	1,5

What physiotherapy techniques are used to treat CPPS?

In complex therapy, apply:

Electrogalvanic rectal stimulation. The use of sinusoidal modulated currents gives an analgesic effect, normalizes the tone of the prostate and the blood flow of the main vessels. SMT therapy has an irritating effect on the receptor apparatus of the skin, impulses from the receptors enter the central nervous system, where a predominant focus of irritation by these currents is created, which should be stronger in strength than the dominant associated with the disease. In this regard, the flow of pathological impulses from the pain zone to the cerebral cortex is interrupted. There is an analgesic effect. Currently, one of the physiological and effective methods of treating patients with CPPS is the method of endourethral and endorectal electrical stimulation of the pelvic organs.
Transcutaneous epidural spinal cord stimulation, caudal anesthesia with bipivacaine with methylprednisolone. Perhaps the use of transcutaneous electrical nerve stimulation. With peripheral electroanalgesia, electrodes are located in areas of local pain, projection or exit of nerves, reflex zones.
With segmental electroanalgesia - electrodes in the region of paravertebral points at the level of the corresponding segments. With the relief of pain, the procedure can last up to several hours.
Transurethral microwave thermotherapy, transrectal hyperthermia. Currently, there are two types of temperature exposure - thermotherapy and hyperthermia. Modern equipment appears for the simultaneous use of urethral and rectal heating against the background of exposure to a traveling magnetic field. This possibility allows you to optimize the impact and reduce the duration of treatment with the maximum percentage of favorable outcomes even in advanced cases, reduce pain in pelvic pain.
Ozone therapy is the use of special mixtures saturated with medical ozone and oxygen for the treatment of a person, the prevention of diseases.
Laser therapy.

What does laser therapy do for prostatitis and CPPS?

The most commonly used low-intensity infrared laser irradiation, which has a high penetrating power and allows you to irradiate the prostate, both through the skin of the perineum and through the wall of the rectum. Upon contact of an infrared laser with biological tissue, the following is achieved: activation of metabolic processes, an increase in energy production in cell mitochondria and, as a result, acceleration of regeneration processes; stimulation of a faster change in the phase of edema by the phase of proliferation with the formation of a scar in the focus of inflammation; prolongation and potentiation of the action of drugs, which can significantly reduce their doses; strengthening tissue immunity; providing analgesic, and in some cases, analgesic effect. Treatment of chronic prostatitis is carried out in combination with traditional therapeutic methods. It is possible to carry out laser therapy by installing one emitter above the womb, and the second - transrectally, using a rectal nozzle in the same mode. In this case, the irradiation mode is set depending on the activity of the inflammatory process. Prophylactically, the procedures are most indicated in the autumn-spring periods of the year.

What are trigger points, trigger stimulation?

Separate localized anatomical zones of discomfort or pain in the perineum and pelvis can be trigger points leading to the development of myofascial pain. Compression on these points causes a sensation of pain and the patient's reaction in the form of involuntary movement. Trigger points are found in the region of motor nerve endings. Thus, the trigger point (TP) (trigger zone, trigger area), the focus of hyperirritability of the tissue, which is painful when compressed, and with increased sensitivity reflects pain and soreness. Trigger stimulation - stimulation in the rhythm of fluctuations in brain potentials. Therapeutic effects on trigger points include: thermal treatments, massage, ischemic compression, anesthetic injections, electrical nerve stimulation, yoga, acupuncture, biofeedback, relaxation exercises. The most common method is triggered photostimulation. The impact on myofascial starting (trigger) points is carried out with the help of pelvic massage. It is recommended to perform it with the patient on the left side. Internal pelvic massage is a labor-intensive type of therapy. In some cases, to achieve moderate progress, the duration of the procedure can be up to an hour. As a rule, several months of treatment with a weekly interval are necessary. Treatment is carried out 2 times a week for 4 weeks, 1 time per week for 8 weeks, then as needed.

What modern method of treatment of chronic pelvic pain is used?

Botulinum toxin is a drug that really opens up new possibilities in medicine. First you need to try to solve the problem with drugs. If this does not help, then there is currently an effective method of injecting Lantox botulinum toxin. In urology over the past 10 years, the main successes are associated with it. The very quality of Botax is also used, as in cosmetology - muscle relaxation. The introduction of Lantox is not a very painful procedure. If desired, they can be performed under local anesthesia. The drug is injected into the muscles, which leads to their relaxation. Processes are back to normal. This method of treatment has the least number of side effects. It's not surgery, it's not implantation. And most of the time it's done on an outpatient basis. Usually the drug works for six months, and then repeated injections are required. But there are times when one procedure is enough. There are patients who feel great for several years. Treatment is aimed primarily at improving the quality of life of patients. The effectiveness of treatment is close to 80%.

