Chronic Pelvic Pain Syndrome in Women

According to the National Institutes of Health National Library of Medicine, chronic pelvic pain in women is a common condition that affects up to one in seven women. There are many possible causes of pelvic pain. If the pain lasts for three to six months, the brain becomes overly sensitive to pain and feels even mild pain as severe pain. This type of pain is called centralized pain and CPPS is a centralized pain syndrome.

CPPS in women may start with causes of pain that can include endometriosis, inflamed bladder, physical trauma, irritable bowel syndrome, pelvic inflammatory disease, sexual abuse, and many other causes. Depending on the cause, the pain may be described as sharp, dull, crampy, burning, or shooting. Pain may get worse when urinating, having a bowel movement, or having sex. It may also get worse during menstrual periods.

See more: Chronic Pelvic Pain Syndrome in Women

CPPS in women can be hard to diagnose because the cause of pain may be gone even though the feeling of pain continues. Mild pain caused by normal sensations like a menstrual period or sexual intercourse may trigger severe pain. Blood tests, urine tests, and imaging studies can be done to look for the cause of pain, but sometimes these tests are normal. In many cases, the diagnosis is made based on the history and the symptoms. Stress, depression, and anxiety commonly contribute to CPPS.

Treatment of CPPS may start with treating the cause of pain if it is found. For example, if a woman has endometriosis or pelvic inflammatory disease, treating these conditions may reduce CPPS symptoms. In many cases, other treatments may also be needed to control CPPS, and finding the right treatment may require a team of health care providers. For these reasons, CPPS is often treated best in a pain rehabilitation clinic or center.

Some of the more common treatments can include:

• Over-the-counter pain relievers
• Hormone treatments or birth control pills for pain related to menstrual periods
• Antibiotics if an infection is suspected
• Antidepressants
• Physical therapy
• Spinal cord stimulation
• Pain control injections
• Psychotherapy

Chronic Pelvic Pain in Men

Chronic pelvic pain in men is unexplained pain in the pelvic area with pain when passing urine and pain in the groin, penis, or the area between the scrotum and anus, called the perineum. There may also be strong and sudden urges to pass urine and pain after ejaculation. This condition is also called chronic nonbacterial prostatitis. Like CPPS in women, this condition is often associated with stress and anxiety.

Possible causes of pain include inflammation of the prostate gland caused by aging or prior infection. Other possible causes include low testosterone and undetected infections of the prostate gland. In the United States, this condition is most common in men over age 50.

Diagnosis of male CPPS includes a rectal exam of the prostate gland, urine testing, prostate fluid testing, and blood testing. Tests are often negative and the diagnosis is made by the history and symptoms. Treatment options include:

• Antibiotics
• Over-the-counter pain medications
• Medications that improve prostate symptoms called alpha-adrenergic blockers
• Physical therapy
• Psychotherapy
• Antidepressant medication

See more: Chronic Pelvic Pain Syndrome in Women

Chronic Pelvic Pain Syndrome Home Remedies

CPPS can have a negative effect on the quality of life and mental health. Finding ways to reduce stress and anxiety may help. Some recommended home remedies include:

• Meditation
• Deep breathing
• Exercise
• Avoiding constipation
• Taking a warm bath

CPPS is a difficult condition to live with and it can take time to find the cause and the right treatment. Even if the cause is not found, which is not uncommon, working with a team of health care providers familiar with the condition frequently reduces symptoms and improves the quality of life.

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Further complicating the screening process is that several medications and a number of other modifiable factors may alter the results of the PSA lab test, leading to inaccurate readings that may overestimate or underestimate your risk of having prostate cancer found on a biopsy.

PSA is a liquid protein produced by the prostate that helps liquefy semen and is crucial to successful natural conception. The prostate normally secretes a small amount of PSA into the blood. The PSA lab test simply analyzes your blood to see how much PSA it contains. PSA is measured in nanograms (one-billionth of a gram) per milliliter (one-thousandth of a liter). The PSA lab test results are used to help assess a man’s need for a prostate biopsy, which is necessary to diagnose prostate cancer.

What Affects the PSA Lab Test and PSA Levels?

A number of factors are known to affect, to varying degrees, your PSA levels:

1. Age

PSA levels, on average, rise as men get older, possibly because the prostate leaks more PSA into the bloodstream.

2. Benign prostate enlargement (BPH)

BPH is a non-cancerous enlargement of the prostate that occurs with age. As men get older, the risk of BPH rises.

3. Prostatitis

This prostate disorder is an infection or inflammation of the prostate. It also can cause PSA elevations. (See our post Prostatitis Causes More Than Pain.)

4. Urinary tract infections

UTIs can affect PSA levels.

5. Prostate procedures

Examples include prostate surgery, cystoscopy, or a prostate biopsy. Your doctor will inform you about how long you should wait after one of these procedures before undergoing a PSA test.

6. Sex

Ejaculation can cause the prostate to transiently leak more PSA into the blood for about one to two days.

7. Prostate stimulation

Prostatic massage or a digital rectal exam may cause minor PSA elevations.

8. Riding a bicycle

Bicycle riding for a long distance may cause temporary spikes in PSA, possibly because the seat applies pressure on the prostate. You may have to abstain from bicycle riding at least 24 hours before having your PSA measured.

9. Obesity

Being very overweight can result in lower PSA levels.

10. Medications

A number of medications can trigger lower PSA results. The medications that can affect PSA results are:

• 5-alpha reductase inhibitors—dutasteride (Avodart) and finasteride (Proscar)—which can reduce PSA levels by about 50 percent in many men who take them.
• Some herbal and dietary supplements
• Aspirin
• Statins
• Thiazide diuretics

So, if you choose to undergo PSA screening, it’s important to understand these factors that can influence your PSA lab test results and inform your physician if any of them apply to you.

Don’t Rely on PSA Levels Alone

Given the inexact nature of the PSA lab test and the various factors that can influence its results, experts recommend that the test be used in conjunction with a digital rectal exam (DRE). During that procedure, a doctor inserts a gloved finger into the rectum to feel the prostate through the rectal wall and find any lumps or other abnormalities that might indicate cancer. If you decide to be screened, ask for both tests, because that combination is least likely to miss cancer. DRE is usually done after your blood test to prevent falsely raising PSA from the exam.

For more on prostate health, see our special report written by the editors of Men’s Health Advisor with Cleveland Clinic: Prostate Health.

The post What Can Skew a PSA Test? These 10 Factors Can Affect Your Numbers appeared first on University Health News.

Studies show that PSA screening saves lives for people with prostate cancer, because it finds cancer early when it is most treatable. [1] Prostate cancer is the second leading cause of cancer deaths in men after lung cancer. [3] So, you would think all men should get PSA testing throughout their lives to screen for prostate cancer. Unfortunately, it is not that simple. [1-4]

What’s a Normal PSA?

The main problem with PSA is that it is not a very reliable test. There is no settled normal range that can tell if you have prostate cancer. [2] You can have a normal PSA and still have prostate cancer, and you can have an abnormal PSA and not have prostate cancer. In fact, most men with a high PSA don’t have prostate cancer. [1]

A PSA level goes up with prostate cancer but it also goes up with age. PSA can go up with two very common prostate conditions, benign prostatic hyperplasia (BPH) and inflammation of the prostate (prostatitis). [1-3] PSA can even go up after having sex or riding a bicycle. [2]

PSA is measured in nanograms per millimeter (ng/mL). Although most doctors would consider a PSA of less than 4 ng/mL normal, some doctors say anything over 2.5 is abnormal. This is what the studies say:

• About 15 percent of men with a PSA under 4 have prostate cancer.
• About 25 percent of men with a PSA between 4 and 10 have prostate cancer.
• About 50 percent of men with a PSA over 10 have prostate cancer. [2]

The Problem With Prostate Cancer Screening

The only way to diagnose prostate cancer is with a prostate biopsy. You would think it would be worthwhile to do PSA screening for all men and a prostate biopsy on every man with an abnormal PSA, but that is not the case. [1-4] Prostate biopsy has risks. It can cause bleeding, pain, urinary retention, and a urinary tract or prostate infection. [4] Since most men with a high PSA do not have prostate cancer, these risks are important to consider. [1-4]

There is also a problem with prostate cancer itself. Even if a biopsy shows prostate cancer, many men with prostate cancer will never have any serious problems from their cancer. They will die from something else. For these men, the treatment can be worse than the disease. Treatment can cause serious urinary and sexual problems. [1-4]

Because most men with a high PSA do not have prostate cancer and many men with prostate cancer do not need treatment, guidelines for PSA screening rely heavily on a discussion of the risks and benefits with your doctor. [1-5]

PSA Screening Recommendations

Different medical organizations have slightly different guidelines. These are the guidelines for PSA screening from the  American Urological Association, the specialists who diagnose and treat prostate cancer:

• PSA is not needed under age 40.
• PSA is not needed for men ages 40 to 54 unless they are at higher risk for prostate cancer. Being African American or having a family history of prostate cancer puts you at higher risk.
• PSA should be considered for men ages 55 to 69 after discussing the risks and benefits of the test and of prostate cancer treatment.
• PSA is not recommended for men age 70 or older. [5]

What Happens After a PSA Test? 

If you and your doctor decide to do a screening test and the test is normal, you may not need to think about another test for a few years. If the test is abnormal, you and your doctor will discuss the risks and benefits of further testing:

• You may have another screening test before or after your PSA called a digital rectal exam (DRE). During DRE, your doctor places a gloved finger into your anus to feel your prostate. If your prostate feels enlarged or abnormal, your doctor may recommend further testing or a biopsy.
• Further testing could include another PSA test or a more specialized PSA blood test that may tell your doctor more about your prostate cancer risk. There are many options including tests called prostate health index, PSA velocity, PSA density, free PSA and others.
• Further testing may include an imaging study (MRI or trans rectal ultrasound)) of your prostate. [2]
• Your doctor will consider any further testing, your PSA test, and your DRE, along with your age, overall health and your risk factors. You and your doctor should use this information to weigh the risks and benefits of a prostate biopsy. [1-4]

The bottom line on PSA as a screening test for prostate cancer is that it is still a valuable test when used along with your DRE, other tests, and your personal risk factors to help you and your doctor decide if you would benefit from a prostate biopsy. [1-5]

Other Uses for Prostate Specific Antigen Testing

Outside of prostate cancer screening, there are other uses for PSA testing. If you have had a biopsy that shows a slow growing prostate cancer, your doctor may advise watchful waiting. In this case, PSA testing may be done periodically to see if your cancer becomes more active. Any increase in PSA could be considered abnormal. If you have been treated for prostate cancer, periodic PSA testing may be done to see if there are any signs of cancer coming back. Any increase would be abnormal. [3]

If you have symptoms of prostate cancer, PSA testing may be done to find out if you have prostate cancer. When you already have symptoms, PSA is no longer considered a screening test. It is a diagnostic test. [3] Let your doctor know if you have any of these prostate cancer symptoms:

• Problems passing urine, like slow flow, increased frequency, or loss of control
• Blood in your semen or urine
• Trouble getting or keeping an erection
• Weakness or numbness in your legs or feet
• Bone pain in your hips, back, or ribs [6]

RECOMMENDED FOR YOU

• How to Avoid Prostate Cancer
• 12 Risk Factors for Prostate Cancer
• Beyond the PSA Test: Options for Screening
• It Isn’t Time to Abandon the Prostate-Specific Antigen Test Just Yet
• PSA Lab Test Results: These 10 Factors Can Affect Your Numbers 
• An Abnormal PSA Result: What Comes Next?
• Are You Keeping Tabs on Your PSA Levels?

