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Jeanette Potts [En Español]: Let's talk about pelvic pain in men. And I also want to say that my goal is to ban or prohibit the use of the word "prostatitis."

Jeannette Potts: And in English, I just want to say that I hope that we can prohibit, I'd like my goal to be that we have a prohibition of the word, "prostatitis."

Jeannette Potts [En Español]: Let's start with a lesson in taxonomy of encephalitis. And we see that there is category one, viral. Category two, bacterial. And category four, asymptomatic. But category three is a headache. I hope that by seeing this classification you think it is ridiculous or absurd. Absurd.

And it's true. Because I invented this classification. Thank God this classification doesn't exist. But we have tolerated this ridiculous classification of prostatitis. (NIH prostatitis classification system). Acute, chronic bacterial prostatitis. And then we have this designation category three. Not bacterial, inflammatory prostatitis, blah blah blah... This is 95 percent of patients. And this is pelvic pain. Only.

It's like saying someone has a headache. And we are going to treat and evaluate it as if it were encephalitis. And what if it is prostatitis?


You are not going to miss out on the diagnosis. The patient is not well, has malaise. Most patients have a fever. They have urinary symptoms. Sometimes, they have urinary retention. In recurring cases, the same microorganism exists. It is very easy to make this diagnosis. And if you still have any doubts, do a urine culture. If you feel tempted to write a prescription for a quinolone, or any other antibiotic for four to six weeks, please, first do a urine culture. Two urine culture tests must corroborate each other before subjecting the patient to four to six weeks of antibiotics.


That is a very big commitment and also it is very risky for the patient. I was part of the 2002 Giessen consensus. And this is what we published. The way to treat these men, and we also have to remember that urine culture tests are positive in seven percent of cases (patients with UTI). And additionally, in seven percent of controls (healthy patients or without UTI). Meaning urine cultures are not something that should not cause us a lot of stress. We have to do them. But, as we said in the 2002 consensus, we must have two confirmatory urine cultures, because there is a great deal of bacterial contamination, as sometimes, this only reflects a change in the patient's intestinal flora. And please, remember this, too.


In the 1996 publication, where the NIH classification was published, the same authors said that it had never been proven that category three of the NIH prostatitis classification was caused by infection. And it also hasn't been proven that it is a prostatic disease. I drew this cartoon to say that the prostate has been misjudged. And it is imprisoned as if it were the cause, guilty.


And it's not true. 95 percent of cases that are considered prostatitis, are not. And is the cause of the symptoms urological? It is possible it might sometimes be derived from a urological source. But we are well aware of the difference, that there may be obstruction due to benign prostatic hyperplasia (BPH), due to bladder neck hypertrophy, a urethral stricture. There may also be a stone at the bladder or at the ureterovesical junction (UVJ), infections. The patient might have a urinary infection. And this has to be ruled out. It could be a neoplasm... Sometimes... urological metastatic cancer or another cancer.


The symptoms might also derive from the colon, or it might be another type of cancer which can also cause pain, or ischemic causes, such as testicular torsion, an infarction of the prostate, or any other organ. But most of the cases of pelvic pain are not related to a urological problem. The thing is that pelvic pain syndrome should be approached this way: there is a functional disorder or what we now call central sensitization syndrome. There are neuropathic causes, psychological causes, and psychosocial factors that can also contribute to the symptoms. Myofascial syndrome.


But here, as I put it, on the little wheels that can be a cause, are infectious diseases. And also urological problems. But the majority of causes are these other diagnoses. And, what further complicates things, is that most patients don't have a single problem.


They have several problems that sometimes are mixed up in the same case. We have to look at our patients' lifestyles. What do they do for a living, what they are passionate about, what they do to relax. If they have to be on the road for long periods at a time. If there is a lot of stress. We must also have a comfortable environment and patient trust to talk about sexual factors.


How his sex life is, how his sex life as a couple is. And we must also ask about porn addiction, which is very common. And this can also cause a behavior called edging, which is when these men are about to reach an orgasm, they hold off, and postpone the orgasm, and they do this multiple times during sexual intercourse. And I feel that this behavior predisposes them to pelvic pain.


We have to know about the person's bowel movements. How is his bowel evacuation?


Not only if he has a bowel movement every day, and that’s it. We need to know if it’s painful, if he feels satisfied after his bowel movement, if he evacuates completely... For example, I use the Bristol stool chart to classify and identify how the patient’s bowel movements are and also to educate him.


Our goal for the Bristol stool chart is to be in type four or five (shown in the image). This is our goal.


We also need to know what he does in his spare time, if he plays a sport and if he is exercising in a good way, if he is careful not to get hurt. Really, what we have to recognize is that there are no shortcuts. It takes time to approach these cases. I start with an evaluation of the spine. Because sometimes, the patient's pain might be referred pain from vertebral discs and you have to recognize those cases. I also look at the legs and feet. It is incredible what an orthotic can do, for example, to improve orchialgia.