What is prostate massage?

Prostate massage is one of the most famous ways to treat patients with chronic prostatitis. Proposed in 1858, Lowenfeld is widely used in the complex treatment of patients at the present time. This procedure is performed only by a doctor. Finger massage of the prostate gland improves blood circulation and reduces venous congestion in it, promotes the flow of arterial blood into the tissue of the gland and thereby improves its trophism and function, helps to eliminate secretion stagnation and improve drainage of acini. It is recommended to take into account the following principles when performing prostate massage: the more pronounced changes in the prostate, the less active the number of prostate massage sessions should be, rough prostate massage is unacceptable, because it can exacerbate and spread the inflammatory process, the procedure begins with less intense movements , and ends up being more intense. First, one lobe is massaged. Then the same movements are performed on the other lobe of the gland. With congestion in the seminal vesicles or their increase, massage should begin with the seminal vesicles. In conclusion, sliding movements are made along the median groove, while the secret of the prostate gland enters the urethra. The criterion for a properly performed massage is: the absence or reduction of pain. The duration of the massage is from 0.5 to 1.5 minutes. After the massage, the patient is advised to urinate. The duration of the course is from 3 to 8 weeks.

What course of treatment for chronic pelvic pain syndrome can be offered?

Initially, pain points of sensitivity of trigger zones are determined - Zimmermann's zone, prostate, perineum, above the womb, etc. General anesthesia is performed with NSAIDs, local anesthesia (blockade with novocaine and antibiotics of trigger zones, sacral nerves, spermatic cord according to Lorin-Epstein). Further, sedatives and antidepressants (enerion, melipramine) are used. Long-term neurostimulation of the tibial nerve, anus, intracavitary urethral electrical stimulation, long-term digital electromassage of the prostate and trigger zones through the rectum are carried out. Next, phonophoresis with testosterone or hydrocortisone is carried out on trigger zones, laser magnetic therapy on the Ashu point. It is necessary to take antibiotics for up to 3 months.

What is the prevention of prostatitis and chronic pelvic pain syndrome?

