What is the latest on multiple sclerosis life expectancy? Find out the types of MS, causes, symptoms, and how to live a healthy life with the condition.

Types of Multiple Sclerosis

There are three main types of MS:

• Relapsing-remitting MS (RRMS): Affecting about 85% of individuals with MS, RRMS involves clearly defined attacks of new or increasing neurologic symptoms followed by periods of partial or complete recovery.
• Primary progressive MS (PPMS): This type affects about 10-15% of people with MS. Symptoms gradually worsen over time rather than suddenly appear.
• Secondary progressive MS (SPMS): Usually occurring after RRMS, SPMS involves a build-up of disability independent of any relapse.

Causes of Multiple Sclerosis

While the exact cause of MS is not clear, some factors that may contribute to the development of the condition include:

1. Genetics: There is a 1.5% chance of a child developing MS if their parent has it, and a 2.7% chance if their sibling has it.
2. Viral and bacterial infections: Epstein Barr virus, which causes glandular fever, has been linked to MS.
3. Low levels of vitamin D: Vitamin D is absorbed through the sun and certain foods, and low levels may be a risk factor.
4. Smoking: Chemicals in cigarette smoke can negatively affect the immune system.
5. Childhood obesity: Overweight individuals are often low in vitamin D, and obesity can cause inflammation and an overactive immune system.

Symptoms of Multiple Sclerosis

Individuals living with MS can experience a variety of symptoms, including:

• Bladder and bowel issues
• Fatigue
• Learning, planning, and thinking difficulties
• Mental health issues, such as anxiety and depression
• Sexual problems
• Speech issues
• Swallowing difficulties
• Mobility and muscle issues
• Numbness and tingling
• Pain
• Vision problems

Living Life With Multiple Sclerosis

The average lifespan for someone with MS is 25 to 35 years after diagnosis. However, with proper care and management, individuals with MS can live long, healthy lives. This includes:

• Regular checkups with a doctor
• Exercising regularly
• Eating a healthy diet
• Getting flu vaccines each fall

It’s important to speak with your doctor to determine the best methods for managing your MS and maintaining good physical and mental health.

FAQs About Life Expectancy of Multiple Sclerosis

How Long Do People with MS Live?

The average lifespan for someone with MS is 25 to 35 years after diagnosis. However, this can vary greatly from patient to patient, and with proper care, individuals with MS can live long, healthy lives.

Can You Live a Normal Life with MS?

Yes, you can live a long, healthy life with MS as long as you care for your health and manage the underlying symptoms. Speak to your doctor about the best methods for you.

Prognosis and Life Expectancy for MS

MS itself is not usually fatal, but the disorder may lead to complications that can be life-threatening. The most common causes of death for individuals with MS are related to secondary complications, such as chronic urinary tract infections and issues with swallowing and breathing. However, with proper care and treatment, the prognosis for individuals with MS has significantly improved in recent years.

Progression of MS

The progression of MS can vary greatly from person to person. Some individuals may experience a steady decline in function, while others may have periods of relapse and remission. The type of MS a person has can also impact the progression, with PPMS generally leading to a more steady decline compared to RRMS, which can have unpredictable flare-ups and periods of recovery.

Factors Affecting MS Prognosis

Several factors can influence the prognosis and life expectancy for individuals with MS, including:

• Age at diagnosis: Those diagnosed at a younger age tend to have a better prognosis.
• Type of MS: Individuals with RRMS generally have a better prognosis than those with PPMS or SPMS.
• Severity of symptoms: Those with more severe or disabling symptoms may have a poorer prognosis.
• Access to treatment: Individuals with access to effective MS treatments generally have a better outlook.

Future Outlook for MS

The outlook for individuals with MS has improved in recent years thanks to advancements in treatment and a better understanding of the condition. While MS is still a chronic, incurable disease, many individuals with MS are able to manage their symptoms and live active, fulfilling lives. Continued research and development of new treatments hold promise for further improving the prognosis and quality of life for those with MS.

Multiple Sclerosis Life Expectancy: What’s The Latest

September 27, 2022

Author:

Jeremy Rodriguez

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According to the National Multiple Sclerosis Society, “multiple sclerosis (MS) is an unpredictable disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body.” Upon getting a diagnosis, MS life expectancy can be quite concerning. In this post, we will answer your questions about MS and life expectancy with MS.

Types of Multiple Sclerosis

There are three main types of MS. These include:

• Relapsing-remitting. Affecting about 85% of individuals with multiple sclerosis, RRMS involves clearly defined attacks of new or increasing neurologic symptoms. These are then followed by periods of partial or complete recovery or remissions.

• Primary progressive. This type affects about 10-15% of people with MS. Symptoms gradually worsen over time rather than suddenly appear.

• Secondary progressive. Usually occurring after RRMS, secondary progressive MS involves a build-up of a disability independent of any relapse.

Causes of Multiple Sclerosis

While it is not clear what causes MS, there is some scientific evidence to support that some environmental factors can cause MS. These include:

• Genetics. However, this is rare. More than 200 genes can affect your chances of getting MS. There is a 1. 5% chance of a child developing MS if their parent has it and a 2.7% chance if their sibling has it.

