We all struggle with how to approach, evaluate, and manage our patients with chronic urologic pain. I have been involved in research and clinical care for this patient population for over 25 years, but have learned many lessons from my urology friends who agreed to provide chapters in this supplement. It was an educational experience for me (and hopefully for the readers of this supplement as well) to discover how my colleagues understand, evaluate, and treat their patients with the various urologic pain syndromes. To put it all together, I have listed below some of the major lessons we can learn from this supplement.
Lesson 1: Mechanisms of chronic urologic pain
A practical understanding of the mechanisms operative in individual patients’ pain experience may allow for optimal development of a personalized, mechanistic, directed treatment strategy.
Lesson 2: Evaluation of the female with urologic chronic pelvic pain syndrome
Assessment of the entire patient, including a complete history, focused physical examination, which must include a pelvic examination (including assessment of pelvic floor), a cystoscopy (under local anesthetic), as well as an understanding of the patient’s quality of life, activities, and treatment goals will improve subsequent management strategies.
Lesson 3: Evaluation of the male with urologic chronic pelvic pain syndrome
A simple assessment with a focused history, physical examination (which includes pelvic floor evaluation as part of the digital rectal examination), symptom inventory, and screening for associated confusable pain conditions will result in a comprehensive determination of the patient’s “clinical picture.” Knowing the individual patient phenotype associated with the UCPPS clinical picture will allow for development of a personalized, phenotype-specific therapeutic plan.
Lesson 4: Medical management of chronic pain
Consider a multidisciplinary and multimodal approach in the management of complex chronic pain. Urologists managing chronic pain must know the options available and be ready to use them.
Lesson 5: Management of interstitial cystitis/bladder pain syndrome
It is our job as urologists to help patients set realistic expectations in order for them to learn to cope and to improve their quality of life. Successful management is to know all your treatment options and then to use them in a multimodal and individualized therapeutic strategy. Be ready to refer to appropriate consultants when other, non-urologic pain generators are present.
Lesson 6: Management of chronic prostatitis/chronic pelvic pain syndrome
The most successful management of male urinary chronic pelvic pain syndrome is not typically accomplished by a sequential monotherapeutic approach, but rather an individualized or personalized phenotype-directed multimodal approach. All the modalities of therapy outlined in the supplement must be considered as a possible therapeutic option for each individual patient.
Lesson 7: Management of chronic scrotal contents pain
The approach to best manage chronic scrotal contents pain includes first conservative therapy, then psychotherapy, physical therapy, medical neuromodulation, and nerve injections, followed by consideration of more invasive surgical options (vasovasotomy, epidymectomy, microsurgical denervation, and orchiectomy).
Lesson 8: Evaluation and management of chronic renal pain
For patients with either unexplained renal/flank pain or one of the enigmatic conditions for which we do not have evidence-based therapies, pharmacologic treatments, ancillary surgical procedures, and psychological support are required to reduce the impact of the pain on the patient’s quality of life.
Lesson 9: Physiotherapy for urologic chronic pelvic pain
It is imperative for the urologist evaluating and managing patients with urologic chronic pelvic pain that they evaluate the pelvic floor for pain, spasm, and/or dysfunction. When diagnosed, the patient can be referred for pelvic floor physiotherapy. A physiotherapist with expertise in pelvic pain management will make a major difference in pain amelioration in these patients.
Lesson 10: Psychological correlates in urologic chronic pelvic pain
It is important for the urologist to understand the various psychological factors that can modulate the patient’s pain experience — stress/anxiety, depression, pain contingent rest, spousal social support, and catastrophizing — as well as be employed in pain coping mechanisms in patients with chronic urologic pain. By recognizing the presence of these factors in individual patients, the urologist can address them and manage them as part of the overall pain management strategy.
Lesson 11: Nurses perspective in management of urologic chronic pelvic pain
A urology nurse dedicated and trained to deal and manage urologic chronic pain patients will allow for a more comprehensive assessment and ultimately improved management of the urology patient with UCPPS referred to a general urology clinic. The nurse can obtain an excellent history by having more time for active listening, can use the various symptom questionnaires, explore associated pain conditions, set up the urologic examination and cystoscopy by the urologist, and assist in developing personalized treatment plans that include patient education. This approach leads to less frustration for both the patient and the urologist, and undoubtedly better overall care and improved outcomes.
Lesson 12: Medical marijuana for urologic chronic pelvic pain
While marijuana or cannabis treatment may not lead to significant pain relief, it is a far superior approach to manage chronic pain compared to chronic opioid therapy. But it does seem to result in a wonderful placebo effect. It is further suggested that marijuana (or at least its placebo effect) appears to help many patients better cope with their chronic pain syndrome. Coping with chronic pain is the key to improved quality of life and improved mental and physical activity. But the urologist who prescribes marijuana must be educated in patient selection (including identifying patients at risk), marijuana components (TCH/CBD combinations), administration alternatives, doses, and clinical followup.
Lesson 13: Neuromodulation for urologic chronic pelvic pain
In many, if not most cases, chronic pelvic pain and associated urinary symptoms are neurologically mediated. By inhibitory stimulation of the pelvic floor and organs via the S3 nerve root, sacral neuromodulation provides an option for some patients with chronic pelvic pain syndrome.
Lesson 14: Nerve injection therapy for urologic chronic pelvic pain
Nerve blocks with short-acting local anesthetics of the spermatic cord nerve and pudendal nerve allows for better diagnosis of neuropathic-related orchiodynia and pelvic floor pain, respectively. Serial injections with long-acting local anesthetics provide the potential for improvement in long-term pain intensity, likely through a neurogenic downregulation process.
The most important lesson
Managing an enigmatic, unexplained condition such as urologic chronic pain can be a confusing exercise in frustration. The most important question learned from this supplement is that when in doubt, who are you going to call? You call your friend and colleague, of course. In this unique supplement, our colleagues have indeed risen to the challenge and provided very practical tips and lessons on how to best manage this common and very important urologic patient population.