Regular sexual activity. Normalization of sexual life is the main direction of prevention of prostatitis. Every man should have certain knowledge about the peculiarities of the rhythm and intensity of sexual activity, the frequency of sexual intercourse, the duration of sexual intercourse, compliance with the psychological requirements for sexual activity, etc. Despite the fact that the concept of the norm of sexual life is relative, there is an average physiological norm for it. Most often, at the age of 20 - 45 years, 2-3 sexual intercourses per week are performed, the duration of which is 1.5 - 2 minutes. Naturally, healthy men may also have deviations in one direction or another from the above averages. Men under the age of 25 have sexual intercourse more often, and men over 45 - less often, but their duration is longer. Sexual activity should occur naturally. If a man seeks to artificially increase the number of sexual intercourse, then this sexual excess can lead to impaired blood flow in the prostate gland, to venous stasis and the development of prostatitis.
Try to normalize your sex life, change partners less often, protect yourself, do not use the practice of interrupted intercourse. The psychological and sexual compatibility of spouses or partners is of great importance, which is sometimes very difficult to achieve. An important role in the prevention of venous congestion in the prostate gland and in the prevention of prostatitis is played by the so-called full sexual intercourse, when sexual intercourse proceeds normally and ends with ejaculation in the vagina. However, in order to avoid conception, men often resort to interrupting sexual intercourse at the time of the onset of ejaculation, for which the penis is removed from the vagina, and ejaculation occurs outside it. Such sexual intercourse leads to congestive changes in the prostate gland, which contributes to the development of prostatitis.
You should also avoid hypothermia, excessive exposure to vibration, trauma to the perineum (long-term cycling). Hypothermia is one of the factors contributing to the stagnation of venous blood and secretion in the prostate gland.
Give up the fashion that makes you constantly walk in tight and tight swimming trunks. Loose cotton underpants are much more hygienic and do not interfere with normal blood flow in the prostate.
Equally important is the timely and correct treatment of inflammatory diseases in the body, especially inflammation of the urethra, since in most patients it is from the urethra that microbes enter the prostate gland.
Particular attention should be paid to the inadmissibility of the abuse of alcoholic beverages. Alcohol increases blood flow to the small pelvis, including the prostate gland, but at the same time disrupts its blood flow, which causes the development of congestive prostatitis. In addition, with the systematic use of alcohol, the level of male sex hormones in the blood decreases, as a result of which prerequisites are created for the development of an inflammatory process in the prostate gland, the appearance of sexual weakness. Smoking and alcoholic drinks are excluded.
The best prevention of prostatitis is an active lifestyle. Move more. Those who spend a significant part of their working time in a sitting position also need to take care of their health, as this is the cause of venous stasis in the prostate gland and also contributes to the development of prostatitis. With insufficient physical activity, active recreation is indicated (volleyball, swimming, tennis, badminton). During physical work, passive rest is recommended. Mandatory daily morning exercises followed by water treatments.
Proper nutrition (balanced composition of food, prevention of constipation). A rational dietary regimen (reinforced for the emaciated and unloading for the obese) requires a sufficient amount of protein and carbohydrates. It is useful to include eggs, veal, cottage cheese, carrots, apricots, cherry plum, pumpkin, beets, watermelon and other vegetables and fruits in the menu. Vegetable fats (sunflower, corn, olive oil) are obligatory in the diet. With infertility, the use of honey is recommended (1-2 tablespoons per day).
Water procedures are useful: wiping, showering, bathing, bathing, which have various effects on the nervous system. So, warm procedures (35 - 38 ° C) calm the nervous system, and cold (15 - 20 ° C) and hot (40 ° C and above) excite. It is recommended to take baths every other day with aqueous extracts of vir rhizomes, mustard seeds and mint herb. A mixture containing 40 g of each plant is poured into 3 liters of boiling water, heated in a water bath for 15 minutes, infused for 45 minutes, filtered and poured into the bath. Common baths with a decoction of oat straw, field horsetail, as well as steam sitz baths with a decoction of chamomile flowers, prickly tartar or dill grass, common oak bark are useful.
The use of medicinal plants with a tonic, multivitamin effect is useful especially in the spring for all men, regardless of the degree of sexual dysfunction. The most commonly used fruits are cinnamon rose hips, common viburnum, mountain ash and sea buckthorn buckthorn, fruits and leaves of black currant, common strawberry, four-leafed cranberries and blueberries, onions of various varieties, common sorrel and garden rhubarb (Tangut). Herbal infusions are shown: primrose officinalis, lungwort officinalis, nettle dioica, knotweed (highlander), regular use of lemon with honey is recommended.

The material was prepared by a urologist, physiotherapist Oleg Viktorovich Akimov

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Chronic pelvic pain syndrome in men

The content of the article:

In this article, we will consider such a manifestation of chronic prostatitis as chronic pelvic pain syndrome in men. We will separately pay attention to the diagnosis and treatment of this condition, since they are very difficult and not always performed in the required amount.

What is chronic pelvic pain syndrome in men

One of the most pressing problems in urological practice is chronic prostatitis. According to statistics, from 5 to 16% of the male population experience this common ailment. Such a high incidence can be partly explained by the fact that the diagnosis of "chronic prostatitis" has become a kind of "basket" for pathological conditions that have not been fully elucidated. This is confirmed by statistics on the forms of the disease. In the vast majority of cases, chronic abacterial prostatitis (CAP) is diagnosed, which is manifested by chronic pelvic pain syndrome (CPPS). According to the classification adopted by the US Institute of Health, this disease belongs to the 3rd category of subgroup A prostatitis with an increased level of leukocytes in the secretion of the prostate (PJ).

The generally accepted classification of types of prostatitis was presented back in the 70s of the last century by G. Drach and co-authors. It provides for the division of this male disease into four categories:

bacterial acute;

Bacterial chronic;

Abacterial chronic form of prostatitis (CPPS or prostatodynia - a syndrome of non-inflammatory chronic pelvic pain);

Asymptomatic inflammatory prostatitis.