• Viral and bacterial Infections. Epstein Barr virus, which causes glandular fever, has been linked to MS but not all people with the virus develop MS.

• Low levels of vitamin D. These vitamins are absorbed through the sun and through foods such as eggs, oily fish, breakfast cereals, and spreads. A blood test can determine if your vitamin D levels are low.

• Smoking. Chemicals in cigarette smoke can negatively affect your immune system.

• Childhood obesity. This might be because overweight people are often low in vitamin D. Additionally, obesity can cause inflammation in your body and make your immune system overactive.

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Symptoms of Multiple Sclerosis

Life with MS can involve numerous symptoms. These include:

• Bladder and bowel issues

• Fatigue

• Learning, planning, and thinking difficulties

• Mental health issues, such as anxiety and depression

• Sexual problems

• Speech issues

• Swallowing difficulties

• Mobility and muscle issues

• Numbness and tingling

• Pain

• Vision problems

Living Life With Multiple Sclerosis

Life expectancy with multiple sclerosis varies from patient to patient, but the average lifespan is 25 to 35 years after diagnosis. The most common causes of death in MS patients result from secondary complications such as chronic urinary tract infections and compromised swallowing and breathing. However, with the right level of care, one can live a long, healthy life with MS. This includes taking steps to promote good physical and mental health, such as getting regular checkups, exercising, eating healthy, and getting flu vaccines every fall. Speak to your doctor to determine the best methods for you.

FAQs About Life Expectancy of Multiple Sclerosis

How Long Do People with MS Live?

Multiple sclerosis life expectancy is difficult to determine because it varies from patient to patient, but the average lifespan is usually 25-35 years after the diagnosis. Usually, most causes of death result from secondary complications of MS.

Can You Live a Normal Life with MS?

You can live a long, healthy life with MS as long as you care for your health regarding the underlying symptoms. Speak to your doctor about proper care.

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MS prognosis and life expectancy

Is MS fatal?

Progression of MS

Factors affecting MS prognosis

Future outlook

FAQs

 

Multiple sclerosis (MS) is a neurological disorder caused by the body’s immune system erroneously attacking myelin, a fatty covering around nerve fibers. The resulting neurological damage can cause a number of MS symptoms, including fatigue, muscle spasms, balance issues, and vision problems.

Depression, trouble controlling the bladder or bowel, and difficulties with sexual health also are common in people with the disease.

Is MS fatal?

MS itself is not usually fatal. However, the disorder may increase the risk of life-threatening complications, such as severe infections or swallowing difficulties, that can set the stage for pneumonia.

On average, the lifespan for people with MS is about five to 10 years shorter than for the general population, but this gap is getting shorter as treatments and care continue to improve.

How MS progresses over time

Most people with MS experience two stages of disease. The first stage is relapsing-remitting MS (RRMS), which is characterized by episodes of new or worsening symptoms (relapses), interspersed with periods of partial or complete recovery from symptoms (remission).

Most RRMS patients will gradually enter a progressive phase of disease, called secondary progressive MS (SPMS), in which symptoms continually worsen over time, even when no relapses occur.

The time it takes to progress from RRMS to SPMS often varies substantially from person to person and potentially can be influenced by the use of disease-modifying therapies (DMTs). If left untreated, about half of RRMS patients would progress to SPMS within 10 years of disease onset. But when most patients received treatment, only about 10% converted to SPMS, and over a median of 32 years.

In approximately 15% of MS patients, the disease will enter a progressive phase immediately, with symptoms that continually get worse over time. This disease form is referred to as primary progressive multiple sclerosis (PPMS).

In general, symptoms worsen more quickly in progressive forms of MS (SPMS or PPMS) than in relapsing disease.

Although MS is often categorized as either “relapsing” or “progressive,” these categories are far from absolute and may overlap. People with progressive MS can experience disease relapses and periods of relative remission, while individuals with relapsing disease may experience some symptom progression between relapses.

EDSS: Measuring disability progression

Disability progression in people with MS is most commonly tracked with a standardized measure called the Expanded Disability Status Scale, or EDSS. This scale ranges from 0, indicating no disability, to 10, for death. Scores increase in increments of 0.5 as disability progresses.

From scores of 0 to 4.5 in the EDSS, individuals are able to walk without any aid and their disability is measured based on impairments in functional systems. These systems represent groups of nerves responsible for specific tasks. Each is graded on a scale of 0 (no disability) to 5 or 6 (severe disability).

The EDSS assesses eight functional systems:

• pyramidal: muscle weakness or trouble moving the limbs
• visual: problems with vision
• cerebellar: tremor, loss of balance, and coordination problems
• brainstem: uncontrolled eye movements and difficulty talking or swallowing
• sensory: numbness or unusual sensations
• bowel and bladder: changes in gastrointestinal and urinary tract function
• cerebral: difficulty with thinking or memory
• other: any other neurologic finding attributed to MS

From scores of 5 to 9. 5, the EDSS is assessed mainly based on an individual’s ability to walk.

