A burning sensation when urinating may not be due to infection

SINGAPORE – For years, Mr Rajesh Pahwa, 55, lived with a persistent pain in his groin — specifically in the left scrotum and tip of the penis.

Despite spending more than S$5,000 on multiple doctor visits here and overseas, tests and imaging scans in the last three years, there were no clear answers to his mysterious symptoms, which included pain in his thigh and a burning sensation when urinating. The pain was sometimes severe, causing him to limit his fluid intake to avoid visiting the toilet.

“Doctors ran tests and scans but found nothing concrete. I sought a second opinion in India but there was still no diagnosis,” said Mr Pahwa, an accountant. He was eventually diagnosed with chronic pelvic pain syndrome at the National University Hospital (NUH).

Characterised by pain in the pelvic area for three months or more in the absence of an active infection, it is estimated that chronic pelvic pain syndrome affects around 2 to 3 per cent of the population here.

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The condition is often seen in men in their 40s and 50s and can also affect women, said Dr Joe Lee, a consultant at NUH’s department of urology and its director of Andrology and Male Reproductive Medicine.

Dr Lee estimated that NUH’s urology clinic, which handles approximately 120 patients per day, sees around three to four patients each day with symptoms associated with chronic pelvic pain syndrome.

Tan Tock Seng Hospital (TTSH) sees approximately 60 to 80 cases each year, more commonly sexually active men. Many patients with the condition have other urological conditions like benign prostate hyperplasia (prostate enlargement) and premature ejaculation, said Adjunct Associate Professor Ronny Tan, consultant and director of andrology in the department of urology at TTSH.

While not life-threatening, the persistent pain can be incapacitating. Ranging from mild to severe, the pain can be persistent or episodic and made worse by urination, defecation and movement, said Dr Lee.

“Work, social life and relationships can get badly affected due to the persistent pain. Sexual dysfunction can also arise. Patients may have difficulties at work or be forced to abandon activities they enjoy. Those with severe chronic pelvic pain syndrome are often frustrated, depressed or even suicidal,” said Dr Lee.

TIGHT TENDER POINTS IN PELVIC MUSCLES

The exact cause of chronic pelvic pain syndrome is not fully understood. However, tender points in the muscles and the surrounding connective tissue, known as active myofascial trigger points, can be identified in half the patients with the condition, said Dr Lee.

Tight tender points in the pelvic muscles may likely develop due to long-term muscle strain or trauma, previous inflammatory conditions or stressful situations that led to muscle spasm and reduced circulation in the affected areas, he said.

For example, posture that puts stress on the pelvic muscles, such as from sitting or cycling for long hours, has been associated with chronic pelvic pain, said Dr Lee. At-risk groups also include those with previous genito-urinary infections, pelvic trauma (from sexual assault, for example) and psychological issues such as anxiety or depressive disorder, he added.

A diagnosis is usually made using detailed patient medical history and physical examination, said Dr Lee.

“Most patients with chronic pelvic pain would have undergone multiple physical examinations and investigations such as blood tests, urine tests and imaging scans where the findings are usually normal. Everything may look perfectly normal but the pain is real for the patients,” said Dr Lee.

Nonetheless, these “normal findings” help doctors exclude other medical conditions that can cause pelvic pain, such as conditions of the digestive or urinary tract including organ inflammation and tumours, as well as gynaecological conditions in women, said Dr Lee.

The condition, said TTSH’s Adjunct Assoc Prof Tan, is often challenging to treat. “In most cases, we are unable to completely cure it,” he said.

Current treatments available include the use of medications, such as anti-inflammatory medications, analgesia and antibiotics, he said.

Patients may be taught physiotherapy exercises to relax their pelvic floor muscles, said Dr Lee.

Other relief methods include using a heat pad or bottle on the perineum to ease symptoms. Most men report relief of symptoms after a prostatic massage, usually performed by a urologist in the clinic to obtain prostatic secretions to detect bacterial growth, said Adjunct Assoc Prof Tan.

“Current treatments (of medications and physiotherapy) are only effective to a certain extent in reducing pain. Many patients continue to have persistent pelvic pain so a new and effective treatment is needed,” said Dr Lee.

NEW TREATMENT ON TRIAL

Mr Pahwa recently found relief after enrolling in a new treatment on trial at NUH that uses low-intensity shockwaves, or acoustic waves. The treatment works by stimulating an increase in blood circulation in the pelvic floor muscles, which helps relax the affected muscles and reduce pain, said Dr Lee.

Mr Pahwa was found to have tender trigger points in his perineum after undergoing a physical examination.

Shockwave therapy is currently used as a non-invasive treatment for erectile dysfunction in some hospitals here, including NUH and TTSH. Sports medicine specialists were the first to use this treatment modality to treat tendinitis and other inflammatory conditions, said Adjunct Assoc Prof Tan.

TODAY understands that NUH is currently the only hospital here that has extended shockwave therapy to treat chronic pelvic pain syndrome.

It intends to recruit around 20 adult male patients for the trial to confirm its efficacy in the local patient population, before offering it as routine treatment for chronic pelvic pain syndrome, said Dr Lee. Mr Pahwa is the first patient to complete the new treatment.

Adjunct Assoc Prof Tan said TTSH could use the treatment for chronic pelvic pain syndrome but has not come to a consensus on treatment protocol.

After undergoing four sessions of the treatment, Mr Pahwa noticed “50 to 60 per cent less pain” and improvement of symptoms. The burning sensation that occurs at the tip of the penis has subsided although he still feels some pain in the thigh and scrotum.

“I feel happy that life is going back to normal. It’s very irritating when you go to the toilet and experience a burning sensation every time you pass urine,” he said.

Mr Pahwa has also changed his lifestyle and taken steps to control his stress levels, which he learnt could be linked to chronic pelvic pain. He visits the gym regularly now and has started his own business to better manage his workload and stress.