Draft Definition of Leading Etiology Theory

[webslave]

This is my thumbnail of the leading theory of the cause of our discomfort. Please suggest amendments or corrections.

https://www.ucpps.men/viewtopic.php?t=9341

[MS]

Mark,

This sounds like a great all-encompassing theory. Just some minor, anecdotal suggestions:

Such individuals tend to tense the muscles of their pelvic floors subconsciously and continuously, leading to a hyperirritability of the muscle fibers. The hyperirritable bundles of fibers within the muscles of the pelvic floor become "knotted", inelastic and unable to contract or relax.

Suggestion: insert something metioning the "self-perpetuating" nature of the muscle contractions.

and all the symptoms of sterile prostatitis, urethritis, orchialgia, epididymitis, cystitis and vulvodynia.

And prostadynia?

special forms of pelvic muscle relaxation training

And stretching?

nerve therapy (neurontin, Botox*)

Nitipick: Is Botox a nerve therapy or a muscular or neuromuscular treatment

MS

[webslave]

"self-perpetuating" - don't think that adds to the definition. It is self-perpetuating by definition. (central sensitization, neuronal windup).
"prostatodynia" - a loose term that is covered by prostatitis, IMO. One could also use "prostatism" etc.
"Stretching" - yes, I will add this. Good point.
Botox affects nerves.

[alprost]

Such individuals tend to tense the muscles of their pelvic floors subconsciously and continuously, leading to a hyperirritability of the muscle fibers. The hyperirritable bundles of fibers within the muscles of the pelvic floor become "knotted".....

I think overall you are correct - It is probably the most accurate desciption I've read which I'm sure will be bourne out by research, eventually. However, I disagree with the suggestion that the sole cause of chronic prostatitis / chronic pelvic pain syndrome is the tendancy for certain individuals to continually tense their pelvic floor muscles under stress. This is also the only real fault I can find with the Wise/Anderson book. Whilst I'm certain that this may be the case for some, I have read many anecdotal accounts of people developing chronic prostatitis / chronic pelvic pain syndrome from many different 'initiating events, such as: Falling astride a fence (ouch!); having a vigorous and painful prostate examination; needling a genital wart on the foreskin; a lower back injury; pelvic surgery; long periods of sitting and stress at work, and in some cases, bacterial prostatitis. Jerome Weiss also lists similar causes/factors:

The most common events that lead to injury are:
1. chronic tense holding patterns that develop in childhood as a result of sexual abuse, traumatic toilet training, abnormal bowel patterns, guilt surrounding sexual feelings, dance training or stress;
2. repetitive minor trauma or straining with constipation or urinary obstruction;
3. sudden brief severe strain sustained in sports, dance or gymnastic accidents;
4. direct physical trauma from bicycling, childbirth, urologic or gynecologic instrumentation or surgery;
5. inflammation of pelvic organs such as prostatitis, cystitis, urethritis, endometriosis, vaginitis, proctitis or anal fissures;
6. referred pain from other attaching muscle groups or viscera or nerves.

Source: http://www.jmweissmd.com/article.htm

I recently spke with my own Physio about this, and his opinion is that the causes of chronic pelvic pain are 'multifactorial', but the end result is the same: Pelvic floor muscle spasm; neural wind up and central censitisation, leading to pain and voiding dysfunction.

I think this point is important in that a common final outcome may mean the identification of a treatment strategy which will help a large proportion of patients.

I also think it is important as it puts bacterial prostatitis in it's correct place in the grand scheme of things: Rather than actually being CPPS, it should be seen as one of many possible initiating events.

[webslave]

Good point, will modify definition.

[Bill in NH]

[Good point, will modify definition. ]

Mark,

Along the same line, I think you should remove or at least modify “tense, anxious … dispositions”. It is hard to judge someone’s prior disposition after they have developed Pelvic Myoneuropathy. It’s not hard to image how this condition could cause a previously mellow person to become very tense and anxious. In addition, the more vocal and visible sufferers may not be representative of all those affected. The marked discrepancy between the prevalence of the condition in population based surveys and lack of general awareness of the condition suggests that there are a lot of silent sufferers whose dispositions have not be tallied.

