Perineal pain

Specialty: Nephrology and urology.

• perineodynia
• male or female pelvic floor pain

Why it occurs

• Chronic prostatitis / Chronic pelvic pain syndrome (inflammatory or non-inflammatory condition of the prostate that causes persistent perineal pain lasting more than 3 months)
• Acute bacterial prostatitis (severe bacterial infection of the prostate that produces severe swelling of the gland)
• Prostatic or perianal abscess (localized purulent collection that generates throbbing pain and local swelling)
• Pudendal nerve neuralgia (entrapment or irritation of the pudendal nerve in Alcock's canal that exacerbates pain when sitting and is relieved when standing up or sitting on the toilet)
• Interstitial cystitis (suprapubic pain may radiate intensely to the perineum)

Initial workup

Careful rectal examination (essential in men to evaluate the size, consistency and pain of the prostate; vigorous prostate massage is contraindicated if acute prostatitis is suspected due to the risk of bacteremia); urine culture and semen culture; transrectal ultrasound (to rule out prostatic abscess) or pelvic MRI to evaluate the anatomy of the pudendal canal or look for perineal fistulas.

Standard management

• Ciprofloxacin — 500 mg every 12 hours orally for 4 to 6 weeks if chronic bacterial prostatitis is diagnosed, given its excellent penetration into the prostate tissue
• Pregabalin — 75-150 mg every 12 hours orally to modulate neuropathic pain in pudendal neuralgia or chronic pelvic pain syndrome
• Tamsulosin (0.4 mg daily orally to reduce hypertonia of the urethral sphincter and bladder neck frequently associated with perineal pain in men).