SOURCES

1. Memorial Sloan Kettering Cancer Center, Prostate Cancer Screening
2. American Cancer Society, Screening Tests for Prostate Cancer
3. American Society for Clinical Chemistry, Lab Tests Online, Prostate Specific Antigen (PSA)
4. CDC, Prostate Cancer, What Are the Benefits and Harms of Screening? 
5. American Urological Association, Early Detection of Prostate Cancer (2018)
6. American Cancer Society, Signs and Symptoms of Prostate Cancer

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The National Institute of Health (NIH) has divided prostatitis into four categories: acute bacterial prostatitis (category I), chronic bacterial prostatitis (category II), chronic prostatitis/chronic pelvic pain syndrome (category III), and asymptomatic inflammatory prostatitis (category IV).

All forms of prostatitis are non-cancerous conditions. Some studies have suggested a possible link between prostatitis and prostate cancer but others studies have shown no association between the two conditions. Research investigating whether or not there may be a relationship is ongoing.

Men with asymptomatic inflammatory prostatitis (category IV), as the name implies, do not experience any symptoms. Men suffering from one of the other three categories often experience one or more of the following prostatitis symptoms:

• Urinary Frequency: Men with prostatitis often experience the need to urinate often.
• Urinary Urgency: Prostatitis can cause the sensation of an urgent, immediate need to urinate.
• Urinary Retention: Symptoms related to the obstruction of urine flow caused by the inflamed prostate often occur with prostatitis. These can include difficulty initiating urination, a weakened urine stream, and the inability to completely empty your bladder.
• Painful Urination/Painful Ejaculation: Prostatitis can cause pain both during urination and ejaculation.
• Lower Abdominal Pain/Perineal Pain: Prostatitis can cause pain in the lower abdomen, groin, and/or the perineum, the area between the scrotum and rectum.

Men with acute bacterial prostatitis will additionally often experience systemic symptoms such as fever and chills and will notice that their symptoms begin suddenly and intensely. Men with chronic bacterial prostatitis may have low-grade fevers but their symptoms often are much milder than those experienced with acute bacterial prostatitis. Men with chronic prostatitis/chronic pelvic pain syndrome may have symptoms that range in severity and wax and wane unpredictably.

Acute Bacterial Prostatitis (ABP)

Acute bacterial prostatitis is the least common form of prostatitis, accounting for less than 5 percent of prostatitis cases. It occurs when bacteria infect the prostate gland causing the sudden onset of painful inflammation. It is most often caused by the bacteria Escherichia coli (E.coli), a common cause of urinary tract infections, but it can be caused by many other bacteria including sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhea.

Chronic Bacterial Prostatitis (CBP)

Chronic bacterial prostatitis is caused by the same organisms that can cause acute bacterial prostatitis and many of the symptoms are the same, although the symptoms are generally milder in CBP and last longer.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

CPPS is the most common form of prostatitis, accounting for 90-95 percent of all prostatitis cases. Some estimates suggest that 10 to 15 percent of U.S. men suffer from chronic pelvic pain syndrome. CPPS can be a frustrating condition for both patients and physicians because the cause is often unknown and treatment options are limited. It is thought that CPPS might possibly be due to an undetectable bacterial infection, an immune response to a past infection, or pelvic nerve impairment.

Asymptomatic Inflammatory Prostatitis

This is the rarest form of prostatitis and is usually an incidental discovery found when a doctor is testing for another urinary tract or reproductive disorder such as infertility. The only finding in asymptomatic inflammatory prostatitis is the presence of white blood cells in the urine or semen after prostatic massage. All other laboratory and physical exam tests are normal and the patient is always asymptomatic. No treatment is required and there are no known complications.

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In these asymptomatic men, prostate cancer is often detected during routine screening with tests such as a digital rectal exam, urinalysis, and possibly a prostate specific antigen (PSA) test by their healthcare professional. This is particularly true of men with early stage prostate cancer, but may also be true of men with more advanced cancer.

Other men with prostate cancer may experience symptoms ranging from mild to severe that may mimic symptoms of other prostate conditions, including benign prostatic hyperplasia/BPH (non-cancerous enlargement of the prostate gland) and prostatitis (inflammation of the prostate).

Some of these prostate cancer symptoms are more common than others and tend to occur in more localized prostate cancer (cancer limited to the prostate gland or adjacent tissues) while others are more likely to occur in men whose prostate cancer has spread or metastasized to other parts of the body. If you experience any of these symptoms, you should consult your healthcare provider immediately.

Common Prostate Cancer Symptoms

• Urinary frequency: Men with prostate cancer may feel the need to urinate more often, particularly at night.
• Urinary retention: Prostate cancer may cause the sensation of not being able to empty your bladder completely.
• Weak urinary stream: Some men with prostate cancer may feel that their urinary stream is diminished or that they dribble urine.
• Difficulty initiating urination: It may be difficult to begin urinating in some men suffering from prostate cancer.
• Painful urination: Urinating may cause pain or discomfort (dysuria) in some cases of prostate cancer.
• Blood in the urine: Prostate cancer can result in blood in the urine (hematuria) in some men.
• Painful ejaculation: Some men suffering from prostate cancer experience pain with ejaculation.

Other Prostate Cancer Symptoms

Some prostate cancer symptoms are less common and in some men may be associated with more advanced disease.

• Bowel problems: Because the prostate lies just in front of the rectum, prostate cancer that has caused significant enlargement of the prostate or that has spread into nearby tissues including the rectum, may cause intestinal problems such as constipation or diarrhea.
• Erectile dysfunction: Some men may experience impotence if the prostate cancer has affected nerves involved in an erection.
• Blood in the semen: The prostate gland secretes fluid that is part of semen. Cancer in the prostate may cause irritation and inflammation, leading to blood in the semen.
• Lymphedema: If the prostate cancer blocks flow of lymphatic fluid in lymph nodes or lymphatic vessels, men may experience swelling of the pelvic region or legs.
• Bone pain: When prostate cancer spreads, one of the tissues in the body that it often spreads to is bone. Pain in the back, hips, legs, or feet may result if the cancer has spread to bones of those regions.
• Unexplained bone fracture: Metastatic bone disease may result in fractures that occur with only very mild accidents or trauma that would normally not precipitate a break in bones.
• Numbness in the lower extremities: Prostate cancer that has metastasized to the spine may cause compression of nerves resulting in numbness or tingling of the hips, legs, or feet.
• Fatigue: Men with early stage prostate cancer may experience fatigue, but significant fatigue is more likely to occur with cancer that has spread.

If you experience any of these prostate cancer symptoms, you should consult your healthcare provider immediately. There are many tests and procedures available for prostate cancer diagnosis and many options for prostate cancer treatment.

Originally published in February 2016 and updated.

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These bacteria are notorious for fermenting carbohydrates into gas and their overgrowth is responsible for classic SIBO symptoms like gas and bloating. The good news is that SIBO treatment with either conventional or natural antibiotics is proven effective, especially if a SIBO diet is followed simultaneously. 

What are the symptoms of SIBO

The main SIBO pain and symptoms are digestive in nature, although some people with SIBO have no gastrointestinal-related symptoms at all. Digestion-related SIBO symptoms include:

• bloating
• flatulence
• abdominal discomfort and pain
• diarrhea.

Because SIBO is associated with malabsorption of nutrients, many subtle and not-so-subtle symptoms of vitamin and mineral deficiencies may occur, including:

• joint and muscle pain
• fatigue
• neuropathy (tingling, numbness, or pain in the extremities).

In extreme SIBO cases, there may be obvious signs of malabsorption, including weight loss and excessive fat in the stool (steatorrhea).

Health conditions related to SIBO

A number of diseases are associated with SIBO, including the following:

• Irritable bowel syndrome
• Rosacea
• Restless leg syndrome
• Macrocytic anemia (due to vitamin B12 deficiency)
• Microcytic anemia (due to bleeding ulcers)
• Liver diseases (cirrhosis and nonalcoholic hepatitis)
• Celiac disease
• Fibromyalgia [2]
• Parkinson’s disease [3]
•  Hypothyroidism [4]
• Inflammatory bowel disease (ulcerative colitis and Crohn’s disease) [5]
• Chronic pancreatitis [6]
• Autoimmune disease (rheumatoid arthritis) [7]
• Chronic prostatitis [8]

What causes SIBO?

SIBO develops when the normal mechanisms that control balance among the gut bacteria are disrupted. One of the most common processes that leads to bacterial overgrowth syndrome symptoms is decreased gastric acid (hydrochloric acid) secretion. Many people, especially as they get older, don’t make enough hydrochloric acid to properly digest food in the stomach. Heartburn sufferers who regularly use antacids or proton pump inhibiting drugs (purple pill) are also at increased risk of SIBO. Another common cause of bacterial overgrowth is statis (dysmotility) in the gut, which allows the bacteria to proliferate because the contents of the gut do not get pushed through quickly enough. Irritable bowel syndrome and certain medications like pain killers (narcotics) and proton pump inhibitors are common causes of stasis, as are many of the conditions listed above. Once present, bacterial overgrowth may cause inflammation in the mucus lining of the intestine, further exacerbating SIBO and its typical symptoms.

Testing for SIBO

The gold standard for diagnosing SIBO is an invasive, expensive, and rarely used test in which contents are collected from the small intestine and the numbers of bacteria are directly measured. To make SIBO detection easier, breath tests are used instead. A number of breath tests are now available and are becoming commonplace in gastroenterologists’ clinics, although there is some disagreement as to which tests are the most accurate and exactly how they should be interpreted. The most common tests are hydrogen breath tests. Patients are given a specific amount and type of carbohydrate (usually in the form of glucose and lactulose) and then hydrogen concentrations in the breath are measured over a period of time. With SIBO, bacteria in the small intestines ferment these carbohydrates and hydrogen is produced.

SIBO treatment

Conventional SIBO treatment is currently limited to oral antibiotics with variable success. Typically, a short course (10-14 days) of rifaximin is used. Rifaximin is a unique antibiotic in that very little of it actually gets absorbed—most stays in the gastrointestinal tract. This means it is generally less toxic and therefore better tolerated than most antibiotics. However, rifaximin is extremely expensive and can still cause allergic reactions and/or a number of adverse effects, including, ironically, adverse effects on the gut microbiome. Perhaps most importantly, when used as the sole therapy, rifaximin’s success rate for SIBO treatment is only 49.5%.[9] Repeated courses of the antibiotic frequently must be used.

