neuroanatomy, neurophysiology and clinical presentation of ... · neuroanatomy, neurophysiology and...
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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, gastro-enterological 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
Abnormal central processing
Abnormal efferent signaling
Abnormal afferent signaling
Psychological, behavioural, sexual
consequences
Changes in organ function
Sensory problems
Sensitization
Regional and systemic changes: viscero/viscero/somathic hyperalgia, Trophic, autonomic, endocrine, immune responses
Referred 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
Sensitization and sprouting in chronic pain
Bladder Sphincter Urethra
Filling faze: detrusor relaxes urethra/sphincter is closed Emptying faze: detrusor contracts urethra/sphincter opens 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
T10-L2
S3-S4
Pelvic plexus
PMC
PS External urehral sphincter
Bladder
Efferent Neuroanatomy of Bladder-sphinctercomplex
nervi errigentes nervi pelvini
Bladderneck, Prostate Urethra
brain
OS
Pudendal nerve
NANC
OS
Hypogastric nerve
OS
PS
Bladder function and dysfunction
T10-L2
S3-S4
Pelvic plexus
PMC
PS
External urehral sphincter
Bladder
Afferent Neuroanatomy of Bladder-sphinctercomplex
Bladderneck
brain
Hypogastric nerve
Pudendal nerve
nervi errigentes nervi pelvini
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
T10-L2 LSt-cells
S2-S3
Pelvic plexus
Pudendal nerve
MPOA PVN, PGi
PS
penis
prostate vas vesicula, bladderneck erectile tissue
Cav
ern
osa
l ner
ves
nervi errigentes nervi pelvini
NANC
Striated muscles (S2-4)
Prevertebral ganglia
Hypogastric nerve OS
Sexual function and dysfunction
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.
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
Conclusion