Is CPPS a form of CRPS?
This paper was written about female chronic pelvic pain, but may well apply to men too. The author, Dr Janicki, states that "Actually chronic prostatitis is probably another example of CRPS that involves complex visceral hypersensitivity." (personal correspondence with webmaster)
Is Chronic Pelvic Pain a form of Complex Regional Pain Syndrome?
Author: Thomas I. Janicki, MD
I would like to propose, that Chronic Pelvic Pain is a form of the entity referred to as Complex Regional Pain Syndrome.
Complex Regional Pain Syndromes (CRPS) I and II have been recognized for over a century as Reflex Sympathetic Dystrophy and Causalgia (Wilson 1999), (Stanton-Hicks, Janig et al. 1995). Both of the syndromes are characterized by chronic pain usually out of proportion to the injury and a constellation of symptoms involving the autonomic nervous system (Baron and Janig 1998), (Birklein, Riedl et al. 1998), (Schurmann, Gradl et al. 2000). In the majority of the patients, the pain can be improved by sympathetic block or regional sympathectomy. The clinical features of the CRPS include chronic pain, increased sensitivity to touch and vibrations, a difference in the temperature, perfusion, sweating and appearance of the skin between the involved and uninvolved side (Sieweke, Birklein et al. 1999). The concept of Sympathetically Maintained Pain (SMP) has been advanced as an explanation for persistent symptoms (Stanton-Hicks 2000), (Wong and Wilson 1997).
Chronic Pelvic Pain in some patients shares many features with Complex Regional Pain Syndrome. The similarities include:
- increased response to pain
- ovulation triggering severe and prolonged pain attacks
- hyperalgesia in the pelvis, as seen during pain mapping under conscious sedation (Demco 1998), (Howard, El-Minawi et al. 2000).
Pain is worse in dependent position as with patient sitting or standing.
Pain can be induced by relatively minor stimuli: minimal endometriosis, minor pelvic adhesions and occult hernias.
These findings represent the pain triggers rather than a sole cause of the pain. There are also findings suggestive of the Autonomic Nervous System involvement in some of the patients suffering from chronic pelvic pain. One of the most common laparoscopic findings is diffuse congestion of all pelvic vessels [webmaster's note: a study has shown men with CPPS have increased blood flow in the prostate area] including superficial vessels in the peritoneum as compared in patients without chronic pelvic pain.
More than 60% of patients will notice improvement or elimination of the pain after presacral neurectomy (Lee, Stone et al. 1986), (Perry and Perez 1993) (superior hypogastric plexus is part of autonomic nervous system).
It is true that some of the CRPS symptoms are not applicable in the pelvis: the difference between involved and uninvolved side does not apply since, the pelvis is in the midline. Differences in sweat production, temperature control of the skin and trophic changes in the bones are also not recognizable in the pelvis.
Proposed model for involvement of the Autonomic Nervous System in Chronic Pelvic Pain.
I view the autonomic nervous system (ANS) as the operating system of our body. It runs programs for every function of our body (breathing, circulation, immune response, voiding, etc.); it also adapts its programs to the environment (Janig 1985), (Janig 1988), (Janig and McLachlan 1992), (Green, Janig et al. 1997). It is also the bridge between the mind and the body (Lazar, Bush et al. 2000), (Kubota, Sato et al. 2001), (Telles, Nagarathna et al. 1998), (Rogers, Dubey et al. 1979). The autonomic nervous system is connected to every system and organ in our body: the immune system, the hormonal system, the heart, the vessels, etc., at the same time, it is closely associated and under the influence of CNS/cortical domain, where it is affected by thoughts and conscious and unconscious emotions (Naliboff, Solomon et al. 1995), (Oishi, Kasai et al. 2000). In the event of acute pain, involvement of the autonomic nervous system is seamless and predictable. It increases blood flow to the injured area, it activates immune response and keeps checking on it, etc. All these activities are done under CNS/cortical domain modulation. When the pain lasts longer than expected, or if CNS/cortical modulation is inadequate, due to the present stress or past emotional traumas, the pain becomes part of the environment and the autonomic nervous system adapts to it. For the autonomic nervous system the pain does not have either positive or negative qualities, it is just a part of the environment and it will be serviced. The new program will include the pain stimuli and or the pain equivalents (bladder irritability). Once this maladaptive routine starts, removal of the initial pain stimulus may not result in the elimination of the pain, as the program will acquire other, usually not painful stimuli to fill the need. If we accept this model of the Chronic Pelvic Pain, it is obvious that the removal of pain triggers by itself will not alleviate the pain and a comprehensive multidisciplinary approach to the treatment is the logical choice. As the CNS/cortical domain exerts direct influence over the function of the autonomic nervous system, stress reduction measures and psychotherapy are essential to the success of the treatment.
Thomas I. Janicki, M.D.
Associate Clinical Professor of Obstetrics and Gynecology
At Case Western Reserve University, Cleveland, Ohio, USA
1611 South Green Rd. #216
Cleveland, Ohio 44121
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