OPERATION GREEN LIGHT

Neuroanatomy, Neurophysiology
and
Clinical Presentation
of
Visceral Urological Pain
Prof Dr K. Everaert
Functional urology
Department of Urology
Ghent University Hospital
Gent, Belgium
Chronic pelvic pain
Definition: chronic pain in the pelvis without obvious local pathology that can
explain the pain, mostly associated with sexual, urological, gynaecological, gastroenterological and emotional symptoms.
Prevalence: estimated around 10%
Fenotype: generalized pain (CPP-syndrome) versus localized pain (chronic
prostatitis, orchialgia, interstitial cystitis,…. Pain is accompanied by a lot of
dysfunction and loss in QOL.
Sensitization, sprouting, activation
sympathetic
Sensitization
Abnormal afferent
signaling
Abnormal efferent
signaling
Abnormal central
processing
Sensory problems
Changes in organ
function
Psychological,
behavioural, sexual
consequences
Regional and systemic changes: viscero/viscero/somathic hyperalgia,
Trophic, autonomic, endocrine, immune responses
Referred pain
Sensitization and sprouting in
chronic pain
Complex regional pain syndromes :
Starts from somatic or visceral or neuropathic or dysfunctional pain
 Neuropathic-like pain accompanied by
muscle spasm (pain cycle, pelvic floor dysfunction)
and vasodilatation and vasoconstriction
 Neurogenic inflammation
 Important dysfunction
Bladder function and
dysfunction
Filling faze:
detrusor relaxes
urethra/sphincter is closed
Bladder
Emptying faze:
detrusor contracts
urethra/sphincter opens
Sphincter
Urethra
When 1 aspect is dysfunctional, lower urinary
tract symptoms occur (LUTS) :
- incontinence, urgency, frequency,
nocturia
- slow stream, difficulties to start
postmicturition dribbling
Bladder function and
dysfunction
PMC
Efferent Neuroanatomy of
Bladder-sphinctercomplex
OS
Hypogastric nerve
PS
External urehral
sphincter
T10-L2
OS
Bladder
Bladderneck, Prostate
Urethra
brain
OS
NANC
Pelvic plexus
nervi errigentes
nervi pelvini
Pudendal nerve
PS
S3-S4
Bladder function and
dysfunction
brain
PMC
Afferent Neuroanatomy of
Bladder-sphinctercomplex
Hypogastric nerve
T10-L2
Bladder
Bladderneck
External urehral
sphincter
Pelvic plexus
PS
nervi errigentes
nervi pelvini
Pudendal nerve
S3-S4
Bladder function and
dysfunction
Afferents of the Lower Urinary Tract
Bladder function and
dysfunction
AFFERENTS : interstitial cells (Cajal like cells)
• Superficial network of IC: the sensing
network (valinoied receptors), connect
urothelium – nerve fibers – IC cells off
detrusor - detrusor
• Detrusor network of IC: modulators of
autonomous activity, rather then
pacemakers
- Purinergic P2Y receptor
- Cholinergic M2-3 receptors
- Vallinoied receptors
- NGF
Van Der Aa Fr, 2007
Bladder function and
dysfunction
AFFERENTS
FOR URGE and
PAIN
Steers W 2002
Sexual function and
dysfunction
prostate
vas
vesicula,
bladderneck
erectile tissue
penis
Cavernosal nerves
Prevertebral ganglia
OS
MPOA
PVN, PGi
T10-L2
LSt-cells
Hypogastric nerve
Pelvic plexus
NANC
PS
nervi errigentes
nervi pelvini
Pudendal nerve
Striated muscles (S2-4)
S2-S3
Chronic Bladder Pain Syndrome
Definition, prevalence:
Also known as interstitial cystitis
Often starts with a urinary tract infection, pelvic trauma, surgery
Has a phasic evolution but sometimes progressive
Symptoms are these of cystitis and an overactive bladder, but due to sphincter
spasms also emptying phaze symptoms are present
Inflammation of the bladder wall leads to damage to the GAG-layer of the bladder
Both the dysfunctions as the GAG-layer damage provoke more UTI
Chronic inflammation ends in scarring and shrinkage of the bladder ending in an
extremely painful bladder with invalidating frequency and nocturia.
