Non-inflammatory chronic pelvic pain syndrome can be caused by bladder neck hypertrophy

Little is known about the etiology of the non-inflammatory Chronic Pelvic Pain Syndrome (CPPS, NIH category IIIb). We conducted this study to determine whether endoscopic and urodynamic evaluation provide objectively measurable parameters that may support the rationale of therapeutic strategies for patients who failed to respond to medical treatment of non-inflammatory CPPS.

The 48 patients included in this study fulfilled the NIH criteria for non-inflammatory chronic pelvic pain syndrome category IIIb. All patients had received multiple courses of antimicrobial and/or anti-inflammatory drugs, but suffered recurrent symptoms. An endoscopic and urodynamic evaluation was performed after any medical treatment had been discontinued for at least 6 weeks.

At urethrocystoscopy, no patient had endoscopic evidence of obstruction due to urethral stricture, but 29 patients (60%) were found to have significant bladder neck hypertrophy. At urodynamic evaluation, these 29 patients had an increased detrusor opening pressure DOP (49 vs. 29 cmH(2)O), an increased detrusor pressure at maximal flow P(det,Q(max)) (55 vs. 34 cmH(2)O), a decreased maximal flow Q(max) (10 vs. 17 ml/s) and an increased postvoid residual urine PVR (67 vs. 17 ml) when compared to the 19 patients with a normal appearing bladder neck. These differences were statistically significant (p<0.05). When assessed with the NIH Chronic Prostatitis Symptom Index (CPSI) the two groups showed no difference in the domains of pain and quality of life impact but urinary symptoms were significantly more pronounced in the presence of bladder neck alterations.

Patients with non-inflammatory CPPS who fail to respond to medical treatment with antibiotics and/or anti-inflammatory drugs may have morphological alterations in form of bladder neck hypertrophy. This can be suspected when urinary symptoms, residual urine and decreased Q(max) are present. These can be assessed by non-invasive methods. Endoscopic and/or urodynamic evaluation seem to be justified in these patients in order to establish the diagnosis, consider alpha-adrenergic blockade and avoid unnecessary antibiotic treatment.