Pelvic pain in men: focus on prostatitis
In men, inflammation of the prostate gland is the leading cause of chronic pelvic pain. According to the U.S. National Institutes of Health (NIH) classification, four categories of prostatitis are distinguished. Chronic pelvic pain syndrome corresponds to Category III — chronic abacterial prostatitis. It is the most common form with unclear etiology.
This category is subdivided into two variants:
- IIIA — inflammatory (leukocytes are detected in the secretion).
- IIIB — non-inflammatory.
In addition, pain can accompany a long-standing bacterial process (Category II), which responds poorly to therapy, as well as rare specific forms — granulomatous prostatitis (against the background of syphilis, tuberculosis, or fungal infection) and malakoplakia (a special type of granulomatous inflammation).
Pelvic pain in women: chronic salpingo-oophoritis
In women, pelvic pain is most often the result of prolonged inflammation of the uterine appendages — chronic adnexitis. The process proceeds with periodic exacerbations triggered by hypothermia, stress, or menstruation. Patients complain of dull, aching pain in the lower abdomen radiating to the lower back, thigh, and rectum.
Constant discomfort leads to a complex of associated disorders:
- Psychoemotional disorders: insomnia, irritability, nervousness, depressive states.
- Sexual dysfunctions: decreased libido and pain during intercourse (dyspareunia).
- Menstrual cycle disorders: oligomenorrhea, opsomenorrhea, menorrhagia, pronounced premenstrual syndrome.
Menstrual disorders are due to the fact that inflammation narrows the ovarian vessels and impairs microcirculation. This reduces the production of steroid hormones, causing anovulation or corpus luteum insufficiency.
Pathogenesis and morphological changes in the lesser pelvis
Chronic inflammation in the appendages triggers a cascade of structural changes that sustain the pain syndrome. Inflammatory infiltrates form in the fallopian tubes, connective tissue proliferates, and closed cavities with fluid — hydrosalpinges — develop.
A massive adhesive process develops in the pelvic cavity. Not only the uterus and fallopian tubes are involved, but also adjacent structures: the ovaries, bladder, intestinal loops, omentum, and pelvic walls. It is the adhesions and impaired tubal patency (tubal-peritoneal factor) that become the main causes of severe complications — infertility and ectopic pregnancy.
Diagnostics and differential search
Chronic pelvic pain is nonspecific, therefore it requires careful differential diagnosis with colitis, pelvic plexitis, endometriosis, as well as ovarian cysts and tumors.
Main examination methods:
- Bimanual examination: makes it possible to detect limited mobility of the uterine body (indicates adhesions) and elongated formations in the appendage area (hydrosalpinx).
- Ultrasound examination (ultrasound): effectively visualizes pelvic mass lesions.
- Laparoscopy: indicated in case of antibiotic ineffectiveness and prolonged pain. It allows for visual assessment of adhesions, the presence of hydrosalpinges, and identification of Fitz-Hugh-Curtis syndrome (adhesions between the diaphragm and liver following gonococcal or chlamydial adnexitis).
- X-ray hysterosalpingography (HSG): used to assess tubal patency, but is currently used less and less due to a large number of diagnostic errors in image interpretation.
Acute conditions: pelvioperitonitis
If infection from the uterus or its appendages penetrates the pelvic cavity, secondary inflammation of the pelvic peritoneum develops — pelvioperitonitis. Unlike chronic syndrome, this disease manifests acutely. Patients experience sharp, intense pain in the lower abdomen. According to the nature of the pathological contents, the process is classified into serofibrinous and purulent.
To remember the causes of chronic adnexitis, use the three "I" rule: Inadequate treatment of the acute process, Insufficient host reactivity, Atypical (specific) properties of the pathogen.
Class and exam questions
Which category does chronic pelvic pain syndrome in prostatitis belong to?
According to the NIH classification, this is Category III — chronic abacterial prostatitis. It is divided into subcategories IIIA (inflammatory variant with leukocytes in the secretion) and IIIB (non-inflammatory variant).
Why is the menstrual cycle disrupted in chronic adnexitis?
Inflammation causes dystrophic changes in the ovaries and narrowing of the vascular lumen. Impaired microcirculation reduces the synthesis of sex steroid hormones, leading to anovulation or corpus luteum insufficiency.
What is Fitz-Hugh-Curtis syndrome?
This is the formation of adhesions between the liver surface and the diaphragm. The syndrome is a consequence of previous acute salpingo-oophoritis, predominantly of gonococcal or chlamydial etiology.
What else to study on this topic
- Classification of prostatitis according to the NIH: analysis of categories I, II, and IV
- Morphological changes in the fallopian tubes: formation of hydrosalpinx
- Tubal-peritoneal factor of infertility and ectopic pregnancy
- Acute pelvioperitonitis: serofibrinous and purulent forms
- Rare forms of prostatitis: malakoplakia and granulomatous inflammation
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