Chronic Bladder Pain Syndrome
Diagnosis:
Mainly clinical: pain in relation to filling of the bladder with frequency and nocturia +
micturition diary + urine analysis + uroflowmetry and residual urine are needed.
Urodynamics, cystoscopy, bladder biopsy and potassium instillation test are optional
Chronic Bladder Pain Syndrome
Therapy level 1:
1) Early pain therapy: amitryptiline, nortryptiline, duloxetine….
tramadol
gabapentine, pregabaline
2) Treat filling faze symptoms
- bladdertraining
- anticholinergics, beta-3-agonists
3) Treat emptying faze symptoms
- pelvic floor rehabilitation
- alpha-blocking agents
- intermittent catheterization
Chronic Bladder Pain Syndrome
Therapy level 2:
1) Bladder instillations with:
- DMSO (anti-inflammatory)
- GAG-layer replacers (Heparin, Uracyst, Cystistat, Iauril…)
2) Bladder injections with onabotulinumtoxinA
3) Treat filling faze symptoms
- onabotulinumtoxinA
- sacral neuromodulation
4) Treat emptying faze symptoms
- sacral neuromodulation
Therapy level 3:
When these fail: partial or radical cystectomy with enterocystoplasty, neobladder or
urinary diversion
Chronic Prostatitis/Prostatodynia
Definition:
Chronic pain syndrome localized to the prostate, also called abacterial chronic
prostatitis or prostatodynia
Symptoms of prostatitis with negative culture (3-glass specimen test) sometimes
leucocytes, sometimes only inflammatory markers like interleukines
Pain often extends to obturator region, testes, inguinal region and flanks
Chronic Prostatitis/Prostatodynia
Diagnosis:
Mainly clinical: pain in the prostate with frequency and nocturia + micturition diary +
urine analysis (3-glass specimen test) + uroflowmetry and residual urine are needed.
Urodynamics, cystoscopy , sperm analysis are optional
Chronic Prostatitis/Prostatodynia
Therapy level 1:
1) Early pain therapy: amitryptiline, nortryptiline, duloxetine….
tramadol
gabapentine, pregabaline
2) Treat filling faze symptoms
- bladdertraining
- anticholinergics, beta-3-agonists
3) Treat emptying faze symptoms
- pelvic floor rehabilitation
- alpha-blocking agents
- intermittent catheterization
Chronic Prostatitis/Prostatodynia
Therapy level 2:
Many suggestion, no proof of efficacy: thermotherapy, lasertherapy, TURp,
onabotulinumtoxin, sacral neuromodulation
Therapy level 3:
Radical prostatectomy: no proof of efficacy, unethical without multidisciplinary
approach, high complication rates
Chronic Orchialgia
Definition and prevalence:
Chronic pain localized to the testis and existing for at least 3 months and disturbing
for the daily life activities. Many men have some discomfort (they realize having a
testis with certain movements) which is not taken in account here.
Prevalence estimated at 1%
In 15-20% pain starts with surgery like inguinal hernia repair, vasectomy or
epidydymitis
Chronic Orchialgia
Diagnosis:
Mainly clinical
Urine analysis, sperm count and bacteriology, ultrasound, urofllowmetry with
residual are suggested
Sometimes MRI /Ct-scan of the pelvis, transrectal ultrasound, cystoscopy,
neurological evaluation,… but rarely leads to a diagnosis and are only advised when
abnormalities are suggested by the first level of diagnostics.
Chronic Orchialgia
Therapy:
Conclusion
 Understand pelvic organ innervation and dysfunctions
 Use painkillers early and in sufficient dose
 Use different painkillers by understanding their differences in working
mechanisms
 Treat dysfunction and pain early, avoid sensitization
 Collaboration with pain clinic when urologist is not comfortable with installing
pain therapy
 Destructive surgery only in highly invalidating cases, collaboration with pain
clinic is helpful in patient selection
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