In the 1990s, experts at the Institute of Health defined CPPS as “a condition in which pain, urination problems, and sexual dysfunction in a man occur.” After some time, this definition, as well as the presence/absence of pathogenic bacteria in urine and pancreatic secretions, became the basis for the scientific classification of prostatitis.
Although prostatitis is one of the most common diseases of the prostate, the first scientific studies on its prevalence among the population began to be carried out only in the 90s. The following statistics can be found in the scientific literature:

The number of cases of the disease is up to 3.8 per 1000 men per year;

The prevalence is from 4 to 14%.

Moreover, the incidence of CPPS has nothing to do with demographic characteristics and age. This pathology has become much more common than bacterial prostatitis - it affects men 8 times more often. And prostatitis caused by a bacterial infection occurs in only 10% of cases. The quality of life in men suffering from prostatitis is significantly deteriorating. This means that the disease is a serious problem that should not be underestimated.

Causes of chronic pelvic pain syndrome in men

The etiology of chronic pelvic pain syndrome is not yet fully understood. Many experts believe that most often chronic prostatitis is associated with infectious processes in the lower urinary tract. However, there is another theory, according to which chronic prostatitis is associated with autoimmune processes. There is also an opinion that with prostatitis, inflammation of the prostate gland is chemical in nature and is caused by urine reflux. But none of these assumptions today can not be fully confirmed, so modern medicine refers to chronic prostatitis as a disease caused by various causes.

In some cases, the connection of prostatitis with the influence of pathogenic bacteria is obvious. Such forms of prostatitis are classified as bacterial (acute or chronic). As for CPPS, the effect of bacteria has not yet been confirmed. Laboratory studies can identify such microorganisms in the prostate of patients with CPPS: from gram-negative bacteria- Enterococcus, Escherichia coli, from Gram-positive- staphylococcus. In some cases, the presence of corynobacteria, mycoplasma and chlamydia is detected.

The nature of the course of the inflammatory process, as is known, is associated with the characteristics of immunity. Some experts involved in the study of CPBT have found that in some patients, T cells overreact to sperm plasma. And this may indicate that CPBT is associated with the action of autoimmune factors.

In the event of a violation of the immune response in the body, cytokines are produced - substances that take part in the development of the inflammatory process in CPBT. And in patients of this group, the following cytokines are determined in the blood: IL-1, IL-1b, IL-6, IL-8, TNF-a. This suggests that in the prostate gland, as well as in the seminal ducts, there is a pronounced inflammation.

The relationship between chronic prostatitis and intraprostatic reflux has also been studied. Experiments with experimental models of reflux in animals and humans give results confirming the possible relationship between an increase in intraurethral pressure during urination and urine reflux into the pancreatic ducts with the development of symptoms of prostatitis.

After examining the composition of the urine and secretion of the prostate gland of patients, doctors concluded that due to reflux during urination, the prostate ducts undergo chemical irritation and become inflamed. In a chronic inflammatory process, the release of some mediators begins. One of them is nerve growth factor. As a result, the number of C-fibers increases. These nerve endings are constantly stimulated, and the man suffers from pain. This mechanism was shown by physicians on the example of pathological processes developing in the tissues of the bladder of patients with cystitis. (Interstitial cystitis has pain symptoms similar to the sensations in chronic forms of prostatitis).

Other studies in this area have shown that in the calculi of the pancreas there are components of urine, which, when urinating, penetrated into the ducts. If there is an obstruction of the duct by a calculus, the intraductal pressure increases significantly. For this reason, the prostate epithelium is subjected to constant mechanical stress, and an inflammatory process develops in it. Sometimes irritation of the epithelium is caused directly by the calculus.

In some cases, CPBT may be associated with myalgia, which occurs due to the tension of the muscle tissues of the pelvic floor, which are in a spastic state. In patients of this category, the pain syndrome makes itself felt when they sit or engage in physical activity - it is at this time that the spasm occurs. In this case, a rectal digital examination allows you to note spasms of the external sphincter, and pain occurs in the paroprostatic region.

Other underlying causes of CPPS may be: damage to the intervertebral discs, pinched pudendal nerve, neoplasm in the spinal cord or pelvic organs, osteitis pubis.

In recent years, there has been a growing number of specialists who support the theory that CPBT is one of the manifestations of a condition that can be defined as a “functional somatic syndrome”. This condition is also manifested by persistent headaches, fibromyalgia, irritable bowel, rheumatological and dermatological symptoms.

The role of such an important negative factor as stress should not be underestimated. In the work of A. Mehik et al., it is stated that in patients with CPPS signs of stress are recorded much more often than in healthy men from the control group. Thus, 43% of patients complained of sexual dysfunction, and 17% of men with CPBT had carcinophobia. Hypochondriacal disorders, depression, hysteria are quite common in CPPS.

