Biofeedback therapy for chronic pelvic pain syndrome

Asian J Androl 2003 Jun; 5: 155-158             

Keywords: biofeedback; therapy; pelvic pain; prostatitis; chronic

Abstract

Aim: To evaluate the efficacy of biofeedback therapy in patients with chronic pelvic pain syndrome (CPPS). Methods: From November 2001 to April 2002, patients visiting the Urological Outpatient Clinic of this Hospital were evaluated by means of the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and classified by the NIH classification standard. Sixty-two patients of CPPS category III were involved in this study. All patients had been treated by conventional approaches such as antibiotics and alpha-blockers for more than half a year without any improvement. The expressed prostatic secretion results were as follows: WBC 5 to 9/high power field, lipid +~+++ and bacterial culture negative. Their NIH-CPSI were 12~40. All the 62 cases complained of micturitional irritation (frequency, urgency, splitted stream and sense of residual urine), 32 cases, of pain or discomfort at the testicular, penile, scrotal, pelvic or rectal region and 13 cases, of white secretion-dripping. The patients were treated by the Urostym Biofeedback equipment (Laborie Co., Canada) 5 times a week for 2 weeks with a stimulus intensity of 15 mA~23 mA and duration of 20 minutes. Results: Sixty patients were significantly improved or cured, while no significant improvement in the remaining 2. No apparent side effect was observed. The NIH-CPSI dropped to 6 to 14 with an average reduction of 21 (P<0.01). In the 60 improved cases, pain was relieved after 2~3 treatment courses and other symptoms disappeared after 4~5 courses. Conclusion: Biofeedback therapy is a safe and effective treatment for CPPS. Large randomized clinical trials are needed to confirm its efficacy and to explore the mechanism of action.

1 Introduction

Genitourinary symptoms are frequent reasons for office visits by the males, and prostatitis is a common diagnosis [1]. The National Institutes of Health have redefined the categories of prostatitis as types I, II, IIIa, IIIb and IV and developed a score evaluation method, the NIH-chronic prostatitis symptom index (NIH-CPSI), for chronic prostatitis symptoms. The chronic pelvic pain syndrome (CPPS), the NIH type IIIa/IIIb prostatitis, was characterized by pelvic pain and voiding symptoms [2]. Despite that only less than 10 % of prostatitis cases were bacterial, a much higher proportion of men with the diagnosis of prostatitis receive antimicrobials [1, 3]. Pelvic floor tension myalgia may contribute to the symptoms of CPPS. Therefore, measures that diminish pelvic floor muscle spasm may improve these symptoms. Based on this hypothesis, Clemens et al. [4] treated 19 patients with CPPS in a 12-week program of biofeedback-directed pelvic floor re-education with desirable results. The present study was designed to assess the efficacy of biofeedback treatment for CPPS with NIH-CPSI and explore its possible mechanism of action.

2 Materials and methods

Between November 2001 and April 2002, chronic prostatitis patients visiting the Urological Outpatient Clinic of this Hospital were assessed and 62 patients, aged 18~52 (mean 32) years and did not have a history of neurological injury or a urological surgery, were recruited. They were diagnosed non-inflammatory, non-bacterial chronic prostatitis (NIH type-IIIb) based on the symptoms (NIH-CPSI: 16 to 40) with a negative bacterial culture and a white cell count below 10/high power field in the expressed prostatic secretion or VB3 urine. They had been treated by conventional approaches such as antibiotics and alpha blockers for more than half a year without any improvement. Transrectal prostatic ultrasonography showed capsular irregularity and thickening, mixed echoes and sometimes calcification area, but no prostatic hyperplasia or nodules. All the 62 cases complained of micturitional irritation (frequency, urgency, splitted stream and sense of residual urine), 32, of pain or discomfort at the testicular, penile, scrotal, pelvic or rectal region and 13, of white urethral dripping at the end of urination or bowel movement. None complained of hematuria.

Patients were evaluated using NIH-CPSI, a nine-question questionnare. Digital rectal examination (DRE) was done to detect pelvic muscle tenderness and its ability of contraction.

The biofeedback apparatus, a noninvasive devise, was purchased from the Laborie Co., China. It provided a working anal electrode for delivering electric stimuli and 3 surface electrodes for recording electromyogram. The activity of the pelvic muscles was shown at the computer screen.

The patient was side-lying, with the working electrode inserted into the anus and 3 surface electrodes applied around the perineum. The program was recommended by the manufacturer with a stimulus intensity of 15 mA~23 mA and duration of 20 min/time. The patient was instructed to perform repeated pelvic contraction and relaxation, each lasting 10 seconds follo wing the electronic stimulus. A treatment course was consisted of 5 times of stimulations a week for 2 weeks. During the treatment the patient could observe the effectiveness of his contraction and relaxation through the curve on the screen and adjusted his effort for the development of a maximal effect. Patients were then instructed to perform the pelvic exercise at home, three times daily and 100~300 contractions and relaxations every time. Patients were encouraged to continue the pelvic exercise after the biofeedback application to maintain the therapeutic effect. After the treatment, patients were evaluated again as before.

Data were expressed in median (range). The differences between pre-treatment and post-treatment values were analyzed using the Wilcoxon signed-rank test under the SAS circumstance. P<0.05 was considered significant.

3 Results

The overall score of the patients ranged from 12 to 40, the pain score, 6 to 19, the urinary symptom score, 0 to 10 and the quality of life impact score, 6 to 12. DRE showed that 52 patients had tenderness of pelvic muscles around the prostate and were unable to relax the pelvic floor efficiently either as a single or rapid repetitive effort.

