PPOD Case Report 9

PPOD Syndrome Diagnoses: bilateral inguinodynia (chronic inguinal pelvic pain), suprapubic myalgia (superficial suprapubic pain), bilateral orchialgia (testicular pain), phallodynia (penile pain), proctalgia (rectal pain), urinary urgency (urgent urination), post-micturition dribbling (urinary dribbling after voiding), nocturia (frequent nighttime urination), obstipation (intractable constipation).

A 41-year-old male was seen for the primary complaints of chronic bilateral testicular, penile, pelvic and rectal pain. He stated that about 15 years earlier, while working for a construction company, he began to experience the onset of sharp right-sided testicular pain. Initially, his pain occurred only on an intermittent basis, however, over the next several years, it became more frequent and severe. Approximately 10 years following the onset of his right testicular pain, he began to experience left-sided testicular pain as well. Gradually, over the next few years, his testicular pain became more intense, and as it did, he additionally began to experience the onset of intense rectal, anal, suprapubic, penile and bilateral inguinal pain. In addition, he found that his pelvic, testicular and penile pain would be further aggravated by intercourse and that these symptoms would become especially pronounced at the moment of orgasm, and continue to persist for several days afterward. At about this time, he also began to experience symptoms of urologic and enterologic dysfunction that included urinary urgency, post-micturition dribbling, urinary sluggishness, frequent nighttime urination, severe chronic constipation, intense ongoing rectal pain which was made significantly worse with defecation and spontaneous painful spasming of the anal sphincter. The severity of his constipation required that he take high doses of laxative each day on an ongoing basis in order to achieve any emptying of the rectum. And yet, even with ongoing laxative use he could evacuate his rectum only once every 4-5 days and only with great difficulty and pain. He had consulted with a number of different urologists and colorectal surgeons and underwent multiple physical examinations and various tests including several sonograms of the abdomen and testicles, a pelvic MRI, and a pelvic CT scan. None of these studies however, were able to reveal the presence of any type of abnormality. As a result, he was treated symptomatically with various medications for pain and depression, trigger point injections, prolotherapy, several different nerve blocks, biofeedback, physical therapy, chiropractic treatment, exploratory surgery of the testicles and a surgical denervation of the testicles. Unfortunately, as none of these procedures had been able to provide any improvement in his condition, it was finally recommended that he undergo a pudendal nerve decompression surgery. However, because of the significant potential risks associated with this procedure it was his desire to seek another opinion. Although all of his prior diagnostic studies had been negative, he none-the-less exhibited clear and unequivocal evidence of the mechanically induced pelvic pain and organic dysfunction syndrome on his PPOD syndrome examination. Treatment resulted in a gradual but progressive improvement of his condition. Following the first few treatments, he experienced a typical post-treatment flare, marked by a distinct exacerbation of his pelvic and genital pain symptoms. However, after 2 1/2 weeks of treatment he was beginning to note an overall reduction in the intensity of his testicular, penile, pelvic and rectal pain. In addition, his post treatment flare had resolved. Following 3 1/2 weeks of treatment his pelvic and genital pain symptoms were significantly improved overall and he had become aware of improved bladder and bowel function. His was able to empty his bladder freely without any accompanying urgency, sluggishness or difficulty. In addition, he was able to evacuate his rectum every 1-2 days without the need of his laxatives. After several more weeks of treatment his testicular, penile, rectal and pelvic pain had completely resolved and he was able to engage in intercourse, to the point of orgasm, without experiencing the intense pain that he did previously.