I also look for myofascial trigger points. These are like little knots that you palpate with your fingers. It is also often found that the area is weaker and that there is a limitation in the range of motion. And sometimes, this physical evaluation rewards us, and allows us to find that there is a spasm in the muscle that is limited.


Here, for example, in yellow, we see the psoas muscle. And in purple, we see the pattern of referred pain associated with the psoas muscle. This is well-known and can be one of the causes of “prostatitis” or pelvic pain in men. Here are the adductor muscles. All these muscles or sources of pain have to be assessed during our physical examination. And there are many more. This is the obturator internus muscle, and it's my favorite one to examine, too. This is assessed with the patient lying down. And with a finger inside the rectum, palpating this muscle. And here is the piriformis muscle. And there are many more. But these are the things to keep in mind when we perform a physical examination, or when we are assessing patients.


This is the right hemipelvis. We are seeing from inside in a sagittal section, the pathway of the pudendal nerve. And here we see that it has several branches. The branch that goes to the rectum, a branch that goes to the perineum, and another branch that goes to the scrotum and penis. It is common when the patient says that he feels a burning at the tip of his penis, that he has a pudendal neuropathy. So we carefully check the Alcock's canal to see if it is possible to reproduce the symptoms and the pain by palpating the pudendal nerve.


The diagnosis may also be confused when compressing, squeezing, or irritating the posterior femoral cutaneous nerve. This complaint is very similar to pudendal neuralgia. You have to keep these things in mind when you approach these patients. And this is how I do the internal rectal exam. Very slowly. I'm checking all of these muscles. And I check the coccyx to see if there is any movement. The coccyx bone should move one or two centimeters without causing any pain.


I also check the pudendal nerve and the anterior aspect of the levator ani muscle. And lastly, I check the prostate, because the prostate is very sensitive to touch in all men. That does not indicate prostatitis or any problem. Everyone's prostate is very sensitive, but what I want to do by checking the prostate last is to educate the patient on all of the other possible causes of pain or discomfort different than the prostate.


This is a study we conducted several years ago. I am very proud to have helped design the study. We found that it was very successful. Given that in 15 years of NIH studies, this was the only study with positive results.


But unfortunately, physical therapy has become the new ciprofloxacin. And this is terrible. In other words, physical therapy is now being prescribed with the same negligence with which ciprofloxacin was previously prescribed. Without a physical exam, without evidence, and no further follow-up. What I mean is that there has to be a diagnosis. You can't just send patients to physical therapy.


This patient has chronic and acute diverticulitis. He received five years of antibiotics for a presumed prostatitis. This man did not need physical therapy. He needed a doctor to make the diagnosis. And all of his symptoms resolved with a hemicolectomy.


This is a 36-year-old man who has an acetabular chondrosarcoma. And he had to undergo a hemipelvectomy to cure this cancer. He didn't need physical therapy. He needed a doctor.


This is another man whom I previously referred to. He saw six physical therapists in 26 years of problems. No, sorry, 25 and a half years. This man did not need physical therapy. He needed a urologist and surgery. In this scenario, the functional somatic syndrome (FSS) and the central sensitization syndrome (CSS) are also very common. The functional somatic syndrome is defined as a constellation of symptoms which are frequently persistent. They cause a lot of stress.


And, with all of the medical evaluations, there has never been a definition or a definitive diagnosis. This perpetuates the patient's anxiety and stress. Here is a list of all the recognized syndromes as functional somatic syndrome. There is one for every medical or surgical specialty. It even includes interstitial cystitis.


When I first saw this list in 2000, I conducted a study, and reviewed my patients who had been referred to me for prostatitis. And I found that almost 50 percent had a psychologically related diagnosis. And that 65 percent fulfilled the diagnostic criteria of a functional somatic disorder. The thing that is very important and significant from this study is that the prevalence of this syndrome is only four percent worldwide. Maybe eight percent if we only consider women.
That means that "prostatitis” is more of a global problem. It is not exclusively a urologic problem or a disorder related to the prostate, but rather a “global” problem.


Here, one research group used data from the prostatitis group. They compared men with prostatitis...(It's not prostatitis) But with “chronic prostatitis category three.” They compared them with healthy controls. We can see that these men identified themselves as having problems in each of these organs and systems.


I mean, they diagnosed themselves. This is part of it, and for me, it corroborates the fact of it being a “global syndrome.” Dr. Yunus changed the taxonomy of this disease. It is not functional somatic syndrome and not central sensitization.


It's a better way to describe this problem that has predispositions. Like sleep, genetics, stress, problems in childhood, and accordingly, we started moving toward central sensitization. This is provoked; it begins or starts like a two-lane highway. It also begins to influence and magnify symptoms. We see this very often in our patients. The other studies sponsored by NIH that address this issue with a multidisciplinary approach are finding everything that we have observed for years. That 75 percent of patients with pelvic pain define their pain in the pelvis and outside of the pelvis. And, with more symptoms that are not from urological causes. It is more common that these problems are associated with sleep and the quality of sleep. Depression is also much higher among people showing central sensitization.