The main symptom of CPPS is an obsessive feeling of pain or discomfort in the perineum and pelvis. In some patients, pain radiates to the abdomen, lower back, or vulvar area. A very common phenomenon is pain that accompanies ejaculation. The second most common symptom is urinary problems. They occur in about 50% of men with CPPS. Also, patients often have sexual disorders (erectile dysfunction) and psycho-emotional disorders. Such symptoms most negatively affect the quality of life of a man. In terms of quality of life, CPPS is comparable to serious conditions such as Crohn's disease, coronary disease, or myocardial infarction.

The pathogenic basis of pelvic pain lies in the prolonged tension of the muscles of the pelvic floor and / or the inner thighs, which leads to the described symptoms. Increasing the tone of any muscles of the pelvic floor and adjacent to them can lead to irradiation of pelvic pain in the rectum, bladder, glans penis.

Symptoms associated with chronic prostatitis are usually assessed using the NIH-CPSI scale. It consists of nine questions that cover all aspects of CPPS (such as pain, discomfort, difficulty urinating, problems in sexual life). The informativeness of this method has been repeatedly confirmed by medical practice and scientific research (clinical and epidemiological). At the moment, the scale has been translated into several foreign languages and is successfully used for diagnostic purposes.

A definitive diagnosis of CPPS can only be made by exclusion. Therefore, diagnostic measures are aimed at identifying / excluding other diseases that cause similar sensations of pain and discomfort. First of all, we are talking about problems with the intestines, pathologies of the nervous system, obvious diseases of the urogenital area.

Clinical research consists in the analysis of the patient's complaints and a careful study of the anamnesis. Of particular importance here are data on sexually transmitted infections, and on inflammatory diseases of the urinary tract. In addition, the presence of comorbidities that may affect the development of CPPS (eg, diabetes mellitus or changes in immune status) must be taken into account.

During a clinical examination, it is necessary to examine the external genitalia of a man and palpate them. In the same way, the lower abdomen, perineum and groin area are examined, and a digital rectal examination is performed.

To obtain accurate information about the condition of the prostate gland, ultrasound (transrectal) is performed. Of course, there are no specific signs of CPPS, but stones and calcifications can be found. A Doppler study shows the activation of blood flow.

The 4-glass test, developed in 1968 by E. Meares, T. Stamey, is generally accepted in the diagnosis of CPPS at the moment. It involves the analysis of four samples: the first (reflects the condition of the urethra) and the middle (allows to diagnose primary or secondary cystitis) portions of urine, prostate secretion or the third portion of urine obtained after prostate massage (detection of uropathogenic bacteria) and the diagnosis of post-massage urine with the release of non-pathogenic bacteria ( the presence of more than 10 leukocytes in the secretion of the prostate or urine indicates the presence of an inflammatory syndrome of chronic pelvic pain). This study determines which category prostatitis belongs to (according to the US National Institutes of Health classification), and also detects urethritis. This test is often cited by experts, although it is time consuming and its validity has not been investigated.

For patients who do not suffer from urethritis, a less complex test was developed in 1997 (author - J. C. Nickel). It involves the analysis of only two portions of urine - pre-massage and post-massage. If significant bacteriuria is observed in the pre-massage portion, acute bacterial prostatitis or an infectious process in the urinary tract can be suspected. If bacteriuria predominates in post-massage urine, chronic bacterial prostatitis is likely to occur. Leukocytosis without the presence of bacteria in the post-massage portion is indicative of inflammatory CPPS (category III-A). If neither bacteria nor leukocytes are detected in the urine, then we are talking about a non-inflammatory form of CPPS (category III-B). The test has a sensitivity of 91% and is therefore indicated as a first-line test in a screening study.

A patient diagnosed with CPPS is recommended to have a PSA (prostate-specific antigen) test. Most often, in such patients, this indicator is normal, but in some cases an increase is recorded. This is evidence of inflammation in the prostate gland. In this case, antibiotic therapy is carried out and then the PSA test is repeated. If its level is still elevated, the doctor may decide that a prostate biopsy is needed.