[webslave]

No sure about that, Bill. It is my experience that most of us do have that sort of disposition. If so, it should be mentioned, even if there is a possible feeling of "blame the patient". Remember, it's just a theory at this point, but here is at least one study suggesting that there is a distinct psychological profile of patients.

BJU Int 2001 Jul;88(1):35-8

Fears, sexual disturbances and personality features in men with prostatitis: a population-based cross-sectional study in Finland.

Mehik A, Hellstrom P, Sarpola A, Lukkarinen O, Jarvelin MR.

Division of Urology, Department of Surgery, Oulu University Hospital, Finland.

.... CONCLUSIONS: This survey showed that psychological stress is common in men with prostatitis. Urologists and general practitioners should consider that a consultation with a psychiatrist may be appropriate for selected men with prostatitis.

J Psychosom Res 1996 Oct;41(4):313-25

Psychological and physical factors involved in chronic idiopathic prostatitis.

Berghuis JP, Heiman JR, Rothman I, Berger RE.
Department of Urology, University of Washington School of Medicine, Seattle, USA.

Idiopathic prostatitis is a common, often chronic condition in which psychological factors are suspected to play a role. Men with chronic prostatitis (n = 51) and a control group of 34 men without any chronic pain condition, equivalent on demographic characteristics, were compared on psychological and perineal muscle tension measures. Prostate-specific antigen and expressed prostatic secretion cell counts were also measured. Chronic prostatitis patients were consistently more elevated than controls on hypochondriasis, depression, and hysteria (MMPI), and on somaticization and depression (Brief Symptom Inventory), and were less elevated on masculine/instrumentality (Personal Attributes Questionnaire) scales. A cluster analysis of MMPI profiles revealed that 57% of the chronic prostatitis patients produced generally unelevated MMPI profiles, whereas the remaining 43% fell into two groups with distinct patterns of distress. The results indicate depression and psychosocial distress are common among chronic prostatitis patients, calling for careful evaluation and attention to psychological symptoms.

Urology 1988 Dec;32(6):507-10

Stress prostatitis.

Miller HC.
Department of Urology, George Washington University, Washington, D.C.

A group of 218 men complaining of symptoms of chronic prostatitis were identified. Symptoms included pelvic and genital pain with or without voiding or ejaculation, urinary frequency and/or urgency, and often a thin watery urethral discharge. Of the group 134 (60%) were followed carefully. With nothing but stress management therapy 110 patients (86%) reported that they were "better," "much better," or "cured." Physiologically, the therapy makes sound medical sense. It is suggested that the term "stress prostatitis" is an appropriate label for this condition.

Ann Clin Res 1981 Feb;13(1):45-9

Psychic disturbances in patients with chronic prostatitis.

Keltikangas-Jarvinen L, Jarvinen H, Lehtonen T.

A psychological study, which included personality testing (BDI, MMPI, RO, TAT), was performed on 42 patients with clinical symptoms of chronic prostatitis. The patients were characterized by prolonged symptoms and poor response to treatment by general practitioners. Some degree of psychic difficulty was revealed in 80% of the patients, and signs of severe psychic disturbance in 20 to 50%. The outstanding psychic symptoms were anxiety, depression, affect-lability, weak masculine identity and other sexual disorders, and even psychotic features. This pattern of psychic disorders corresponds with that described for borderline personality. The common occurrence of specific psychic and sexual disturbances suggests that these psychic factors may have a causative role in chronic prostatitis.

[Bill in NH]

['and with tense, anxious, and often atopic (allergy-prone) dispositions']

Mark,

Could you at least move 'often' before 'with' to allow for the possibility that the tension and anxiety may be the effect rather than cause in at least some sufferers. None of the studies you cite convinces me that the personality traits were the cause rather the the effect and they remind me of all the psychology literature on peptic ulcer disease before the discovery of H.Pylori (I'm not suggesting a bacterial cause to CPPS, just the possibility of some other factor). Also, I think there is an important distinction between a person with a disposition to be tense and anxious and an otherwise normal person who simply has experienced a very stressful event or series of events as did the rats in the experimental model of IC produced by cold restraint.

[webslave]

I agree, and I will change it.

[alprost]

Good point, will modify definition.

The new definition is spot on.

[Bill in NH]

[I agree, and I will change it.]

Thanks Mark - now I can relax. Your definition looks good.