EDSS score	What it means
0	No signs of neurological abnormalities
1	No disability, but minimal signs in one functional system
1.5	No disability, but minimal signs in two or more functional systems
2	Minimal disability in one functional system
2.5	Minimal disability in two functional systems, or mild disability affecting one system
3	Moderate disability in one functional system or mild disability in three or four systems, without any walking difficulties
3.5	Moderate disability in one functional system, with more than minimal impairment in multiple others, but no difficulty walking
4	Significant disability, but able to function mostly independently in daily life. Able to walk 500 meters (about one-third of a mile) without aid or rest
4.5	Significant disability that may necessitate some minor help in day-to-day life. Able to walk 300 meters (about one-fifth of a mile) without aid or rest
5	Severe disability that causes substantial impairment in daily life, necessitating accommodations. Able to walk 200 meters (about a tenth of a mile) without aid or rest
5.5	Severe disability to the point that some activities that had been a part of normal day-to-day life can no longer be done independently. Able to walk 100 meters (about 330 feet) without aid or rest
6	Requires a walking aid, such as a cane or a crutch, to walk 100 meters (about 330 feet) with or without stopping to rest
6.5	Requires two walking aids, such as a pair of canes or crutches, to walk 100 meters (about 330 feet) without stopping to rest
7	Unable to walk more than a few feet, even with aid. Requires a wheelchair to get around but is still up and about for most of the day, and is able to maneuver the chair and get in and out of it independently
7.5	Unable to take more than a couple of steps, and needs help getting in and out of a wheelchair and wheeling around
8	Unable to stand, and usually reliant on a wheelchair that is motorized or pushed to get around, but still up and about for much of the day. Generally still has function in the arms and can still take care of most self-care activities
8.5	Stays in bed for most of the day, with some impairment in arm function and ability to handle self-care functions
9	Unable to get out of bed but still able to communicate clearly and eat voluntarily
9.5	Confined to bed without the ability to communicate effectively or swallow properly
10	Death due to MS

 

Factors affecting prognosis

No two people with MS experience exactly the same symptoms or patterns of disease progression. Much like there are risk factors for developing MS, there are varying components that also can affect the disease course. These include:

• treatment
• lifestyle factors
• biological traits
• disease-intrinsic factors
• demographics, such as race and sex

Treatment

Perhaps the most important factor that affects the trajectory of MS in the modern day is treatment. Disease-modifying therapies, known as DMTs, are currently approved in the U.S. and several other countries for all the main MS types.

Beginning treatment as early as possible is highly recommended for MS patients. Long-term outcomes are generally better for patients who start treatment early in the course of their disease.

All currently approved DMTs work by reducing the inflammatory attack that drives MS. These medications have been proven in clinical trials to reduce disease activity — by lowering relapse risk, preventing new damage in the brain, and/or slowing the accumulation of disability.

Each of the available treatments has its own safety and efficacy profile, and patients are advised to talk to their healthcare team about whether certain medications might benefit them.

Lifestyle factors

A number of lifestyle factors can affect the progression of MS. For example, more physical exercise has been linked to both better physical and cognitive outcomes over time. Depending on the kind and duration of exercise, patients also may experience less brain tissue degeneration and fewer relapses.

People with MS should also take smoking into account, as a number of studies have shown that the disease tends to be more severe in people who smoke cigarettes. MS patients who smoke are typically advised to try and quit or cut back.

Dietary habits also have a substantial impact on MS, although the nuances are still not fully understood. While there isn’t any “optimal diet” for people with MS, consuming lots of fruits and vegetables, more whole grains, a variety of lean proteins, and less processed food or refined sugar is usually recommended.

Chronic stress also has been noted as a potential contributor to MS relapses and disability progression. Stressful events that contribute to a disruption in routine have been associated with the development of new inflammatory brain lesions.

Biological and disease-related factors

An individual’s age at MS symptom onset has been shown to be a main factor in determining the course of MS. In general, the older the age at onset, the faster the disease progresses. However, the frequency of relapses over a person’s lifetime usually is greater in people diagnosed at younger ages.

The early course of MS also provides prognostic information about how the disease is likely to progress. Experiencing more relapses or a substantial increase in disability early in the disease course is associated with a higher risk of severe disease progression and cumulative disability.

Measuring inflammation and damage in the nervous system via MRI scans also can help to provide prognostic information about the likely disease course. Typically, greater damage on such scans is broadly tied to more severe symptoms and disability.

Obesity – a body mass index higher than 30 – has been linked to a more severe disease course. This is most likely because more adipose tissue, or body fat, leads to chronic inflammation in the body, which contributes to further nerve damage in MS.

Demographic factors

Race and ethnicity have also been shown to affect MS severity. In the U.S., MS patients who are Black or Latin American tend to have more severe disability worsening and a higher death rate. These differing outcomes are thought to be driven by interconnecting factors including genetic differences, geographical location, and socioeconomic disparities.

While the disease is less common in men than in women, males tend to have a poorer prognosis than females. Males generally experience worse recovery after relapses, have higher rates of brain damage and cognitive impairment, and are more likely to develop progressive forms of MS and become substantially disabled.

In females, relapses and brain lesions are more common than in males, but females tend to have fewer brain lesions with permanent nerve damage. Some MS symptoms also vary by sex. For example, motor symptoms are generally more common in males, while vision problems are more common in females.