And, thanks to our colleague, Dr. Tripp, we saw this problem of not being able to cope with or manage their symptoms increases a sense of helplessness in these patients. And is also associated with the severity of the symptoms. The treatment that we see works the best in these cases, what helps manage and treat the patient, is the empathy of the doctor.


His explanation of the physiology of the symptoms. In other words, validating the patient's concerns and theoretically explaining why they are having problems, not just saying, "you have prostatitis," and that’s it. The diagnostic workup should be limited. This has also been shown as helping improve the patient's symptoms. Because doing a lot of diagnostic tests increases anxiety. And the probability of finding abnormalities in these diagnostic tests is very low. It just causes the patient to have more symptoms. The emphasis should be on management, and not on the cure. Help him manage his symptoms and problems, but sometimes, we will not be able to cure him. Because there are many factors that can cause this disorder.

Having psychological help, psychological support, also helps these patients a great deal. They may have more time for reflection, self-gratification, giving thanks, being appreciative. Things like that to help them, even with meditation. In order to decrease the severity of the pain. And lastly, temporarily, I use antidepressants or neuromodulators - which also help with this disorder - And help us to decrease neuronal impulses and stimulate certain neurotransmitters in these cases of pain. This helps me a lot, too, if I find that the patient has a neuralgia. Such as pudendal neuralgia. I use them temporarily. I hope you no longer feel like these men, who are blind, trying to see something that is a syndrome with multifactorial causes. And not just see that the stem (of the elephant) is a penis and that the tail is a frog? Or something like that.


I would like you to start seeing the entire patient and all the possible causes in these cases. And I hope you know that you must not use the NIH classification of prostatitis, but rather a threshold... Sorry, a wider “umbrella.” Keep the goal in mind. Define the diagnosis about these different categories.


Thank you.

Diane Newman: Thank you very much, I love that last slide of the elephant. These individuals get shifted and go back and forth between providers. We find that primary care providers don't know what to do with them. They come over to urology and again, I'm not sure many urologists know what to do with them either. Especially since it's not usually prostatitis, it's not usually an infectious thing. You wonder, where does this person lie really, as far as evaluation. Like someone like you has expertise but for most individuals who haven’t, how do they find the right provider?

Jeannette Potts [En Español]: The question is, I have this expertise, but how does the patient find someone with this knowledge?

Jeannette Potts: I would say that it's just a matter of having a little bit of time and awareness, because I would love to say I'm special. But I'm really not. I just feel like you can teach yourself. After all, I had to teach myself because there is no CME for this. My CME is from my patients and trial and error. So, I had the good fortune of maybe in the beginning of my career having a little more insulated time, and because I was not a surgeon, I only did outpatient surgery so my outpatient surgery was well remunerated. So the rest of my time I didn't feel the pressure. I didn't even know. Honestly, Diane. I didn't even know there was a code for new patients or follow-up patients that was different. I enjoyed practicing medicine, and some people might just say that's naive or nice, that's just stupid. But that's really how I was.

Jeannette Potts [En Español]: In Spanish. Of course, I don’t think I’m the only one who can do this. I’m not doing anything special. With experience, you learn from your patients. At the beginning of my career, I was able to isolate myself and have more time. And, since all of my procedures were in the clinic (outpatient procedures) and they were very well compensated. I didn’t feel the pressure to do more procedures. I’m also not a surgeon. I didn’t have the pressure to have an operating room. I think that helped me, too. I didn’t even know there were classifications and codes for billing purposes. On the one hand, I was very innocent and maybe stupid, but that way I really enjoyed my career.

Diane Newman: Well, do you find then, just like in the U.S., these individuals do end up in urology. Right? That's what happens in Latin American countries; it's the same thing, right?

Jeannette Potts: Yes, and sadly I was told by many of my colleagues, we just took that whole prostatitis, NIH, and with NIH we just kind of took that out of homage and respect for the United States. We do like to brag or boast that we're the world leaders. And then we act irresponsibly.

Diane Newman: It's true. Again, I think due to ignorance people don't know what to do with these patients. And I think that's a real problem within the medical field. Like you say, time is of the essence, and of course, you do need time to sit and really listen to this person's history. To determine the differentiation between what is pelvic pain, what may be some urinary symptoms. And then what type of evaluation, as you presented, really doesn't allow this sophisticated testing that we do is not going to be helpful in this population.

Jeannette Potts: Yeah, and it does take decades to right, to take the ship, and change course. I think we talked about it at another time. This Swan-Ganz catheter, I think it took 27 years to convince people that the Swan-Ganz catheter was actually causing death. It took 27 years to convince people, because how could something giving us all this extra data be harmful to the patient.

Diane Newman: Right, well thanks so much, this is really helpful and I know our audience here in the U.S. and in Latin America and South America will really enjoy these translated talks. So thanks so much.

Jeannette Potts: Thank you.