Concluding remark about the urodynmic findings

Urodynamic and ecographic studies have shown a high prevalence of urodynamic abnormalities. Are these under-diagnosed in male urologic patients? The problem with any of the above conditions is: what came first? In some cases physiological changes may be the obvious precursor, in other case they may be caused by the subsequent chronic inflammation. Urography and trans-rectal ultrasound should be performed to rule out these problems.

CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, miktionsfysiologi, miktion, urodynamic findings, ultrasonography.

Urodynamic problems and intraprostatic pressure

An often overlooked factor seems to be screening for physiological and mechanical and fluid dynamical causes related to bladder, prostate and seminal vesicles. Studies have found physical abnormalities, and a transrectal ultrasonography study found physical (urological) abnormalities or other conditions in as many as 70% of the patients ! (1)

The most common cause of pathology is reflux(2), or urine flow up into the canalicoli (i.e. prostate) is caused by urethral strictures (due to trigonitis or urethral stenosis, both uncommon in men, or muscular hypertonus or physical abnormalities(3)) or sclerosis/dysectasia of the bladder neck (cervicis vesicae) affecting normal defluition (“deflux”) of urine (micturition). Non-infectious epidydimitis may also occur for the same reasons. Reflux is thought to cause inflammation by the presence of purine and pyrimidine (uric acid) in the urine. (Aside: high values of uric acid in blood causes gout.) Another possible cause of inflammation could be turbulent flow of the urine damaging urethral tissues.(4)

A recent ultrasound study of the bladder neck area found differences of: prostate volume, hypoechoic periurethral zone volume, posterior prostate lip thickness, bladder neck thickness and bladder muscle (detrusor) thickness between CPPS patients and controls. No differences in calcifications were found.(5)

A study indicated that NIH-IIIa patients have significantly higher intraprostatic pressure than IIIb or BPH patients(6), This may be caused by strictures, as mentioned above, muscular tension or concretions, or by tissue damage caused by blood pressure and other problems affecting interstitial tissue pressure.(7) This latter would also be consistent with the presence of inflammation markers.

Fall et al. concluded that: “Urodynamic studies [of prostatitis patients] demonstrate decreased urinary flow rates, incomplete relaxation of the bladder neck and prostatic urethra, as well as abnormally high urethral closure pressure at rest. The relaxation of the external urethral sphincter during urination is normal”.

CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, miktionsfysiologi, miktion, urodynamic findings, intraprostatic pressure, ultrasonography, reflux. stenosis, trigonitis, varicocele, detrusor, urethral sphincter.
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(1) Nicolai M, De Thomasis R, Di Federico G, Palmerio A, Iantorno R, Tenaglia R. [Role of transrectal echography in the evaluation of obstructive seminal vesicle pathology in prostatitis syndrome] Arch Ital Urol Androl. 68 (5 Suppl):101-4, 1996.
(2) Mehik A, Leskinen MJ, Hellström P Mechanisms of pain in CPPS: influence of prostatic inflammation. World J urol 21:90-94, 2003
(3) Hochreiter WW Zbrun S CPPS and voiding dysfunction. Curr Urol Rep 5(4):300-304, 2004
(4) Martinez-Borges AR Turbulent urinary flow in the urethra could be a causal factor for benign prostatic hyperplasia. Medical hypothesis 67(4):871-875 2006
(5) Dellabella M, Milanese G, Muzzonigro G. Ultrasound evaluation of bladder neck complex alterations in CP/CPPS. 2005 EAU meeting, Istanbul. (Also published in J Urol 176:112-118, 2006. Correlation between…)
(6) Mehik A, Hellstrom P, Nickel JC et al The CP/CPPS can be characterized by prostatic tissue pressure measurements. J Urol 167(1):137-140, 2002
(7) Mehik A, Leskinen MJ, Hellström P Mechanisms of pain in CPPS: influence of prostatic inflammation. World J urol 21:90-94, 2003

Urodynamic findings

Coordination of voiding, sphincter and pelvic floor activity differs from controls. Average sphincter pressure is increased, while urine flow is decreased. Bladder neck and prostatic urethra may not be completely relaxed. Functional urethral length is increased and resting closure pressure may be higher than normal. Urethral sensitivity was increased, while the profile pattern is dysfunctional and/or obstructed. Cystometry is normal.(1)

It is unclear whether the muscular findings are causing the symptoms or an effect of an underlying pathology.

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, urodynamik
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(1) Zermann DH, Ishigooka M, Doggweiler R, Schmidt RA. Neurological insights into the etiology of genitourinary pain in men. J Urol 161(3):903-908.