Future outlook: Can you live a normal life with MS?

After an MS diagnosis, patients and their healthcare teams typically will work together to come up with a care plan suited to the individual. This often involves:

• regular appointments with a neurologist to monitor disease progression.
• the use of DMTs to prevent relapses and slow the progression of MS.
• other medications or therapies to help manage individual symptoms.

Certain changes in lifestyle also may help some MS patients to better manage their disease. These can include:

• quitting smoking.
• exercising and losing weight.
• finding strategies to reduce stress.

Multiple sclerosis is a lifelong disease, and disease manifestations vary substantially from person to person. For some people with MS, the disease causes noteworthy disability shortly after it manifests, whereas others may go decades without ever developing symptoms that substantially interfere with their daily life.

With modern care, most patients retain a fair degree of mobility throughout their lives. It is estimated that about two-thirds of patients are still able to walk some 20 years after being diagnosed, although some may require assisted devices, such as supports to aid in walking, or scooters used on occasion to save energy and avoid fatigue.

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Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

Presbyopia correction | Optics Medical Center

Posted at 14:37h
Problems of vision
by bdmin

Over the years, the human eye loses the ability to focus on nearby objects. At the household level, this phenomenon is called senile farsightedness, among professional ophthalmologists – presbyopia, a condition in which the natural lens becomes less flexible, loses its ability to change shape and position (focal length), gradually losing accommodation. This process is considered normal, natural aging of the body.

Clinical manifestations begin at the age of 40-45 years, at the present time at the peak of creative and physical strength, when problems with vision at a close distance significantly reduces the quality of life. Therefore, the issues of correcting this condition are becoming one of the most relevant in modern ophthalmology. And she offers a variety of solutions to the problem of correcting presbyopia.

Throughout a person’s life, there is a gradual change in vision. Presbyopia is the inability of the eye to see clearly at close range, associated with age-related changes in the optical system of the eye. Normally, a person has the ability to clearly see the world around him both when looking at a distance and near. This possibility is realized due to the work of the accommodative apparatus (that is, the adaptation of our optical system for a clear perception of objects located at different distances). The main role belongs to the change in the radius of curvature of the surface of the lens (the lens located inside the eye). One of the important factors that physically does not allow the optical system of the eye to be adapted for viewing objects or text at a close distance is the compaction of the substance of the lens itself, which leads to a decrease in the elasticity of the lens capsule and the plasticity of its nucleus.

This most noticeably occurs at the age of 38-48 years with excessive work at close range, a certain type of work activity, lifestyle, and non-observance of time intervals when working at close range. Initially, the presence of concomitant pathologies of other organs and systems is important, at risk are patients with diabetes mellitus, patients receiving treatment with glucocorticoids, people with chronic inflammation of the eyes, hereditary predisposition. In the initial stage, there may be no symptoms. Sometimes patients do not even notice a decrease in distance vision, since the eyes are a paired organ and for a long time a better seeing eye can compensate for a decrease in visual acuity to a certain limit. Changes can only be diagnosed by an ophthalmologist during a detailed examination using special equipment.

When the opacities are located in the posterior pole of the lens, patients notice glare and decreased vision in bright sunlight and, accordingly, vision will improve when they are indoors, at dusk. But, if we discuss the features of reading in early presbyopes 40-45 years old, then it should be noted that they often notice difficulties in reading in conditions of just low light and almost complete recovery of the ability to read when the light is increased. Basically, patients’ complaints are reduced to a decrease in near visual acuity, including in the usual glasses that they wear all the time.

So, other things being equal, presbyopia occurs earlier in people whose household or professional activities are associated with the examination of small objects, and the less the contrast of objects with the background, the stronger this factor.

Correction of presbyopia can currently be implemented in three ways: spectacle correction, contact correction, surgical correction. Most often, we resort to the first method – spectacle. It comes down to the selection of an additional correction for near – addition, which gradually intensifies as needed and the severity of the symptoms of presbyopia.

Spectacle correction can be performed with monofocal or multifocal (progressive) lenses. The advantages of monofocal glasses (i.e. for only one distance, for example, for reading) can be: ease of fit, good quality of vision at the final distance, ease of adaptation, ease of manufacture, low cost and availability, but the main disadvantage is the limitation of the depth of the clear vision zone a small area at a certain distance. This limits their use in most modern professions or forces them to change the position of the glasses on the bridge of the nose, to look into the distance over the glasses.

A variation of monofocal correction – monovision spectacle correction implies the correction of one eye for distance, and the other for work at close range. Has significant limitations.

Multifocal glasses (progressive) provide the patient with high quality vision at different distances. This is currently the most ergonomic correction method. Advantages – clear vision at all working distances, no image jump when moving from the top to the bottom of the lens, the external similarity to a conventional single-vision lens and the ability to have one pair (not several) glasses for constant wear.

But progressive glasses have their own peculiarities, which bring certain difficulties. The patient must be aware of them. First of all, about the need to adapt to new glasses, which is longer compared to monofocal glasses, and about the possibility of complaints about the distortion of visible objects, changes in the perception of distance, dizziness, nausea, and double vision. In particular, this applies to the primary appointment of progressive or spherocylindrical correction in adulthood or old age.