Herbal antimicrobials and SIBO diet for eliminating SIBO symptoms

A recent study conducted by physicians at John’s Hopkins and the University of Pittsburgh, which you can read about in SIBO Treatment with Herbs Is as Effective as Antibiotics; Combine with a SIBO Diet for Even Better Results, found that SIBO treatment using herbal supplements containing combinations of herbs with antimicrobial properties was as effective as rifaximin.[9] Many natural and integrative practitioners today are testing and treating patients for SIBO using combinations of conventional antibiotics, herbal antimicrobials, and other natural-based therapies, including various versions of the SIBO diet, which restricts carbohydrates for a limited time in order to reduce the bacteria’s food source. In part 2, learn about the best diets for eliminating SIBO symptoms and how diet can best be combined with herbal antimicrobials for the most effective natural SIBO treatment.

[1] Ther Adv Chronic Dis. Sep 2013; 4(5): 223–231.

[2] Rheumatol Int. 2014 Aug 14. [Epub ahead of print]

[3] Parkinsonism Relat Disord. 2014 May;20(5):535-40.

[4] Indian J Endocrinol Metab. 2014 May;18(3):307-9.

[5] J Crohns Colitis. 2014 Aug 1;8(8):859-65.

[6] Pancreatology. 2014 Jul-Aug;14(4):280-3.

[7] Ann Rheum Dis. 1993 Jul;52(7):503-10.

[8] Can J Urol. 2011 Aug;18(4):5826-30.

[9] Glob Adv Health Med. 2014 May;3(3):16-24.

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A problem in the bedroom is not something most men care to discuss, but when pressed they may admit that sexual intercourse is not like it used to be when they were younger. Some men may therefore avoid sex and intimacy, which can damage relationships. Premature and painful ejaculations are two very common problems that often can be resolved, depending on the cause. According to urologist Sriram Eleswarapu, MD, PhD, of the Men’s Clinic at UCLA, he hears about premature ejaculation (PE) almost every day.

In fact, premature ejaculation is more prevalent than erectile dysfunction (ED). Primary care physicians frequently refer men to a urologist who specializes in treating sexual issues.

How Long Should Sex Last?

How long sex should last is a common, but broad question. The answer depends on what a person means by sex. Scientifically speaking, most studies refer to sexual duration as intravaginal ejaculation latency time (IELT), which counts the time from penetration to ejaculation. The average is about 5.5 minutes. But the range can be anywhere from 30 seconds to 44 minutes, leaving plenty of room for personal interpretation.

“Some men might consider ejaculation at the 20-minute mark too soon,” Dr. Eleswarapu explains. “I am more interested in what a man is experiencing rather than a stopwatch event. If I can make your sexual life better that’s my goal.”

Diagnosis and Treatment

While the absolute prevalence is unclear, estimates suggest that PE affects about 25 percent of men. If it happens infrequently, there is no cause for concern. The International Society for Sexual Medicine (ISSM) uses three criteria to define PE:

1. The time between penetration and ejaculation is shorter than desired.
2. Men feel they cannot control when they ejaculate.
3. Men feel distressed about their situation.

Diagnosing PE typically involves a medical history, physical exam, and series of questions. For example, physicians will want to know how long PE has been a problem, when it started, and how much control a man has over ejaculation. Some health conditions may cause PE, such as inflammation of the prostate (prostatitis), diabetes, high blood pressure, anxiety, and hormonal imbalances.

Pain can result from prostate cancer, pelvic radiation, nerve damage to the penis, and blockages in the ejaculatory system, such as from cysts or stones. Psychological problems can also be a culprit, especially if a man has pain only when with a partner and not whecn masturbating. Treatment aligns with cause and can include antibiotics for STDs, medications that reduce inflammation, time to heal nerve damage, and sex therapy.

If the underlying cause isn’t due to a health condition, physicians typically start with sex therapy. Whether men participate alone or with their partners, these sessions can help people develop greater understanding of personal needs, what can be done about them, and it can also assist in expanding sexual repertoire.

Behavioral therapy refers to what a person can do. For example, it includes what’s called the “squeeze” technique which may enable a man to better control ejaculation. Many studies have shown that topical agents that reduce sensation to the penis also are effective. Allow the topical to fully dry as it could rub off on a partner and inadvertently numb that person, too. Prescription medications that can be helpful include antidepressant selective serotonin reuptake inhibitors (SSRIs).

“SSRIs can be taken on an as-needed basis or as a daily medication,” says Dr Eleswarapu. “The decision for this is guided by the patient’s symptoms and other parts of the evaluation.”

There are many other therapies, including pelvic floor therapy, a go-to choice of Dr. Eleswarapu, who says it’s especially useful to men who have pelvic pain, prostatitis and other pelvic floor dysfunctions. If you have ED and PE, treating the former with sildenafil (Viagra) or tadalafil (Cialis) can resolve the latter. For more details on PE, see Dr. Eleswarapu’s excellent video at http://tiny.cc/4d7oiz.

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You’ve probably seen those commercials where people have to run off to the bathroom at the most inconvenient times, forgo outings because of the frequent urge to urinate, or avoid social situations for fear that a sudden cough or sneeze will lead to leakage. Urinary incontinence, involuntary loss of urine, can be quite embarrassing. It’s also quite common. It’s estimated that up to 40 percent of older adults may experience urinary incontinence (UI). Incidences increase as people reach their seventh and eighth decades.

“It’s often an underreported problem because many older adults think urine leakage is a natural part of aging, but it’s not,” says geriatrician Grace Chen, MD, UCLA Division of Geriatrics.

Urinary incontinence can occur for many reasons: Some are unique to a person’s sex, while others apply to both men and women. For example, diuretics, antidepressants, sedatives, and some herbal remedies may cause UI. Health issues related to UI include constipation, obesity, urinary-tract infections, diabetes, kidney problems, nerve damage, Alzheimer’s disease, and arthritis.

Process of Elimination

Every day the kidneys filter about 120 to 150 quarts of blood to produce 1 to 2 quarts of urine. The amount of urine produced depends on many factors, including how much liquid and food a person consumes and how much fluid is lost through sweating. Thin tubes carry urine from each of the kidneys into the bladder, which is a balloon-shaped organ that expands as it is filled. The bladder can hold about two cups of urine. As the body ages, the bladder may not be able to hold as much. Voiding up to seven times per day is considered normal, with the morning volume typically being higher.

Once the bladder is full, signals sent to the brain convey that it’s time to go. Muscles keep urine in place until you are ready to empty it. Urine is released through the urethra, located at the bottom of the bladder.

Men and UI

The prostate gland surrounds the urethra and is notorious for causing urinary problems in men. Prostatitis, an inflammation of the prostate, can cause debilitating urinary and sexual symptoms. The disease sometime results from infections, which can be treated, but for unclear reasons the infection persists in some men and can be quite difficult to cure. Risk factors for prostatitis include recent history of urinary tract infection or sexually transmitted disease. Prompt treatment of those issues reduces the risk of chronic prostatitis.

Benign prostatic hyperplasia (BPH), enlarged prostate, is caused by excess tissue growth. It irritates the bladder, causing it to contract, even when there is just a little urine present, and creates the sensation of needing to urinate more often. Hormones are suspected to play a role in the development of BPH. The condition is estimated to affect about 60 percent of men by age 60. By age 80, most men are affected by BPH. There are several medications that treat BPH. Lasers and water vapor techniques are also used to remove excess tissue.

UI in men may also result from prostate cancer treatments. In some men, function is restored in about a year post cancer treatment, though some treatments for UI may be needed. Surgical options include an artificial sphincter, urethral sling, and adjustable balloon devices. One study found that men who were not obese and were physically active were less likely to be incontinent after prostate cancer surgery.

Women and UI

Compared to men, women are twice as likely to experience UI. But as in men, the prevalence of the disease increases with age. The postmenopausal decrease in hormone levels may play a role in overactive bladder in women. According to Dr. Chen, women may also have symptoms from weakened or stretched pelvic muscles after childbirth or thinning and drying of the vaginal walls or urethra after menopause. Researchers think having low levels of the hormone estrogen after menopause may weaken the urethra, which may cause UI.

Any surgery that involves a woman’s reproductive organs, such as a hysterectomy, can damage the supporting pelvic floor muscles, especially if the uterus is removed.

UI treatments for women include the use of vaginal rings or creams containing estrogens that can help strengthen the muscles and tissues in the urethra and vagina. Botox injections can help reduce symptoms of an overactive bladder. The effects of Botox are not permanent, but can last six to 12 months. A reusable vaginal pessary is a small donut-shaped device inserted into the vagina. It pushes up against the vaginal wall and urethra to help support pelvic floor muscles and reduce stress incontinence. These prescription devices come in several sizes. Bulking agents, such as collagen injected into the tissues around the bladder and urethra to cause them to thicken, are another option that can reduce the amount of urine that leaks out. Surgical procedures include a sling, which acts as a hammock to support the urethra and hold the bladder in place. Serious complications can occur with this procedure, so it’s essential to fully understand the risks and benefits.

Tips for Better Bladder Health

It may seem like a good idea to drink less fluid to reduce urine leakage, but it isn’t. Adequate hydration is needed for good health, and older adults tend toward dehydration due to a reduction in the ability to feel thirsty. Getting enough fluid helps the kidneys and bladder stay healthy. Fluid helps flush out the urinary tract to prevent infections, and also helps prevent constipation, which makes UI worse. Avoiding caffeinated beverages may help some people prevent urine leakage. Whenever you go, try to empty your bladder completely.

For women, it’s especially important to sit on the toilet and relax rather than hover above the toilet seat to urinate. By hovering, the pelvic floor muscles can’t relax enough, which can result in some urine being left in the bladder. That, in turn, can cause leakage and possibly urinary or bladder infections. It’s also wise to urinate after sex to help flush out any pathogens.

Timed voiding may improve bladder control. Timed voiding means you urinate on a set schedule, for example, every hour. You can slowly extend the time between bathroom trips. When timed voiding is combined with biofeedback and pelvic muscle exercises, you may find it easier to control urge and overflow incontinence.

Pelvic floor muscles support the uterus, bladder, small intestine, and rectum. Kegel exercises, or pelvic floor retraining, can help prevent or reduce UI. However, some women have UI because their pelvic floor muscles are persistently tight, in which case doing Kegels may cause more problems.

Losing weight if you are overweight is helpful as it reduces pressure on the bladder and other urinary structures.

Talking with Your Doctor

To prepare for a visit with you doctor, keep a bladder diary for two to three days before your appointment. Jot down what you ate, how much, and when. Log when you urinate and try to estimate the volume (for example a cup or less). Note how many times your urine leaks, whether you felt a strong urge to do so, and consider what you were doing when the leak occurred (such as if you were lifting something, or if you coughed or sneezed).