The modern PCR technique is based on the detection of nucleic acids. This assay does not require the presence of a viable microbe, as it isolates the remains of dead viruses and bacteria. Moreover, any material taken from a patient is suitable for analysis. The method can be used even after a course of antibiotic therapy. The disadvantage of this diagnostic method is that due to the high sensitivity, if the rules for performing the analysis are violated, a false positive result is possible.

CPPS refers to conditions in which the onset of a placebo effect is possible (manifestations of the disease are reduced by about 30%). Sometimes the mere fact of medical supervision without prescribing special therapy helps to improve the situation.

Naturally, with bacterial prostatitis, antibiotic therapy is the most effective method. Patients in this category are prescribed a course of drugs from the fluoroquinolone group (such as ofloxacin, pefloxacin). Such drugs have a wide spectrum of action, accumulate well in the tissues of the prostate gland and in its secretion. The effectiveness of these antibiotics in bacterial prostatitis has been repeatedly confirmed by comparative studies.

But the usefulness of antibiotics in CPPS is often questioned. Some authors claim that positive results with antibiotic therapy can be achieved in about 50% of patients. There is a clear correlation between positive PCR analysis of prostate secretion and the results of a course of antibiotic treatment. But at the same time, it is still not clear whether there is a relationship between the results of bacteriological tests, the level of leukocytes, the presence of antibodies in the secretion and the result of antibiotic therapy. Antibiotics belonging to the group of fluoroquinolones have a modulating effect on inflammatory mediators. And studies with rats have confirmed that they are effective pain relievers and reduce inflammation. Taking into account the facts described above, it is reasonable to prescribe a course of antibiotic treatment (for several weeks) to patients with newly diagnosed CPPS.

Therapy with ciprofloxacin (500 mg twice a day for four weeks) had a positive effect in 17% of cases. But, unfortunately, this effect was short-lived. Most patients experienced a recurrence of symptoms associated with CPPS within a few months (median 5). A second course of antibiotics no longer had a positive result. Therefore, it can be assumed that the initial success in the treatment of these patients was due to the placebo effect.

When prescribing alpha-blocker therapy to patients with CPPS, physicians proceed from the assumption of intraprostatic reflux during urination. In addition, these substances are able to relax smooth myocytes, thus reducing pressure in the tissues of the pancreas, thereby significantly improving blood flow.

The use of alpha1-blockers (such as doxazosin, alfuzosin, terazosin, tamsulosin) has been described by several authors. According to their observations, a course of therapy lasting less than six months does not give long-term results, and the symptoms of CPPS often recur. If the course is extended to 8 months or more, then there is a change in the expression of alpha1A-adrenergic receptors (either their activity decreases, or the activity of competitive receptors increases). When the drug is withdrawn, the changed receptor retains the properties of alpha1-adrenergic blockade. However, this treatment does not always show good results. So it is ineffective for patients of the older age category, often with benign prostatic hyperplasia (BPH). In addition, the inflammatory process in the prostate is usually more pronounced in them. But in general, alpha-blockers are considered an effective treatment for patients diagnosed with CPPS.

As for the uroselective alpha-blocker, its effectiveness reaches 53% (with a six-month course of 0.4 mg per day). Moreover, studies have confirmed its approximately the same effectiveness in different categories of CPPS.

Used in CPPS and non-steroidal anti-inflammatory drugs. The result is achieved due to the fact that they are able to have an inhibitory effect on the formation of prostaglandins. Although the practice of using such drugs has become widespread, there is very little data proving their effectiveness. The decision to prescribe an NSAID to a patient is made on an individual basis.

Also, in the treatment of CPPS, the 5-alpha-reductase inhibitor finasteride can be used, the principle of action of which is based on the reduction of infravesical obstruction of intraprostatic reflux as a result of a decrease in the prostate. In addition, there is a decrease in pressure in the tissues of the gland, due to which microcirculation is activated. Data from placebo-controlled studies on this drug are as follows: in the group of patients taking finasteride, the reduction in the manifestations of CPPS was 33%; while in the placebo group this figure was 16%.

The medical literature contains information about other drug therapies for CPPS. In practice, drugs such as bioflavonoids, pentosan polysulfate, allopurinol, and phytopreparations were used. All of them give a certain result, however, objective data were not obtained, since studies with the participation of control groups were not conducted.