The patient will need to change the habitual visual behavior: to limit the movement of the head up and down when working at close distances; get used to more distortion when looking through the peripheral part of the lenses in comparison with monofocal glasses – at the beginning of wearing, try to look through the center of the lenses; turn your head, and not just your eyes, when looking to the side, etc. And the selection of a multifocal correction requires a highly qualified ophthalmologist or optometrist.

Traditional progressive glasses provide good vision in everyday life, but for working with a computer and in the office it is recommended to use a modification of progressive glasses, which are sometimes called “office glasses”. “Office” progressive glasses provide an expansion of the field of view and comfort of the visual zones at a distance of up to 5-6 meters. These glasses are not designed to compensate for visual acuity problems beyond 5-6 meters (i.e. distance vision).

Progressive spectacles are recommended for patients of all ages who lead an active lifestyle and require high quality vision at various distances. This is especially true for young presbyopes. “Office” progressive glasses for them may be the first to work at close and medium distances (computer users, musicians, dentists, hairdressers, etc.). Contraindications to the use of progressive glasses are strabismus and nystagmus.

The International Association of Contact Lens Manufacturers reports that the share of multifocal contact lenses is 11% of all soft contact lenses (SCLs) in the world, and among patients over 45 years of age using SCLs, clients with multifocal correction account for 40-67%.

Surgical correction, thanks to micro incisions and modern sparing technologies, provides an opportunity to put an artificial lens, without waiting until the natural lens (crystalline lens) becomes so dense that it reduces not only the quality of vision, but also the quality of life. The possibilities of choice are decided strictly individually, taking into account the structural features of the optical system of the eye of each patient. The final decision rests with the operating surgeon.

Treatment of patients with chronic pelvic pain syndrome in a single center | Kruglov

Introduction

Patients with complaints of pain in the pelvis and perineum are well known to practicing urologists.

These patients are clearly accentuated by the existing symptoms, are characterized by a negative psycho-emotional background, as a rule, they are treated for a long time and without a significant effect by various specialists [1].

Management of such patients is still an unsolved problem.

The stereotype that was previously formed in urological practice to interpret such symptoms as manifestations of chronic prostatitis has long and obviously outlived itself. Chronic pelvic pain syndrome (CPPS) is currently widely discussed.

An examination of the literature on this issue reveals at least two interpretations of this term. On the one hand, CPPS is, according to the accepted classification, one of the variants of chronic prostatitis (categories 3a and 3b), on the other hand, more modern position, CPPS is considered as a major syndrome, one of the many causes of which may be chronic prostatitis [2][3 ].

The term “pelvic pain” came to domestic medicine from foreign medical publications. According to the recommendations of the guidelines of the European Association of Urology (2009), chronic pelvic pain syndrome is persistent or recurring pain in the pelvic region, noted for at least 6 months.

“Pelvic” refers to pain localized in the lower abdomen below the navel, in the lower back and sacrum, as well as in the perineum, in the vulva, vagina, rectum. Often there is irradiation along the anterointernal surface of the thighs and the lower edge of the buttocks. Usually, patients cannot indicate the exact localization of pain and separate the epicenter of pain from the irradiation zone.

Chronic pelvic pain depresses the patient’s psycho-emotional state, sharply reduces the quality of life. It is known that the effect of CPPS on the mental sphere of a patient is comparable to the effect of myocardial infarction, unstable angina pectoris, ulcerative colitis, and more than the effect of toothache and ear pain [4][5]. In the specialized literature, there are indications that 27% of patients with CPPS suffer from severe depression and drug dependence, 18% have significant emotional disorders during the period of exacerbation of the pain syndrome, and almost 35% of patients have a history of indications of suicidal attempts or intentions, which once again confirms medical and social significance of this pathology [3][6].

In addition to pain, the concept of CPPS also includes other manifestations related to disorders of the pelvic organs – increased urination, stool disorders, changes in the tone of the pelvic muscles, sexual dysfunction, psycho-emotional disorders. These symptoms are almost always present to varying degrees in patients with this problem, complicating and confusing the causal relationship between them. That is why recently, in foreign literature, instead of the term “chronic pelvic pain syndrome”, the term “chronic pelvic pain syndrome and dysfunction” is used as a broader one.

It is now recognized that chronic pelvic pain syndrome is a collective name for a variety of pathological conditions, united by the presence of pain in the pelvic area, including those when the prostate gland is only indirectly involved in the pathological process or is not involved at all [7] [8][9].

Pain syndromes in the pelvic region have been described in the literature for a long time, however, the interpretation of their nature still causes great difficulties. This syndrome, according to the figurative expression of D.H. Zermannetal from the University of Colorado (USA) is still a “diagnostic and therapeutic puzzle” [10][11]. L. Hahn (2001) believes that in differential diagnostic terms, one has to keep in mind more than 70 diseases that can cause pelvic pain. And, on the contrary, even with the most thorough examination, any pathology may not be found [12][13].