During your appointment, your doctor will take a medical history, perform a physical exam to look for medical problems, and perhaps order lab tests, such as requesting a sample of urine to check for infections or kidney problems.

If you don’t treat UI, it can lead to urinary tract infections, skin rashes, sores and infections. Though it can be difficult to discuss bladder issues with your doctor, the more he or she knows about the specifics, the better your UI can be evaluated and treated, and the better you will feel.

The post Better Bladder Health for Men and Women appeared first on University Health News.

Chronic pain may be caused by an injury that begins, of course, as acute pain, but then is either so severe or long-lasting that the nerves are permanently damaged. The pain feels more intense and becomes chronic (see “Pain-Causing Conditions and the Areas They Affect”).

For many others, chronic pain can be blamed on one (or more) of the following:

• According to the American Academy of Family Physicians, conditions that may trigger chronic pain include infections, headaches or migraines, back problems, cancer, arthritis, fibromyalgia, nerve damage, and previous surgery.
• Surgery. Estimates vary, but up to 20 percent of back surgeries can fail, leaving continuous pain.
• An unknown reason. In some cases of chronic pain, doctors fail to pinpoint a definite cause.

The first step in gaining control of your pain is education. This chapter explains the many common causes of chronic pain, including the most commonly reported joint disorder (osteoarthritis) and the most debilitating (rheumatoid arthritis). Once you are familiar with what’s causing the hurt, you can learn how to relieve it.

Arthritis

Responsible for causing pain and stiffness in the joints and bone, osteoarthritis (OA) affects 30 million Americans. It’s the most common form of arthritis. Rheumatoid arthritis (RA), which affects about 1.3 million, is the most debilitating form of arthritis. RA is an autoimmune disorder that is chronic and progressive. It causes inflamed joints, painful deformity and often immobility (especially in the wrists, fingers, ankles, and feet).

Osteoarthritis

Also called degenerative joint disease, osteoarthritis is the result of worn joint cartilage and underlying bone. Before age 45, the condition is more common in men; after that, it’s more prevalent in women. By 75, more than 80 percent of Americans either have symptoms or x-ray evidence of OA. Half of people over 65 show evidence of the condition in at least one joint. Nearly half of all Americans will develop knee osteoarthritis during their lifetime.

When you have OA, the cartilage—the cushion in joints that protects the ends of the bones—thins, so the bones rub against each other. The result is pain, inflammation, swelling, and limited movement. The body tries to heal the damage, but it’s not very effective. In the worst cases, bone spurs develop, which are new bone that further worsens the pain and limited movement.

Those at highest risk of OA are obese, have a previous joint injury, or have a family history of the disease. A 2017 study found that weight loss can slow the degeneration of knee joints.

Symptoms. The symptoms of OA depend on which part of the body is affected, but can include:

• Stiffness
• Swelling
• Pain
• Difficulty bending and moving
• Restricted range of motion

Hip OA: Osteoarthritis in the hips causes pain, stiffness, and severe disability. Activities such as moving and bending become limited, making even a simple act like getting dressed a challenge. Those with the condition can feel pain in their hips, groin, buttocks, or knees.

Knee OA: A study published in Arthritis Care & Research found that knee pain when using stairs may be one of the earliest symptoms of knee osteoarthritis.

Spinal OA: Spinal osteoarthritis causes stiffness and pain in the neck or lower back, as well as weakness or numbness in the arms and legs.

Treatment. Treatment for OA includes weight control, rest, medications, alternative therapies, braces, joint injections, surgery, and exercise. Researchers from the University of Melbourne found that increasing knee extensor (quadricep) strength helped relieve OA pain and improved physical function.

In some cases, joint-replacement surgery (arthroplasty) is required. This involves removing damaged joint surfaces and replacing them with plastic or metal parts. Procedures are most commonly performed on the knee and hip joints.

Rheumatoid Arthritis

RA is an immune-mediated inflammatory disease that attacks the lining of the joints. The exact cause of RA is not known but genetic, environmental, and hormonal factors (in women) are implicated.

RA progresses through three stages: 1) swelling in the lining of the joints, 2) rapid division and growth of cells that cause the lining to thicken, and 3) inflamed cells that release enzymes. The enzymes digest bone and cartilage, which causes joints to lose their shape and alignment, both of which affect movement.

Symptoms include:

• Inflammation in the wrist and finger joints closest to the hand
• Fatigue
• Fever
• Feeling unwell
• Pain or stiffness for more than 30 minutes in the morning or after a long rest
• Tender, warm, swollen joints
• Same joint affected on both sides of the body (both wrists, for example)
• Symptoms that last for years

Limit Damage. The earlier you treat rheumatoid arthritis, the less damage you’ll experience. Treatment focuses on minimizing damage, controlling pain, lifestyle changes (joint protection, diet, and exercise), and reducing inflammation through a combination of drugs that usually includes methotrexate, an immune suppressive drug.

A modified-release form of prednisone appears to be more effective at reducing morning joint stiffness than the standard version of the steroid. The drug tofacitinib citrate (Xeljanz) may be used to treat moderate-to-severe rheumatoid arthritis in people who haven’t responded to or can’t tolerate methotrexate.

Disease-modifying arthritis drugs (DMARDs), although effective, aren’t reaching those who need them most. DMARDs aren’t pain-relieving medications. They’re designed to slow the progression of joint damage. Despite their possible success, at least two-thirds of older people aren’t getting these medications because of cost or the reluctance of primary-care physicians to prescribe them due to possible side effects and complications. The oral medication baricitinib (Olumiant), which received FDA approval in 2018, provides a new option for some RA people who don’t respond to current treatments.

Injections, physical therapy, exercise, and surgery are other treatment options. Changes in symptoms and health status must be monitored closely (at least every two to four months) and treatment changed accordingly.

Back Pain

Eighty percent of us will have back pain at some point, most often in our lower backs, but usually it will get better, with or without treatment.

The back’s muscles, bones, joints, ligaments, tendons, and discs must work together in perfect harmony to avoid injuries Even healthy people can suffer from back problems.

No case of back pain is the same. The causes, symptoms, and treatments of back problems vary, meaning they shouldn’t be treated as a single condition.

Lower Back Pain

Lower back pain is the most common cause of disability. In 2018, researchers at the National Institute on Aging and Johns Hopkins University studied 878 aging adults to determine the effects of lower back pain. They found that 31 percent of people had mild low back pain and 16 percent experienced it as moderate-to-severe pain. While gait speed wasn’t affected, pain resulted in greater energy needed to walk and a poor perception of endurance. A worse perception of walking ability is likely to lead to loss of future mobility.

Lower back and/or leg pain are common symptoms of a herniated disc. A disc is like a soft, jelly donut. It sits between the vertebra to make up your spine. When a disc “slips” or becomes “herniated” or “ruptured,” its soft “jelly” middle bit squishes out through a tear in its exterior. The result is usually weakness, numbness, and tingling that radiates from the buttocks to the toes, and often pain.

The pain worsens with walking, standing, and during any activity that causes intra-abdominal pressure, such as coughing, sneezing, or straining with a bowel movement. Muscle weakness can occur in the affected leg, and muscle spasms are common. The pain resolves with or without treatment in up to a third of all cases, but the process can take weeks.

How a Back Strain Happens

The most common back injury is a strain or pulled muscle. Considering the long-term problems associated with other types of back problems, a pulled muscle is by far the least serious, even though at first it feels as bad as the others.

Back strains usually occur after sudden or awkward movements, when lifting or moving a hefty object, or absorbing a heavy or unexpected blow. Even something as small as bending down to tie a shoe can cause a strain.

Structural problems may cause low back pain and accompany strains. A bulging disc (the soft material between vertebrae) may press against a nerve. If the nerve extends downward through the leg, it can cause a shooting pain called sciatica, affecting the buttocks and back of the leg.

The lower back is one of the most frequent areas affected by osteoarthritis. Other structural problems, such as sciatica, herniated disc, and spinal stenosis, are discussed later.

Symptoms include pain and back spasms. If the pain is intense, you need immediate medical treatment, especially if it spreads down one or both legs, causes weakness or numbness, or follows a fall or blow to the back.

Treatment includes:

• Rest your back for 24 to 48 hours; limited, mild movement is better than complete bed rest.
• Apply ice packs for 15 to 20 minutes, three to four times a day for the first 48 to 72 hours.
• Apply moist heat after the first 48 to 72 hours if it feels more comfortable.
• Acetaminophen may relieve pain. Aspirin, ibuprofen, and naproxen may reduce both pain and inflammation. Check with a doctor if you have liver, kidney, or stomach problems before taking these medications.
• Side sleepers: Place a pillow between your knees.
• Back sleepers: Place a pillow under your knees.

Most pain medications have little-to-no effect on back pain. As a result, doctors suggest alternatives such as heat, massage, yoga, spinal manipulation, and acupuncture, claim Australian researchers.

If you start feeling better, don’t overdo it. Avoid sitting in one position for long periods of time. Get up and stretch every 20 to 25 minutes. Slowly and carefully execute each movement required in daily activities before trying to do them in real time and real situations. (See “Back Pain Prevention,” on page 19.)

Facet Joint Syndrome

Facet joints allow the back or neck to extend and rotate from side to side. When the joints are inflamed, movement becomes restricted, leading to pain and a limited range of motion.

While the cause of facet joint inflammation isn’t always known, trauma, degeneration, and osteoarthritis are often blamed. The condition is more likely to occur in the upper part of the spinal column than in the lower back but can develop in either area.

The inflamed site can be sensitive to pressure because the capsule of the facet joints contains sensory nerves. Severe pain occurs when the surrounding muscles become involved. If the dysfunctional facets lie between the shoulder blades, the pain can radiate up to the shoulders and neck.

Treatment options include brief rest, joint immobilization, anti-inflammatory drugs, muscle relaxants, and exercises. Injections also are used. These affect the joint and/or block the associated nerves. For some people, facet nerve ablation can provide longer relief.

Herniated Disc

A herniated disc is a tear in the fibrous ring of tissue surrounding the disc. Some of the soft gelatinous material inside breaks up, bulges into the spinal canal, and may put pressure on a nerve. Anyone can develop a herniated disc, but older adults are especially susceptible.

A bulging disc (as opposed to a herniated disc) has been described as like having low air in a tire. Some of the cushion in the middle of the ring is lost, the disc collapses, and the fibrous ring bulges out. A bulging disc is a normal phenomenon and generally does not cause symptoms, except when it presses on the nerve roots.

A herniated disc is caused by wear and tear on the spine and often manifests after a simple activity, such as bending over, heavy lifting, or any strenuous activities that generates abdominal pressure. That pressure is transmitted to the disc, often in the L4/L5 vertebrae area. Prolonged sitting and repetitive lifting and twisting are risk factors, as is reduced muscle tone caused by a lack of physical activity.