Along with drug therapy, there are other treatments for patients with CPPS. So, physiotherapy methods are widely used today. One of the most effective procedures is pancreatic hyperthermia. Most often, for temperature effects on the prostate, microwave therapy technology is used. Such procedures can be performed transrectally or transurethral. Multiple placebo-controlled studies have been conducted to determine the effectiveness of transrectal thermotherapy. In this case, different devices were used: Prostatron, Prostatherm, Hupertherm Et-100, Primus, Urawave, Termex-2. The efficiency of the method was at the level of 55-75%. While the placebo effect ranged from 10 - 52%.

In some cases, CPPS is treated with invasive and rather complex methods. These include balloon laser hyperthermia and needle ablation. Both procedures are performed transurethral. What is the mechanism of temperature exposure in CPPS has not been fully elucidated. The works of A. Zlotta, 1997, described the blockade of alpha receptors, as well as the destruction of nociceptive C-fibers after the needle ablation procedure. Two uncontrolled studies have shown a good effect of this procedure in patients with CPPS. However, after a placebo-controlled study, it turned out that there were no significant differences in the results of the ablation group and the placebo group. Along with the aforementioned effect, the procedure has a bacteriostatic and anticongestive effect. In addition, it is able to activate the cellular link of immunity.

Traditionally, the most effective way of physiotherapy for chronic prostatitis is prostate massage. However, the effectiveness of the technique has not yet been confirmed by objective data. Conducted studies of the combined technique (massage of the pancreas in combination with a course of antibiotics). This therapy proved to be effective. However, it should be noted that the majority of patients (about 2/3) had a bacterial form of prostatitis, and reliable methods were not used when evaluating symptoms. And this means that the effectiveness of massage exposure in CPPS has not been proven. Nevertheless, the results of a study in which 43 patients took part give grounds to conclude that there is a positive effect of draining the pancreas by systematic ejaculation.

Some researchers describe a reduction in symptoms associated with CPPS with the use of biofeedback and after special physical exercises to relax the muscles (these exercises are recommended for patients with dysfunctional urination and spasmodic pelvic floor muscles).

A number of studies have noted that patients with CPPS improve as a result of procedures such as tibial neuromodulation and sacral nerve stimulation. The effectiveness of these methods varies between 21-75%. But at the same time, it should be noted that reliable data on the advantages of these therapeutic methods compared with placebo have not yet been presented.

The literature describes a study conducted in the use of tibial neuromodulation for the treatment of patients who have not been helped by drug therapy. The study involved 21 men, each of whom underwent 12 procedures (half an hour once a week). Subjectively, 71% of patients noted an improvement. Objective improvement (a decrease in the total score on the NIH-CPSI scale) was noted in 57% of men. In addition, in these patients, the cystometric capacity of the bladder increased, and the volume of fluid required for the appearance of a feeling of fullness increased. They also had a decrease in detrusor pressure and an increase in the rate of urination. In three patients, symptoms characteristic of obstructive urination disappeared, and in five patients, manifestations of dysfunctional urination were no longer observed. Treatment of patients with different types of CPPS by tibial neuromodulation had the same results, which is evidence in favor of the common nature of this syndrome.

Operative techniques for the treatment of chronic pelvic pain are used infrequently. Surgical intervention is resorted to only in some cases, for example, when there is infravesical obstruction.

The scientific literature describes the results of treatment of 34 patients diagnosed with chronic pelvic pain, whose condition did not improve after a course of alpha1-blockers. Further diagnostics (video urodynamic study) showed the presence of obstructive processes localized in the bladder neck (31 patients). Patients in this group underwent limited endoscopic transurethral incision of the pancreas. In 30 operated patients, the manifestations of CPPS significantly decreased. Moreover, the obtained positive result was maintained during further observation for two years.

So, chronic pelvic pain syndrome is one of the most common, but little studied and intractable diseases. Effective therapy in this condition is possible only with reliable diagnosis. However, when making a diagnosis, doctors often have difficulties. This is due to the lack of clear ideas about the etiology of this syndrome and the inconsistency of information about diagnostic criteria. The problem is exacerbated by the fact that there is still no single generally accepted approach to determining the most appropriate method of therapy. Quite a few methods have been developed for the treatment of chronic pelvic pain in recent decades, but, unfortunately, they cannot be objectively evaluated due to the lack of a standardized method for evaluating the results obtained.

The chronic nature of the disease, the deterioration in the quality of life of the patient and the difficulties in diagnosis and treatment often cause pronounced neuroses in men. That is, scientific research aimed at solving the problem of CPPS has not only medical, but also social significance.