Chronic pain in the perineal region may be due to pathology of the internal organs of the pelvis and genital organs, damage to the muscles of the pelvic floor and the osseo-ligamentous apparatus, involvement of peripheral nerves, and may also be caused by psychological and other factors. The organs of the small pelvis are closely interconnected, often have a common innervation, blood circulation, musculoskeletal apparatus. In fact, the entire pelvic area is a vast reflexogenic zone, and the defeat of one organ often involves others in the pathological process.

The complexity and multifactorial nature of the etiopathogenesis of pain syndromes in the pelvic area is reflected in the attempts of foreign authors to systematize these patients. The most well-known and widely used is the so-called UPOINT clinical phenotyping system, which involves the assessment and summation of symptoms in 6 different diagnostic areas, referred to in the original technique as diagnostic domains. In particular, urinary, organ-specific (prostatic), infectious, neurological, psychosocial and muscle pain domains are distinguished. The system has proven to be effective in classifying patients with urological pelvic pain syndromes in a clinically relevant manner for appropriate therapy [14].

According to the literature, the point of view that the role of inflammatory diseases in the pathogenesis of chronic pelvic pain syndrome is becoming more and more dominant. Currently, the main role is given to myofascial (spastic) syndromes of the pelvic floor muscles and neuropathies of the pudendal nerve.

Myofascial pain syndromes (MFPS) are caused by chronic spasm of the musculo-ligamentous apparatus of the small pelvis. These syndromes are quite widespread, but rarely diagnosed in urological practice. Although, for example, Skootsky S. reports 30% of patients with chronic pelvic pain who were diagnosed with myofascial syndromes in specialized clinics for the treatment of pain syndromes, according to Bartoletti R. myofascial syndromes were detected in 13.8% of cases [11][ 15].

Involvement of the pelvic floor muscles and peripheral nerves in the pathological process can occur at various stages of diseases of the pelvic organs and is an integral part of the chronicization of pelvic pain – that is, myofascial syndromes are usually secondary. But the complexity of the situation is that in some cases, the primary disease of the pelvic organs regresses against the background of specific therapy or spontaneously or passes into a latent, difficult-to-diagnose form, and pain in the pelvic region, caused by secondary changes in the muscles and peripheral nerves of the pelvic region, persists and even aggravated, “breaking away” from the root cause.

A long-term muscular-tonic syndrome can lead to muscle dysfunction with the development of myofascial syndrome, the appearance of trigger points characteristic of the latter and the corresponding reflected pain patterns. An increase in the tone of the muscles of the pelvic floor and perineum, together with pain, can initiate dysuric disorders of both mechanical and reflex origin [2][7][16].

On the one hand, the diagnosis of MFPS must be a diagnosis of exclusion. On the other hand, the presence of, for example, “classic” bacterial chronic prostatitis in a patient does not exclude, but on the contrary, also suggests the presence of myofascial complications.

The pathophysiological mechanisms of the formation of chronic spasm of the musculo-ligamentous apparatus are presented as follows.

Any condition that causes pain more or less for a long time leads to a decrease in the threshold of pain sensitivity – this is the so-called central sensitization, which develops when the neurons of the posterior horns of the spinal cord receive a powerful “volley” of signals from pain receptors. At the same time, a progressive increase in neuronal activity occurs in the neurons of the posterior horns, known as the wind-up phenomenon, in which neurons become more sensitive to subsequent impulses. The next step is peripheral sensitization. In the affected organ, the production of nerve growth factor (NGF, NGF) increases. This leads to an increase in the number of receptors affiliated with demyelinated C-fibers, the main role of which is the transmission of chronic pain impulses. Accordingly, an increase in their number leads to an increase in pain in the affected organ.

Given that the pelvic organs have cross-innervation, the number of receptors for C-fibers increases not only in the “original organ”, but in those with which it is associated with cross-innervation – this is cross-sensitization. Such a cross-reaction is typical, for example, for the endo- and myometrium, and the bladder urothelium [9]. However, most muscles are not adapted to function under conditions of prolonged tonic tension, which is a physiological response to pain stimulation. This leads to the appearance of a large number of underoxidized metabolic products in the muscle tissue – secondary disorders appear in the muscle: vascular, metabolic, inflammatory and, as a result, local spasmodic zones are formed, which are called “trigger points” (the term was proposed by Janet Travell, 1942d). These are seals that are felt on palpation and are formed by tense muscle fibers. Thus, the pathogenesis of MFPS is very complicated, but pain that almost always arises and exists for some time triggers a vicious circle of processes that make it self-sustaining even in the absence of the root cause.

The most common pelvic myofascial syndromes include levator syndrome, internal obturator muscle syndrome, and piriformis syndrome.

Levator syndrome is associated with spasm of the levator ani muscle. According to J. Rigaud, this syndrome occurs in 100% of cases in patients with CPPS and is characterized by pain in the anus and rectum, aggravated in the sitting position, pain on palpation of the sphincter. The syndrome of the internal obturator muscle is caused by a spasm of m. obturatorius internus and is manifested by the feeling of a foreign body in the rectum, pain in the urethra and perineum [4][9].