Treat Symptoms at Home

Before heading to the doctor for a herniated disc, try using rest, ice, and anti-inflammatory pain medications. Apply ice for the first 48 to 72 hours before switching to moist heat. Get back to mild activity (like slow, easy walking) as soon as possible. Increasing evidence proves that mild movement is more effective than complete or extended periods of bed rest. If that doesn’t help, you need to see a doctor.

Long-term treatment under a physician’s care includes physical therapy, medications, and epidural steroid injections. Epidural steroid injections deliver steroid medications around the compressed or irritated nerve root. This technique is effective in improving pain and functionality, as well as decreasing disability. It might, in special cases, save people from having unnecessary surgery. Transcutaneous electrical nerve stimulation (TENS) devices, which are available over the counter, send electrical impulses into the area and can reduce pain in some people.

A new technique still at the research phase suggests that tissue engineering, in the form of harvesting and reintroducing the body’s own stem cells, may be a promising way to treat herniated discs in the lower back.

Surgery Candidates

If the disc won’t heal, there’s loss of bowel or bladder function or progressive leg or foot weakness, you may need surgery. Whether you have surgery or not, there’s a five percent risk of the condition recurring and a greater risk of future back pain.

Neck Pain

A herniated disc in the neck is a degenerative condition, sometimes confused with pain from bone spurs or arthritis. In most cases, no specific event triggers the herniated disc.

Symptoms include:

• Neck pain
• Slowed arm reflexes
• Numbness
• Tingling
• Weakness
• Pain that radiates down the arm

Treatment

Elevating the affected arm, bending the elbow, and placing the hand behind the head often relieves pain. This maneuver eases the pressure on the nerve and enlarges the opening through which the nerve exits the spine. Immediate treatment includes rest, NSAIDs, and physical therapy. A heating pad may help relieve muscle spasms.

Long-term relief comes through the use of a heating pad, prescription pain relievers, and physical therapy, which may include traction. A physician may prescribe a systematic series of exercises developed specifically for this type of problem.

Surgery is reserved for spinal-cord compromise, persistent arm pain or progressive arm weakness. When it’s required, the procedure involves removing the disc (discectomy), or a fragment of the disc (microdiscectomy), and fusing the adjacent spinal levels.

Muscle Spasms

Back spasms happen for a variety of reasons. Injury to the muscles, tendons, and ligaments (i.e. back strain) are one cause. More serious medical conditions such as arthritis or a bulging disc also can trigger surrounding muscles to involuntarily contract. The weaker your abdominal muscles, the more prone you are to back spasm. Having tight hamstrings and weak lower back muscles also puts you at higher risk.

There’s no mistaking a back spasm. Its sharp, sudden pain is triggered by an involuntary muscle contraction, often in the lower back. Its pain can be incapacitating. For relief from a spasm try these steps:

➧ Get into a less painful position. Lay on a firm surface, either on your back or side, with a pillow between your knees to take the edge off.

➧ Move. Limited, gentle movement is better than total bed rest. Once the pain becomes tolerable, try walking slowly for a few minutes several times a day.

➧ Apply an ice pack for 15 to 20 minutes, three to four times a day for the first 48 to 72 hours. Cold dulls the pain and may reduce inflammation. You may also use moist heat to increase circulation and make you more comfortable. Or, alternate ice and heat applications. Whatever makes you feel better is the way to go.

Pain relievers like aspirin, acetaminophen (Tylenol), ibuprofen (Advil, Motrin), and naproxen (Aleve) can alleviate pain and reduce inflammation.

If the spasms won’t stop, call your doctor. He or she may want you to come in and may prescribe one of several muscle relaxants, such as cyclobenzaprine (Flexeril), methocarbamol (Robaxin), or carisoprodol (Soma). Spinal manipulation is one of several options that can provide mild-to-moderate relief from low back pain and spasms.

Preventing Back Spasm

Avoid sitting in one position for long periods of time. Stand up and stretch every 20 to 25 minutes. Slowly and carefully practice each movement required during a normal day (i.e. sitting, reaching). Use a lower back support to remind you to evenly distribute pressure on the muscles of the lower back.

When lifting heavy objects, keep your back as straight as possible and use your legs to lift without bending at the waist.

Losing a few pounds will relieve stress on the muscles prone to spasm. Regular physical activity that includes strengthening exercises will help you move more easily and safely. Examples are wall squats, knees to chest, trunk raises, and leg lifts.

Sciatica

Pain that shoots from your lower back through your buttocks and down your leg, possibly into your feet is likely sciatica. Most commonly caused by a herniated disc in the lower back, symptoms can be mild or severe. They range from numbness and tingling to that shooting pain we mentioned.

In rare cases, sciatica causes the loss of bladder or bowel control. If this happens, it’s an emergency that may require surgery. The symptoms may be worse when you cough, sneeze, sit, or do certain types of exercise.

Risk factors for sciatica include:

• Age (30 and over)
• Frequently twisting the back
• Genetic factors
• Diabetes
• An occupation that involves excessive bending, lifting, or driving for long periods of time
• Smoking
• Excess weight

A study of more than 5,000 people found quitting smoking helped reduce back pain in people being treated for spinal problems. The reason, as other studies have shown, is that nicotine increases pain.

Ways to prevent sciatica include, good posture, stretching, walking, swimming, lifting objects safely, sleeping on the back or side, and avoiding sitting or standing for long periods of time.

Spinal surgeons usually recommend a short period of rest followed by exercises to improve flexibility, mobility, and strength in the back. Working with a physical therapist can help chronic pain caused by sciatica. Your doctor also may recommend hot and cold applications. Analgesic and anti-inflammatory drugs, such as naproxen, ibuprofen, and aspirin can dull pain and reduce inflammation.

Spinal Stenosis

Stenosis is a condition in which the spinal canal narrows and puts pressure on the spinal column or nerves. This narrowing may be due to a herniated disc that encroaches on the spinal canal from the front or thickened ligaments in the rear, or even enlarged arthritic facet joints that encroach on the canal from the sides.

A small number of people are born with shortened spinal structures called pedicles, which can lead to symptoms of spinal stenosis at a relatively young age. Stenosis occurs most often in the lower back (75 percent of the time); less often in the neck.

Spinal stenosis is commonly caused by aging (it’s more prominent in those over 50), arthritis, heredity, tumors, trauma, and repeated back surgery. Symptoms include pain in the lower back and legs that can be aggravated by walking and standing. The size of the spinal canal decreases significantly in the erect position (standing and walking) but returns to normal size when sitting or bending forward.

Symptoms include:

• Low back pain
• Numbness, tingling
• Hot or cold sensation
• Weakness
• Leg fatigue with prolonged standing or walking
• Feeling of clumsiness
• Falls

Finding Relief

Lean forward slightly while walking or lying down with your knees drawn to your chest. This position can help relieve pain in the short-term. For more long-term relief, try anti-inflammatory medicines, such as aspirin and ibuprofen, and rest the affected area.

In some cases, epidural steroid injections may be recommended. Unfortunately, they’re no panacea. They don’t provide long-term relief in moderate-to-severe cases.

Minimally invasive spine surgery can effectively treat spinal conditions, including stenosis, herniated disc, and sciatica. This involves smaller incisions, less loss of blood, and faster recovery. Success rates vary greatly.

Breakthrough Pain

Breakthrough pain (BTP) is defined by the American Cancer Society as a flare of pain that occurs even though the person is regularly taking medicine for chronic cancer-related pain.

BTP episodes are unpredictable, may occur more frequently when the person is engaged in a specific activity (incident pain), and may happen toward the end of a dosage period of persistent-pain medication. Pain “flares” vary in length, but peak intensity usually occurs in as little as three minutes and lasts an average of 30 minutes, according to pain specialists at the University of Pennsylvania.

The recommended treatment for BTP is a strong, short-acting opioid medication that works quickly. BTP medication is taken on an as-needed basis as soon as symptoms are experienced.

Cancer-Related Pain

Cancer pain can be caused by the disease, its treatment (including chemotherapy or radiation therapy), or both. Between 30 and 50 percent of people with cancer experience pain caused by the treatment, and 70 to 90 percent of those with advanced-stage cancer report pain from the disease itself.

Tumors may put pressure on organs, bones, or nerves, and they can obstruct the bowels or the flow of blood. The chemotherapy, radiation, and surgery used to treat cancer produce side effects, which can include discomfort.

Cancer pain develops when nerve endings detect damage in the body. The pain signal travels through nerve pathways to the brain, which interprets the message as pain. In some cases, the nerve pathways themselves have been damaged.

Cancer pain should be managed. About 85 to 90 percent of people with cancer and chronic pain can control their pain successfully. Both chronic pain and episodes of acute pain can be eased with medications. That said, 10 to 15 percent of people with cancer may require aggressive interventions or surgery to control their pain.

CRPS

Complex regional pain syndrome (CRPS) is a chronic neurological condition that most commonly affects one limb (i.e. an arm, hand, leg, or foot). This usually occurs after an injury. CRPS is one of the least understood forms of chronic pain, affecting women at twice the rate of men. One study found that siblings of people with CRPS and under the age of 50 were at three times higher risk of developing the condition.

There are two types of CRPS: Type I results from irritation of the peripheral and central nervous system without evidence of nerve damage. The condition might be precipitated by major or minor injury, trauma, or surgery. Type II has the added complication of peripheral nerve damage.

Pain that’s disproportionate to the severity of the initial event might be due to CRPS. It gets worse over time, and the pain can spread to the entire arm or leg. Possible symptoms include:

• Intense, burning pain
• Skin sensitivity
• Swelling
• Sweating
• Color changes in the affected area
• Increased skin temperature in early cases; decreased temperature in advanced cases
• Atrophy and loss of limb function (in late stages)

Treatment

There’s no specific diagnostic test for CRPS, nor is there a cure. The goal of treatment is to rehabilitate the affected limb to avoid loss of function, while trying to control symptoms. Analgesics, antidepressants, corticosteroids, opioids, nerve blocks, spinal or peripheral nerve stimulation, and drug-infusion pumps are a few treatment options. These measures give temporary relief in some people, but the response is unpredictable.

Spinal-cord stimulation provides substantial long-lasting relief to a good percentage of CRPS people for whom other therapies fail to relieve symptoms. Physical therapy and nerve blocks are other treatment options.

No single treatment will produce a long-lasting solution in every person, although CRPS goes into remission in some people. The best outcome is achieved if this condition is treated as early as possible.

According to the National Institute of Neurological Disorders and Stroke, immunoglobulin administered intravenously, low doses of an anesthetic agent called ketamine, and hyperbaric oxygen therapy are emerging treatments for CRPS.

Diabetic Neuropathy

Diabetic neuropathy is a nerve disorder associated with diabetes—specifically with elevated blood sugar levels that are characteristic of the condition. Although arms and legs are most likely to be affected, the damaged nerves can affect different areas of the body, including the brain, retina, heart, kidneys, bladder, stomach, and intestines.

