The Chronic Pelvic Pain Syndrome After Brachytherapy for Carcinoma of the Prostate

Abstract

Bacterial inflammatory prostatitis comprises approximately only 5% of cases of “prostatitis-like” pain. Penile, scrotal and perineal pain associated with voiding complaints may represent prostatitis or pudendal neuropathy. Fibrosis of Alcock’s canal may produce compression neuropathy, or pudendal neuralgia.1 CASE REPORT An asymptomatic 67-year-old man with localized carcinoma of the prostate underwent “sandwich” radiation therapy (combined brachytherapy and external beam radiation therapy) elsewhere in 1999. Radiation dosage was unknown. History included transurethral prostatectomy in 1972 and acute prostatitis in 1986. The patient presented with 20-month history of severe burning at the glans and anus associated with constant perineal and rectal pressure. Hourly urinary frequency increased to every 20 minutes after exercising on a treadmill or stair climber machine, or after squatting while gardening. Clothing or diapers touching the glans stimulated dribbling incontinence. Rising from a sitting position caused a voiding reflex. Pain was aggravated by sitting and driving, and intensified following ejaculation. Pain was reduced by standing, was generally relieved when the patient was recumbent and was always relieved by sitting on a toilet. Severe pain while riding a stationery bicycle caused discontinuation of this lifelong activity. On examination the anus and prostate were sensitive. Compression of the sacrospinous ligament bilaterally reproduced the complaints. Pinprick sensation was normal throughout the pudendal distribution. Peau d’orange was noted in a 10 cm. area of gluteal skin. Evaluation showed pyuria with greater numbers of white blood cells in the voiding bottle 3 (post-prostatic massage) urine. Cultures were sterile. Excretory urography was normal. Cystoscopy revealed granulation tissue in a widely patent prostatic urethra. Urodynamic evaluation demonstrated a small capacity bladder with detrusor instability. Colorectal, gastrointestinal and spinal evaluations were normal. National Institutes of Health category IIIA prostatitis and pudendal neuralgia were diagnosed. Treatment included 10 mg. ketorolac every 6 hours for 5 days, 50 mg. amitriptyline at bedtime and 150 mg. clindamycin 3 times daily. Former treatment with 600 mg. gabapentin 3 times daily was continued. After 2 months of therapy symptoms persisted. Therefore, bilateral pudendal nerve perineural corticosteroid injections were begun.2 A “miraculous” relief of pain occurred 10 days after the second injection, and 2 days after starting levofloxacin 500 mg. per day and increasing the dose of gabapentin to 2,700 mg. per day. Symptomatic improvement included relief of pain, absence of urgency and frequency, and cessation of incontinence. Relief continued at 6 months following injections. DISCUSSION Urogenital/rectal pain, irritable bladder and pain following ejaculation are common in pudendal neuralgia. Bacterial prostatitis may induce similar complaints. Radiation therapy may cause neuritis or fibrosis within Alcock’s canal. Sterile aerobic cultures suggest anaerobic prostatitis. Krieger et al identified anaerobic bacteria in 65% of men with chronic