Currently, there is no consensus regarding the treatment of CPPS, just as there is no way to accurately determine the pathophysiological causes of this disease in each specific case [7][16].

Long courses of antibiotic therapy have until recently been considered the mainstay of treatment for CPPS. However, studies conducted with long-term use of a number of antibiotics have not shown a significant positive result. The results of studies on the use of alpha-blockers are also very controversial. So Cheah P.Y. et al. in their works note the positive effect of the use of drugs of this group in CPPS [15][17]. Alexander R.B. et al. in their publication, on the contrary, they note a slight effect of the use of tamsulosin in patients with CPPS [15].

Anti-inflammatory drugs and immunomodulators as monotherapy are not recommended by many authors due to insignificant leveling of symptoms [2][6][12]. The use of a combination of corticosteroids with antibiotics was proposed as a hypothesis by Tomaskovic I. et al. [15][18]. Yang M.G. and et al. conducted a randomized double-blind study in which they noted a positive effect in the short term.

Foreign authors also note that such treatments as low-intensity shock wave therapy, acupuncture, biofeedback, invasive neuromodulation, the use of botulinum toxin injections require more thorough research to confirm the effectiveness of their use both as monotherapy and in combinations with other treatments [2].

Also in the literature, muscle relaxants and analgesics of central action, antidepressants, local anesthetics and anticonvulsants used for the treatment of neuropathic pain appear in the literature as means of complex therapy for CPPS [15].

The given literature data demonstrates the absence of a generally accepted approach to the diagnosis and treatment of the syndrome, as well as to the etiopathogenetic nature of pain in the pelvic area. Obviously, the final resolution of the complex of contradictions is a matter for the future. However, quite a practical question about the treatment of patients with this symptomatology remains relevant. In our work, we aimed to improve the results of treatment of patients suffering from CPPS.

Materials and methods

The study included 46 patients who underwent course treatment at the urological clinic of the Astrakhan State Medical University on the basis of the Alexandro-Mariinsky Regional Clinical Hospital from 2016 to August 2018.

These were men aged 26 to 57 years, the average age was 32.0 ± 5.1 years.

The main criterion for inclusion of patients in the study is the presence of a leading complaint of long-term pain in the pelvis and/or perineum. The average duration of the disease was 3.8±2.1 years.

Based on the concept of multifactoriality of chronic pelvic pain syndrome, all patients underwent an in-depth examination in order to exclude “dangerous” causes of CPPS, the so-called “red flags” [5][7][19].

The diagnostic complex included the determination of the state of the prostate gland and the severity of inflammatory changes in it and in the urinary system: complete blood and urine analysis, digital rectal examination of the prostate (PG), transrectal ultrasound examination of the pancreas (TRUS), determination of the volume of residual urine, CT of the retroperitoneal space, MRI of the pelvis, microscopic examination and bacterial culture of the secretion of the pancreas, microscopic examination of the urethral smear and PCR diagnostics to exclude sexually transmitted diseases (STIs). All patients over 40 years of age underwent a study of the level of prostate-specific blood antigen (PSA).

In some cases, when a pathology of the seminiferous tubercle was suspected, the examination was expanded by performing diagnostic urethrocystoscopy, which in some cases made it possible to identify hypertrophy and inflammatory changes in the seminal tubercle – such patients were not included in the study.

An additional diagnostic element specific for urological practice was an active search for myofascial pelvic syndromes in these patients to clarify the presence and severity of the neuropathic pain component. For this purpose, patients were examined to identify hypertonicity of the pelvic and perineal muscles, trigger points, and filled out the neuropathic pain questionnaire (DN4), intended for widespread use by practitioners. DN4 was developed as a tool for the diagnosis and differential diagnosis of neuropathic pain.

The exclusion criteria were acute urogenital inflammatory processes, sexually transmitted infections, other diseases of the pelvic organs, accompanied by pain, including vascular and oncological pathology, diseases of the lower thoracic and lumbosacral spine, decompensated conditions of other organs and systems.

Symptom severity was assessed by testing using the International Prostatic Symptom Score (IPSS) questionnaire. Pain severity was additionally assessed using a 10-point Numeric rating Scale for pain (NRS). Symptoms were assessed 3 times: at the beginning of treatment, in the middle of the course and at its completion.

According to the results of the examination, 20 patients (43.5%) showed signs of an inflammatory process in the prostate gland, 26 (56.5%) did not. As a criterion for the inflammatory process, the detection of more than 10 leukocytes in the field of view during microscopy of the secret of the prostate gland, a positive result of bacterial seeding of the secret of the prostate gland was taken.

Case management was organized as follows. Patients with proven inflammatory changes in the prostate gland were divided into two equal and comparable groups: the first group received “standard” therapy for chronic prostatitis (antibiotics, prostatotropic drugs, microcirculation and immunocorrection agents, physiotherapy), in the second group, patients received “standard” treatment in combination with myofascial blockades and neuropathic pain therapy. Patients without inflammatory changes in the prostate were combined into the third group and received only myofascial blockades and neuropathic pain therapy, since we consider it unjustified to prescribe antibiotic therapy in this case.