Although DPN is a disease of the peripheral nerve, it appears that changes within the central nervous system also are related to the development of both painful and painless DPN.

When peripheral nerves are affected, the condition is called peripheral neuropathy. Diabetic neuropathy is related to the duration of the diabetes, which cannot be controlled, and to poor blood sugar control, which can (and should) be controlled.

Between 60 and 70 percent of diabetics eventually will develop some form of neuropathy. The risk increases with age, the amount of time a person has had the disease, and poor control of blood-sugar levels.

In diabetic neuropathy, a loss of sensation is caused by damaged nerves.

DPN is most likely caused by several factors, including high blood glucose and fat levels, low levels of insulin, damage to blood vessels, autoimmune factors, mechanical injury to nerves, inherited traits, and lifestyle choices, such as alcohol use and smoking. Symptoms include:

• Tingling or burning sensation in the arms and legs
• Unaware of stepping on a sharp object
• Unaware of blisters or cuts
• Insensitive to hot or cold

Diabetic neuropathy is diagnosed with a physical exam, electromyogram, computed tomography (CT) scan, magnetic resonance imaging (MRI), and/or nerve-conduction velocity tests.

Diet, exercise, and medications, such as pregabalin (Lyrica), duloxetine (Cymbalta), and other anti-seizure drugs are effective. Duloxetine is normally used to treat depression, incontinence, and certain types of pain, but a review of 18 trials and more than 6,000 people found that it’s also useful in treating diabetic neuropathy.

Spinal cord stimulation (SCS) has emerged as a treatment for DPN. A study of 49 people found that SCS was successful in reducing chronic pain symptoms up to five years after beginning treatment.

The prognosis for DPN people depends on how the diabetes is being managed, says the National Institute of Neurological Disorders and Stroke. Treating diabetes may stop the progression and improve symptoms, but recovery can be slow.

Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is the name for a group of 13 inherited disorders that affect connective tissues (collagen, in particular). Think of these tissues as a form of glue. They provide strength and support to our skin, bones, blood vessels, and other organs. They also support the tissues (i.e., ligaments, cartilage, and tendons) in and around our joints.

In a person with EDS, the connective tissues are extremely loose, meaning they don’t hold things as stable as they should, leaving them able to stretch far beyond the normal range. The result: frequent dislocations, subluxations (partial dislocations), torn ligaments and tendons, chronic pain, fatigue, instability and, sometimes, life-threatening complications such as the rupture of large arteries (in severe forms).

Those suffering from EDS most often present with soft, stretchy, easily-bruised skin, hypermobile joints, and poor wound-healing. While symptoms overlap for the various types, it would be extremely rare for a person to suffer from more than one form of the condition.

Diagnosis and Treatment

Diagnosing EDS isn’t easy. “Although there is a wealth of information easily accessible, it can still take a very long time [often more than 20 years] before the penny drops and someone recognizes the diagnosis and points the individual in the right directions for help,” says Dr. Alan J. Hakim, a London-based rheumatologist and EDS expert.

“Even then, there can be reluctance among some—family members and medical personnel alike—to acknowledge the syndrome, the depth and breadth of its insult, and the psychosocial impact on an individual’s well-being,” says Dr. Hakim.

There is no cure for EDS. Physical therapy, targeted exercises, and pain relief medication can help manage symptoms.

Fibromyalgia

Fibromyalgia is a chronic disorder with extensive symptoms, including areas of the body that are especially sensitive and painful to pressure or touch. The exact cause of fibromyalgia is unknown, but some studies show that genetic factors may predispose certain individuals to the condition. The pain from fibromyalgia is real. It’s more common in women than in men and usually develops between the ages of 35 and 60.

Fibromyalgia is characterized by widespread muscle pain and multiple tender points on the neck, shoulders, back, hips, and extremities. More than 75 percent of people report chronic fatigue as a major symptom and impairment, according to the Johns Hopkins Arthritis Center.

The tender spots vary in severity from one day to another. At times, they can be more severe in the shoulders; at others, more severe in the lower back and legs. Pain can interfere with sleep.

Most people are diagnosed during middle age, but symptoms can develop earlier. Fibromyalgia can cause pain and fatigue, but doesn’t inflame or damage joints, muscles, or other tissues. Other symptoms of fibromyalgia include:

• Headaches
• Irritable bowel syndrome
• Memory problems
• Morning stiffness
• Sleep disturbances
• Restless legs syndrome
• Numbness or tingling in the extremities
• Painful menstrual periods
• Temperature sensitivity
• Depression
• Dizziness

Causes

According to recent research, fibromyalgia is related to how the body processes pain and its hypersensitivity to factors that don’t normally cause discomfort.

A small study published in Scientific Reports in January 2018 found that hyperactive brain networks could play a part in the hypersensitivity experienced by fibromyalgia people. Known as explosive synchronization (ES), this condition can lead to a small stimulus causing a dramatic and synchronized reaction to the brain’s network. The researchers concluded that “the chronic pain brain is electrically unstable and sensitive.”

Those with rheumatoid arthritis, lupus, and spinal arthritis are more likely to develop fibromyalgia than people without these conditions. Fibromyalgia also has been associated with physically or emotionally stressful events, such as car accidents, repetitive-use injuries, and illnesses.

Treatment

People typically see several doctors before getting a diagnosis. Once the condition is identified, a team approach (doctor, pharmacist, physical therapist, and other specialists) works best. Three medications are FDA-approved  for fibromyalgia: duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica). Other drugs prescribed by doctors include analgesics and antidepressants.

A Queen’s University scientist found that combining pregabalin (an anti-seizure drug) with duloxetine (an antidepressant) could improve pain relief, physical function, and overall quality of life in fibromyalgia people, according to the journal Pain.

Nonsteroidal anti-inflammatory drugs, such as ibuprofen, aspirin, and naproxen, are not particularly effective in treating fibromyalgia when taken alone, says the American Academy of Family Physicians (AAFP).

Complementary and alternative therapies, such as massage, chiropractic, acupuncture, and dietary supplements, produce varying degrees of success in treating fibromyalgia. Getting adequate, quality sleep can improve the symptoms of pain and fatigue, and an increasing body of evidence suggests that exercise is an effective treatment.

It’s important to be active with your care. Follow your doctor’s recommendations, make lifestyle changes that will help you feel better, and focus on short-term, realistic goals.

Among the lifestyle changes is an increase in moderate, low impact, planned exercise. Recognize stress and take steps to deal with it (see Chapter 1). Follow a daily routine that includes going to bed, getting up, and eating at regularly scheduled times.

No one treatment plan is effective for everyone. You know how you feel, what you can and cannot do, and how fibromyalgia is affecting your life. Work with your pain-management team to develop a strategy that fits your situation.

Gout

A disease caused by excessive amounts of uric acid and the needle-like crystal deposits left behind, gout is a form of arthritis. The excess uric acid may be due to the body producing too much of it or because the kidneys cannot efficiently remove it from the body.

Affecting more than 8 million Americans, this condition commonly affects the small bones of the feet but also can attack other parts of the body. Relatively few of those affected take measures to avoid the next flare-up, which can be both sudden and severe.

Two recent studies showed that a proper diet and medications could delay, minimize, or even prevent an attack by addressing the causes of gout rather than only its symptoms.

Eat Well

A diet recommended by the National Heart, Lung, and Blood Institute to address hypertension may be part of the solution in dealing with gout. A BMJ study found that the DASH diet (Dietary Approaches to Stop Hypertension) is associated with a lower risk of gout. Researchers used food frequency questionnaires of more than 44,000 men to classify those who followed a DASH diet and those who chose a predominantly Western diet.

A DASH diet is high in vegetables, nuts, legumes, low-fat dairy products, and whole grains. In contrast, the typical Western diet has a high intake of red and processed meats, fried foods, refined grains, as well as sweets and desserts.

Men in both groups were monitored for 26 years to determine the incidence of gout. The DASH diet was associated with a significantly lower risk, suggesting that its effect of lowering uric acid levels translated into a lower risk of gout. The Western diet was linked with a higher risk.

Risk factors in addition to diet include the use of alcohol, gender (men are more likely to have gout than women), age (30 to 50 for the first bout), being overweight (body mass index over 25), and race (African men twice as likely to report gout than Caucasian men).

Treatment

Although gout is recognized as a chronic disease, many doctors and patients treat it as an acute condition. In November 2017, the AAFP issued a position statement based on more than 8,000 patient medical records that stated managing gout with medications and treating it as a chronic condition could help prevent recurrences and associated repeat doctor visits.

Two medications that prevent the production of uric acid are allopurinol (Zyloprim) and febuxostat (Uloric). Allopurinol was approved by the FDA in 1966, but in 2017 the agency approved a combination of allopurinol and lesinurad (Zurampic) for gout-associated hyperuricemia, which is an abnormally high level of uric acid.

A disconnect has existed between available evidence regarding the treatment of gout and putting that evidence into practice. If patients closely follow DASH diet guidelines while physicians are more proactive in treating gout as a chronic condition, flare-ups would decline dramatically.

Headaches

Tension headaches, migraines, cluster, sinus, hormone, acute, exertion, and caffeine headaches—there are at least 30 types of headaches, and the location of the headache offers an indication of its type. (See “Headache Primer.”)

Headaches can be on one side (unilateral) or both sides (bilateral). Some may be intermittent, episodic, or constant while others are acute—they come and go rapidly. Still others persist for days or weeks. When the exact location of the pain can’t be identified, it’s called a generalized headache.

Cluster Headaches

Cluster headaches are one of the most painful types. They cause excruciating pain on one side of the head, around the eyes, and sometimes affect the nose and other areas of the face. They’re called cluster headaches because they occur daily (in clusters). These headaches come on suddenly and can last from 15 minutes to three hours. They’re more common in men and can go into remission for months or years.

Exertion Headaches

Exertion (activity-related) headaches are triggered by physical activity, especially lengthy exercise sessions. They usually develop at the height of exercise and subside when the activity stops, although some can last up to two days.

Exertion headaches are more common in adolescents and adults up to age 50. Most often, they’re harmless, but you can’t make that assumption. See your doctor to rule out underlying serious causes.

Sinus Headaches

Sinus headaches often are caused by a cold, sinus inflammation, allergies, and other respiratory infections. The distinguishing characteristic is deep, constant pressure-like pain in the cheekbones, forehead, or bridge of the nose. This can worsen with sudden head movement or straining, and can be accompanied by fever, runny nose, and clogged ears.

Caffeine Withdrawal Headaches

Unless you’re drinking about 500 mg of caffeine per day (i.e. four to five cups of coffee), you probably won’t have a caffeine-withdrawal headache. If you are drinking that much and suddenly stop, you’re likely to experience one. The problem is temporary, although it may take a few days to return to normal. The solution is simple: Consume less caffeine and reduce intake slowly.

Tension Headaches

Two types of headaches—tension and migraine—are associated with chronic pain (see “Is It a Tension Headache or a Migraine?”).