43 patients completed whole course of treatment (10 times) while 19 patients only completed half of it (5 times) because of the personal reason. Sixty patients were significantly relieved or cured, while 2 without improvement, both appearing of nervous and fragile character.

12 of the 13 patients with white secretion-dripping were improved or cured, while the remaining 1 did not.

Figures 1~4 showed the pre-treatment and post-treatment results. There was a statistically significant improvement in all the aspects, including the total NIH-CPSI, the pain related symptoms, the urinary symptoms and the quality of life impact. There was no side effect. In the overall score, 60 of the 62 patients had a more than 5-point decrease and 35 patients a more than 10-point decrease, the median symptom score decreased from 28 pre- to 7 post-treatment, the median pain score decreased from 16 pre- to 3 post-treatments, that of urinary symptoms from 7 to 3, and quality of life impact from 8 to 3. The symptoms of urgency, hesitancy, nocturia, painful or discomfort urination, splitted stream (not included in NIH-CPSI) were also significantly improved (data not shown). All the 52 patients with tenderness and spasm of pelvic floor were almost completely relieved.

Figure 1. Pre- and Post-treatment overall NIH-CPSI (n=62). Median symptom score decreased from 16 to 3. The minimal and the maximal scores were both decreased.

Figure 2. Pre- and post-treatment pain scores (n=32). Median score decreased from 16 to 3.

Figure 3. Pre- and post-treatment urinary symptom scores (n=62). The median symptom score decreased from 7 to 3.

Figure 4. Pre- and post-treatment quality of life impact scores (n=62). The median score of quality of life impact decreased from 8 to 3.

4 Discussion

CPPS remained a challenge to the conventional approaches for diagnosis and treatment and the connection between pelvic pain and voiding dysfunction was still an enigma. Sometimes the pain and voiding symptoms were not relieved even after radical prostatectomy [5], suggesting that other factors may be involved. Recently several researchers suggested that pelvic floor muscles might play a role [6, 7]. Zermann et al. [6] found that 88 % patients could not contract and relax the pelvic floor muscles and in their 103 patients 4 had a history of preexisting neurological problems and 37, of neurological or urological surgery. In our patients no patient was reported any neurological problem or urological surgery, but 52 of 62 (86.7 %) patients had pelvic muscle tenderness and spasm, similar to those of Zermann et al. [6], suggesting that CPPS itself but not neurological disease or surgery was the main cause of pelvic muscle dysfunction.

Biofeedback therapy was commonly used to treat incontinence or other voiding dysfunction. Recently this approach was recommended for the treatment of CPPS [4, 8, 9], but few theories were developed to support the therapeutic mechanism. Kaplan et al. [10] reported its efficacy in the treatment of pseudodyssynergia in men diagnosed as CPPS. In CPPS there may be pseudody-ssynergia [4, 11]. Clemens et al. [4] used biofeedback and pelvic floor re-education to treat 19 CPPS patients with excellent results; their treatment program consisted of 6 biweekly applications, each lasting 1 h. In this series although some patients were experienced a recurrence, all of them selected biofeedback therapy again and after a second course treatment, and got relieved again (data not show).

Zermann et al. [7] described a 'circuitry' of the central nervous system and the lower urinary tract; therefore, the therapeutic mechanism of biofeedback might include pelvic muscle relaxation and a decrement in the nociceptive afferent impulse.

Repeated contraction and relaxation of pelvic floor muscles may speed the blood flow and thus recuperate the inflammatory process in the pelvic cavity.

In conclusion, biofeedback therapy was a safe and effective treatment for CPPS, but further clinical and laboratory investigations were needed to confirm its efficacy and explore its mechanism of action.

References

[1] Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol 1998; 159: 1224-8.
[2] Litwin MS, McNaughton-Collins M, Fowler FJ Jr, Nickel JC, Calhoun EA, Pontari MA, et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999; 162: 369-75.
[3] Hu WL, Zhong SZ, He HX. Treatment of chronic bacterial prostatitis with amikacin through anal submucosal injection. Asian J Androl 2002;4:163-7.
[4] Clemens JQ, Nadler RB, Schaeffer AJ, Belani J, Albaugh J, Bushman W. Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology 2000; 56: 951-5.
[5] Zermann DH, Ishigooka M, Wunderlich H, Reichelt O, Schubert J. A study of pelvic floor function pre- and post radical prostatectomy using clinical neurourological investigations, urodynamics and electromyography. Eur Urol 2000; 37: 72-8.
[6] Zermann DH, Ishigooka M, Doggweiler R, Schmidt RA. Neurourological insights into the etiology of genitourinary pain in men. J Urol 1999; 161: 903-8.
[7] Zermann D-H, Ishigooka M, Doggweile R, Schmidt RA. Chronic prostatitis: a myofascial pain syndrome? Infect Urol 1999; 12: 84-92.
[8] Nickel JC. Effective office management of chronic prostatitis. Urol Clin North Am 1998; 25: 677-84.
[9] Nickel JC. Prostatitis: lessons from the 20th century. BJU Int 2000; 85: 179-85.
[10] Kaplan SA, Santarosa RP, DAlisera PM, Fay BJ, Ikeguchi EF, Hendricks J, et al. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. J Urol 1997; 157: 2234-7.
[11] Ghobish AA. Quantitative and qualitative assessment of flowmetrograms in patients with prostatodynia. Eur Urol 2000; 38: 576-83.

home

Correspondence to: Dr. Zhang-Qun YE, Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
Email: zhangqun-ye@yahoo.com.cn
Received 2002-12-24   Accepted 2003-03-24