In accordance with the results of the examination, patients underwent blockades of m.levator ani, m. obturatorius internus under electromyostimulation control. The latter seems to be a very essential component of the methodology. Access to the muscles located in the pelvic cavity is limited, so the use of electrical stimulation is the easiest way to control the position of the needle in order to confidently inject the drug into the target muscle group. Abbreviations m. levator ani, m. obturatorius internus under the action of electrical stimulation is determined by palpation per rectum. For this purpose, we used a domestically produced electromyostimulator.

Given the well-known difficulties in the use of botulinum toxin preparations, for myofascial blockades, we used a solution of novocaine 0. 5% 40-80 ml with the addition of 2-4 mg of ropivacaine or lidocaine and 8 mg of dexamethasone. Blockades were performed with a frequency of 2 times a week for a total of 6 procedures and were supplemented with oral administration of gabapentin at a standard dosage (on the first day – 300 mg, on the second – 600 mg in 2 doses, on the third – 900 mg in 3 doses, a course of 2 months)

As clinical diagnostic criteria for improvement against the background of ongoing therapy, the following were taken: a decrease in the intensity of pain on an analog scale, a decrease in the total IPSS symptom index and an improvement in the quality of life, for patients with an established inflammatory process in the prostate gland – elimination of the pathogen during bacteriological examination of the secretion of the prostate gland, a decrease in the degree of inflammatory changes in the secretion of the prostate gland (less than 10 leukocytes in the field of view during microscopic examination of the secretion of the pancreas)

Statistical processing of the obtained data was carried out according to the Student’s method, differences in indicators were considered significant at p<0. 05.

Results and discussion

When analyzing the results, regardless of the presence or absence of an inflammatory process, the effect of pain on the total symptom score does not go beyond the accepted error, and the assessment of pain intensity is the same (Table 1).

Table 1. Baseline characteristics of study patient groups 9

Baseline characteristics of patient groups included in the study

9017 5

IPSS score

IPSS score 9Numerical rating scale la for pain

Numeric rating Scale for pain, NRS

Patient characteristics	3 Group 1	Group 2 Group 2	Group 3 Group 3
Number of patients0180	10	26
Age, years Age years	9 0002 35	36	34
Duration of pain, years Duration of pain, years	2.6 years	2. 5 years	2.4 years
5	5	5
Inflammatory changes in the prostate 3	–
Presence of pelvic myofascial syndromes 0003	+	+
“Standard” therapy for chronic prostatitis	“Standard” therapy for chronic prostatitis + myofascial blockade + neuropathic pain therapy “Standard” therapy of chronic prostatitis + myofascial blockade + neuropathic pain therapy0003	Myofascial blockade + neuropathic pain therapy

zone (32 %), in 18% of patients, pain was localized only in the perineum, and 10% of patients noted the migratory nature of pain, periodically occurring in different anatomical areas of the pelvis. The predominant localization of pain was in no way associated with the presence or absence of the inflammatory process. In the presence of inflammation in the prostate gland during bacteriological examination, the most common microorganisms found were: E. coli – 26.8%, Enterobacter spp. – 16.0%, Enterococcus spp. – 14.6% Staphylococcus spp. – 7.5%, Enterococcus faecalis – 6.3%.

As for the diagnosis of myofascial syndromes, according to our observations, there was also no significant correlation of such symptoms with the inflammatory component in the prostate – positive results of varying severity were encountered approximately equally in both groups. It should be noted that the identification of muscle hypertonicity and trigger points is quite subjective, given the practical impossibility of any quantitative characterization of this condition.

We observed the most pronounced effect from myofascial blockades in patients of the third group, since it was in them that the clinical picture was to the greatest extent due to the muscular-tonic component (diagrams 1, 2). A decrease in the severity of the pain syndrome was noted, as a rule, after the first procedure, but it was rather short-lived, due to the short period of action of the drugs used. In the future, the duration and severity of the effect increased significantly, which, on the one hand, is associated with a cumulative effect, the specific mechanisms of which require clarification, but are presumably associated with gradually developing desensitization, and, on the other hand, with a course of gabapentin.

003

Diagram 2. NRS index dynamics during treatment

Diagram 2. NRS index dynamics during of treatment

such in patients without inflammatory changes in the prostate gland. The effectiveness of blockades in this case confirms the presence of the myofascial component of the pain syndrome in chronic bacterial prostatitis, and the worse overall dynamics, compared with patients of the second group, is consistent with the well-known ideas about the complexity of antibiotic therapy for prostatitis and the need for a long course of antibiotics.

During the course of blockades, in several cases, prolonged pain was noted at the injection site; We did not observe more serious complications.

Conclusion

The problem of developing a unified approach to understanding CPPS is obviously far from being resolved – o6 this is evidenced by dozens of theories and hypotheses of its origin.

Progress in this area should be expected as the differential diagnosis of these conditions improves, the clinical classification of the disease becomes more detailed, and the accumulation of reliable clinical results characterizing the efficacy and safety of drugs. However, even now the correction of musculo-tonic disorders

in this syndrome, it should be recognized as an effective and safe method of therapeutic effect and this method should be recommended for inclusion in complex therapy for CPPS/chronic prostatitis.

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