Tension headaches aren’t accompanied by other symptoms and are usually triggered by fatigue or stress. People who have them describe a feeling of pressure on both sides of the head. Others experience pain that involves the forehead, scalp, or back of the neck. Tension headaches can be mild, moderate, or severe, but aren’t usually debilitating. However, occasional episodes can develop into chronic, long-term pain.

Tension headaches can be caused by contractions of the muscles in the head and neck, and expanded blood vessels in the scalp can contribute to the discomfort. The headaches can be triggered by any number of factors, including an argument with a spouse, traffic, job pressures, working at a computer for long periods of time, and poor posture. Arthritis of the cervical facet joints also might be a cause. A lack of exercise appears to be associated with non-migraine headaches.

These headaches are usually treated with over-the-counter drugs such as aspirin, acetaminophen, or ibuprofen. If you’re experiencing them for more than 15 days a month, you have chronic pain and should see a doctor. He or she might prescribe antidepressants, blood-pressure medication, or anti-seizure pills.

Migraines

A migraine involves recurring episodes (two or more a month) of head pain, plus sensitivity to light and sound. Nausea, vomiting, and neck pain can accompany the discomfort. Ten to 20 percent of the time the person who is about to experience a migraine gets a warning, called an aura. An aura may be a tingling sensation or visual distortion (seeing zigzag lines) that lasts from 10 to 30 minutes.

Migraine headaches are a neurological disorder. Treatment methods are being developed to target peripheral and central nervous systems. Migraines are often misdiagnosed as sinus headaches because pain also is across the forehead and the bridge of the nose.

Triggers. The exact mechanism that causes migraines is not fully understood. Current thinking focuses changes in blood flow and the excitability of brain cells. Though it’s difficult to pinpoint a cause, triggers include:

• Hormonal changes (caused by menstrual periods or estrogen)
• Diet (particularly alcohol, chocolate, monosodium glutamate, caffeine, or marinated foods)
• Bright lights
• Strong odors
• Stress
• Fatigue
• Poor sleep patterns
• Biochemical processes in the brain
• Vascular disease
• Weight (A 2017 study published in Neurology found a 27 percent higher risk with obesity and a 13 percent higher risk in those who are underweight)

Daily fluctuations of variables such as weather, diet, hormone levels, sleep, and stress make it difficult to pinpoint a reason without clinical testing.

Treatment. A physician might suggest changes in sleep or eating habits and will probably prescribe medicines to block the pain. Medications called triptans can prevent or treat a migraine. These include sumatriptan (Imitrex), eletriptan (Relpax), and rizatriptan (Maxalt). Injectable triptans have an 80 percent success rate; triptan tablets are 60 to 70 percent effective in treating migraines. Antidepressants and drugs used to treat high blood pressure (including beta-blockers) can be preventative.

Injecting an anesthetic or onabotu­linumtoxinA (Botox) directly into tender muscles in the head and neck may reduce migraine headache symptoms. Trigger-point injections also may reduce people’s dependence on drugs, which sometimes can trigger additional headaches.

Aspirin, ibuprofen, and naproxen may play a preventative role. The drug—or combination of drugs that works best—depends on the individual. Unfortunately, overuse of these medications is a risk factor for chronic daily headaches.

Erenumab is a new FDA-approved treatment for migraines. It is part of a class of medications called calcitonin gene-related peptide (CGRP) monoclonal antibodies, which significantly reduce the frequency of migraine headaches.

Occipital-Nerve Stimulation. Occipital-nerve stimulation can control intractable migraines. Randomized trials showed significant improvement of daily pain scores, as well as significant decreases in the number of headache days in those who received occipital-nerve stimulation. In 2014, the FDA approved a battery-powered device called the Cefaly headband to prevent or reduce the number of migraine episodes by limiting pain signals.

Exposure to Narrow-Band Green Light. Approximately 80 percent of migraine sufferers report light sensitivity. Harvard researchers found that exposing migraine sufferers to narrow-band green light significantly reduced this side-effect and decreased pain.

Interstitial Cystitis

Interstitial cystitis (IC) is a complex condition characterized by an inflamed bladder wall, a scarred or stiffened bladder, diminished bladder capacity, and bleeding within the bladder. The exact cause of IC is unknown, but some believe there could be a defect in the lining of the bladder. IC is more common in women. When it occurs in men, the symptoms often overlap with prostate problems. Most people with IC are diagnosed in their 40s, but it can happen at any age.

The most commonly reported symptom is frequent urination—up to 60 times a day in some cases. Other symptoms include: chronic pelvic pain, pressure, or tenderness, and pain during intercourse. Combined, these can have a profound negative effect on quality of life.

Many people with IC report that certain types of food trigger symptoms, including citrus foods, chocolate, caffeine, spicy foods, foods rich in potassium, and carbonated beverages. Stress can’t cause IC, but it can make it worse. A diagnosis may require a variety of procedures and medical opinions.

Treatment often includes nonsteroidal anti-inflammatories, antidepressants, antihistamines, and pentosan polysulfate sodium (Elmiron), which is FDA-approved for the treatment of IC.

Other therapies include distention of the bladder, medications placed directly into the bladder, surgery, and transcutaneous electrical nerve stimulation (TENS). Guided imagery and acupuncture have been effective in some cases.

Irritable Bowel Syndrome

Irritable bowel syndrome usually starts in early adulthood, and it affects more women than men. IBS doesn’t permanently damage the intestines, nor does it lead to serious diseases, such as cancer. The cause of IBS is unknown—it can’t be traced to any single condition, but research suggests that people with IBS have a sensitive colon, which overreacts in response to triggers, including certain foods and stress, that wouldn’t bother most others.

IBS is often diagnosed when other gastrointestinal conditions have been ruled out. No specific test can confirm its presence.

The most common symptoms are pain (often below the navel), stomach cramps, bloating, constipation, and/or diarrhea. These can worsen after eating large meals or fatty foods; taking certain medicines; eating wheat, rye, barley, or chocolate; and drinking milk, alcohol, or beverages containing caffeine, like coffee, tea, or soft drinks.

Most people control their symptoms with diet, stress-management techniques, and medications, including the antibiotic rifaximin. Prescription medications can decrease diarrhea, control colon muscle spasms, and reduce pain.

A study at the Mayo Clinic found that those with IBS may benefit from taking pregabalin (Lyrica), a drug commonly used to treat fibromyalgia. To address the psychological components of IBS, relaxation training, meditation, yoga, exercise, avoiding stressful situations, and getting quality sleep can help.

Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is characterized by trigger points, which are tight, sensitive muscle spasms that occur most often in the neck and back. These spasms restrict range of motion, come and go without warning, usually affect one side of the body, and may cause pain that radiates to adjacent areas.

The cause is unknown, but MPS is common among those who engage in repetitive-motion activities. Staying in one position for too long, overusing muscles, having a prior injury, poor sleep patterns, and stress also might cause MPS.

Pain medication, antidepressants, massage, and relaxation techniques can be effective. Direct, sustained (and perhaps painful) pressure on the sensitive part of the muscle can reduce tightness and pain. A few minutes of pressure can provide relief for hours or days. In cases where the pain is severe and limits normal activities, a physician may consider trigger-point saline injections. Botulinum toxin A (Botox) appears to be a promising therapy.

Osteoporosis

Osteoporosis is a progressive disease that causes bones to become thin and fragile. It’s estimated that 50 percent of women over the age of 50 are at risk of having a fracture caused by osteoporosis. Older men who’ve sustained a minor fracture are as likely to have a subsequent fracture as women.

Osteoporosis is the cause of 1.5 million fragility bone fractures (those related to a fall from a standing height or less) a year. Half of these fractures occur in the spine. The consequences of untreated osteoporosis and vertebral compression fractures can be serious, including lung disease.

Fewer than 30 percent of postmenopausal women and 10 percent of men with a prior fragility fracture are treated for osteoporosis. The Journal of General Internal Medicine reported that too few women at risk for osteoporosis were being tested, while too many without a risk factor were being screened for the disease with a bone-density scan.

Many risk factors are controllable:

• Low estrogen (women)
• Low testosterone (men)
• Low levels of calcium and/or vitamin D
• Anorexia
• Anti-seizure drug use
• Inactive lifestyle
• Cigarette smoking
• Excessive alcohol use
• Use of oral steroids

A study presented at the Endocrine Society’s Annual Meeting in March 2018 found that the heart-healthy Mediterranean diet pattern appeared to benefit bones and muscles in a sample of healthy older women.

Gender, age, race, and fragility fractures are also risk factors, but they can’t be controlled. Monitoring these factors may allow you to lower the risk or take preemptive steps before osteoporosis fully develops.

Beware of Fractures

A hip fracture almost always requires hospitalization and major surgery. It can impair a person’s ability to walk unassisted and may cause prolonged or permanent disability, or even death.

Spinal fractures result in height loss, severe back pain, and deformity. Although some people with osteoporosis experience no pain, others have intense pain caused by fractures and muscle spasms.

The long-term effects of untreated osteoporosis are detrimental and include impaired lung capacity, depression, low self-esteem, and increased risk of fractures.

Treatment. Pain associated with osteoporosis is treated by a variety of traditional and alternative therapies, including heat, ice, transcutaneous electrical nerve stimulation (TENS), exercise, massage, and relaxation. Vertebral augmentation, including Kiva implants, kyphoplasty and vertebroplasty, are examples of surgical procedures described in Chapter 3.

Among the drugs approved for osteo­porosis are the bisphosphonates alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast). The FDA-approved ­twice-yearly injectable drug denosmab (Prolia) for the treatment of post­menopausal osteoporosis.

Researchers continue to discover new methods that could potentially lower the risk of osteoporosis. For example, older men and women who have one or two glasses of beer or wine a day appear to have stronger bones than both non-drinkers and heavy drinkers. However, it’s important to consider the potential benefits versus the risks, and most health-care professionals advise that if you don’t drink alcohol, this is not a reason to start.

Pelvic Floor Dysfunction

Pelvic floor dysfunction historically has been associated with women but can occur in men as well. The common denominators are pain in the front part of the pelvic region that can be dull, sharp, steady, or intermittent.

Long-term infection and endometriosis are two causes of PFD in women. Chronic pelvic pain may be caused by irritable bowel syndrome, interstitial cystitis, or muscle spasms. These may be compounded by psychological factors, such as depression or stress. Childbirth, trauma to the pelvic region, obesity, nerve damage, and some surgeries can also cause PFD.

In men, symptoms are often related to the intestines or urinary tract and mimic those of prostatitis, such as urinary frequency, urgency, difficulty in starting urination, erratic flow, and ­pelvic-floor pain.

Both men and women struggle to get an accurate and timely diagnosis of this condition. Diagnosis often involves a process of elimination that might take months or years, and should include a thorough medical history, physical exam, and laboratory tests, as well as imaging when needed.

Treatment

The most effective treatment for pelvic floor dysfunction is pelvic floor rehabilitation. Symptoms such as bladder and bowel problems, as well as pelvic pain, may be relieved by as much as 80 percent with this method.

This involves physical therapy, biofeedback, pelvic floor muscle re-education, relaxation and strengthening exercises, and bladder/bowel training. PFD is a perfect example of how the coordination of care between a physical therapist and a pain physician provides optimal outcomes.

Treatment may include antibiotics (if infection has been detected), prescription and over-the-counter pain medications, relaxation exercises, physical therapy, nerve blocks, and surgery. In cases where no specific cause can be found, the goal of treatment may be to manage pain.

Pelvic pain in general is complex and may require an interdisciplinary team evaluation. The psychological status of the person is critical in making the diagnosis and determining proper treatment.

Shingles

One in three Americans will develop shingles during their lifetime. Most will get it once, but it’s possible to develop it a second or third time.

A viral disease, shingles causes a rash or blisters on the skin. It’s the same virus—the varicella-zoster virus—that causes chickenpox. After chickenpox heals, the virus becomes dormant in the body, but can reemerge if a person’s natural resistance is compromised.

Your risk of shingles increases with:

• A weakened immune system
• Being over the age of 50
• Being ill
• Experiencing trauma
• Being under stress

Symptoms include itching, stabbing, or shooting pains. The skin appears red in the affected area. A tell-tale rash appears after a few days around the waistline or on one side of the face or trunk. Other symptoms include, fever, chills, headache, and an upset stomach.

There’s no cure for shingles, but treatment with antiviral medications—such as acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir)—can help ease the pain and discomfort and reduce the duration of symptoms.

The shingles vaccines Zostavax, which was approved in 2006, has largely been replaced by Shingrix, which was approved in 2017 and is preferred by most physicians. The CDC recommends that healthy adults 50 years and older get two doses of Shingrix, two to six months apart.

Postherpetic Neuralgia

Postherpetic neuralgia (PHN) is a painful complication of shingles. Even after the blisters of shingles heal, nerve pain can remain. Although the pain gradually fades, it can persist for years.

Not everyone with shingles develops post-herpetic neuralgia, but the older you are when you first get shingles, the more likely you are to develop PHN. Half of those over 60 who get shingles develop PHN, while 75 percent of those over 70 get the condition.

The primary symptom of PHN is severe unilateral pain that can lead to insomnia, weight loss, and depression. Other symptoms include:

• Sharp, jabbing, burning, deep, or aching pain
• Itching or numbness
• Unusual sensitivity to touch and temperature change
• Weakness (rarely)

The shingles vaccine can help prevent the disease (and thus its complications) in adults over 60, and it can relieve the pain of post-herpetic neuralgia if the disease occurs.

Skin patches containing lidocaine or capsaicin, antidepressants, anti-seizure medications, painkillers, opioids, and transcutaneous electrical nerve stimulation (TENS) can be effective for many in relieving the pain. Aggressive treatment of acute-phase shingles with sympathetic nerve blocks may decrease the chances of developing PHN.

Treatment with intravenous and oral antiviral medications, such as acyclovir (Zovirax), may reduce nerve pain. Newer anti-neuropathic pain agents, such as pregabalin (Lyrica), also may be effective in treating PHN.

Surgery

Although surgery is often a necessity it can lead to chronic pain. In certain operations—limb amputation, lung surgery, breast surgery, gallbladder surgery, hernia surgery—the incidence of postoperative chronic pain ranges from 11 to 47 percent, noted a study published in the journal Anesthesiology. According to Practical Pain Management 10 percent of surgery people may experience chronic pain at least three to six months following surgery.

Risk factors associated with postoperative chronic pain can be classified as factors existing before surgery (pre-existing pain intensity, obesity, or genetic predisposition), factors that develop during surgery (nerve damage or the effects of anesthesia), and those associated with treatment after surgery (radiation, chemotherapy).

Treating postoperative chronic pain is as complex as relieving chronic pain caused by any other condition. It often requires a team approach and includes pain medications, physical therapy, and counseling.

TMJD

Temporomandibular joint disorders (TMJD) refer to a group of symptoms affecting the joints connecting the lower jaw to the skull. Symptoms include difficulty opening the mouth, pain (jaw, face, ear), headaches, and toothaches, as well as painful clicking, popping, or grating in the jaw when opening or closing the mouth.

Clenching and grinding your teeth, poor head and shoulder posture, an inability to relax, and lack of sleep can cause TMJD. Arthritis, fractures, joint degeneration, or structural abnormalities also can cause contracted muscles and pinched nerves in the jaw, head, and neck.

Suggested treatments include, mouth guards, massage, moist heat, cold applications, and exercises to help relax the jaw. More aggressive therapy involves muscle relaxants, NSAIDs, orthodontics, and, very rarely, reconstructive surgery. TMJD can go away temporarily and return later. Note: Some health insurance contracts have limited coverage for TMJD.

People with chronic jaw pain appear to be more sensitive to pain in other parts of the body. Several genes may be linked to TMJD, which may lead to new drug treatments. A connection between TMJD and depression and anxiety may exist.

Trigeminal Neuralgia

Trigeminal neuralgia occurs when a blood vessel puts pressure on the trigeminal or 5th cranial nerve, the largest of the 12 cranial nerves.

Trigeminal neuralgia is considered one of the most painful conditions you can experience. It can be triggered by something as simple as brushing your teeth, causing sudden sporadic burning or shock-like facial pain along the path of the trigeminal nerve. The pain can last from a few seconds to a few minutes and may repeat itself. A less typical form causes a constant stabbing pain.

The pain can be incapacitating since the nerve travels along the side of your face, down through your jaw line. It also reaches the eye area and cheeks. Because of the location of the pain, trigeminal neuralgia is sometimes mistaken for a tooth problem, prompting unnecessary root canals in an attempt to alleviate the pain.

The distinguishing characteristic is a sudden, electric shock-like pain on one side of the jaw or cheek lasting for up to a couple of minutes. Attacks may occur one after the other, and can be triggered by talking, brushing the teeth, touching the face, chewing, swallowing, or even by a breeze touching the face.

Some trigeminal neuralgia episodes can last for months before disappearing for years.

The disorder is more common in women and mostly affects those over 50. Trigeminal neuralgia should be distinguished from a host of other causes of facial pain. A full history and physical examination, as well as imaging studies, may be required to make a diagnosis.

Treatment

Anti-seizure medications are often used in treatment. The drugs carbamazepine (Tegretol, Carbatrol) and oxcarbazepine (Trileptal) are considered first-line therapy. Researchers at the University of Zurich have shown that a substance temporarily called BIIB074 appears to inhibit the pain of trigeminal neuralgia.

Nerve blocks or radiofrequency ablation of the trigeminal ganglion should be considered before surgery. If medication or radiofrequency ablation fails to relieve pain, surgery may be recommended.

Gamma knife radiosurgery (GKRS) is a treatment option. GKRS is a non-invasive, outpatient treatment that aims narrow beams of radioactive cobalt at the trigeminal nerve. Ninety percent of people have significant pain relief within an average of four weeks after GKRS, and 80 percent have a significant improvement in quality of life.

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Take your time! Gather the information you’ve been given by your clinical team, review this special health report, and do some research on reputable websites to gain a clear picture of treatment options. Then work with your doctor to come up with the right plan. The final decision on treatment is always yours.

Get Organized

One way to help yourself is to create a Personal Health Record (PHR). File your health information and any useful data that comes your way. Include doctors’ appointments, prescription copies, medical receipts, letters from doctors, and information about your disease. You can ask your doctor for copies of referral letters, discharge summaries, and test results.

It can be hard to keep track of such things, but you never know when the information will come in handy. For example, you may be referred to a specialist, but when you attend the appointment, the physician’s office hasn’t received any information on you yet. Presto—you have everything he needs right there in a binder.

If you’re super organized, you may want to create a PHR summary. Whether you create and maintain it in a computer file or write it out the old-fashioned way (pen and paper), a PHR will prove useful when you attend appointments.

Take Control of Your Health

Lifestyle changes can have a significant impact on your health. Take these tips to heart:

• Eat well. Increase your intake of fresh whole foods, especially vegetables and fruits, and decrease your intake of processed foods. Replace some of the saturated fat in your diet with healthier ones, like polyunsaturated vegetable oils. An improved diet may lower the risk of disease progression by reducing inflammation, maintaining a healthy weight, reducing abdominal fat, and improving blood sugar control.
• Exercise. Regular exercise may slow the progression of prostate disease and the impact of symptoms. Walking, yoga, and abdominal exercises are great to start with—under medical supervision if you have other health problems. Exercise helps optimize metabolism, maintain a healthy weight, gain muscle, improve pelvic floor tone, and retain flexibility and mobility.
• Maintain a healthy weight. Being overweight is associated with an increased risk of lethal prostate cancer and BPH. Being too thin can also be bad for health. If you have advanced or metastatic cancer, you may find yourself losing weight without trying. Your clinical team can offer dietary support to ensure you’re adequately nourished and don’t lose too much weight.
• Reduce stress, remain hopeful. Being diagnosed with prostate disease, especially cancer, may trigger an emotional roller coaster. There is no firm evidence that stress-management techniques or a positive mental attitude improve outcomes in prostate disease per se, but your quality of life will be better if you’re happy and calm, and you’ll make better decisions, too. Stress-reduction strategies might include exercise, mindfulness practice, counseling, and spending time with people who make you feel good.
• Stop or reduce smoking. Some research suggests an association between smoking and an increased risk of BPH, prostatitis, and prostate cancer death and recurrence.
• Lean on your support. “No man is an island.” Men thrive when surrounded by people who care for them. Your friends and family may provide valuable emotional and practical support—especially if they’re well informed. Some of your loved ones will be good at offering support; others may not know how to cope. If your diagnosis is advanced prostate cancer, the impact on you and your loved ones will be significant, and you might all benefit from the support of a counselor or psychiatrist.

It may take time to find the right support for you. Seek out calm, unbiased people who make you feel positive and hopeful. Steer clear of negative people who bring you down or make you anxious. Consider joining a support group; Us Too International is one source of contacts (see “Resources,” page 63).

The Future Is Bright

Inspirational speaker Jim Rohn once said, “Take care of your body. It’s the only place you have to live.” Wise words indeed. The lifestyle choices you make every day can significantly impact your wellbeing and health. While there are no guarantees, a healthy lifestyle may reduce your risk of prostate disease and a host of other chronic diseases.

A healthy lifestyle also can lighten the load of prostate disease, potentially slowing its progression and reducing symptoms. Understanding your condition will give you a sense of certainty and autonomy, and help render your decision-making much easier.

We live in an age where there are excellent treatment options for all forms of prostate disease. Over the past 20 years, advances in screening, diagnosis, and treatment have led to improved quality of life and better outcomes, and research continues at a rapid pace. Even though prostate disease is common in men, especially as they age, increasingly these conditions are more manageable, and men can often lead normal lives.

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