Chronic Pelvic Pain Syndrome Following Perineal Trauma

Case at a Glance

A 24-year-old male presents with chronic pelvic pain syndrome (CPPS) following a perineal trauma incident in 2017. Despite extensive medical evaluation and various treatments, he continues to experience persistent pelvic floor dysfunction, sexual dysfunction, and associated psychological symptoms.

Patient's Story

The patient reports that his symptoms began on October 31, 2017, following an incident where external pressure was applied to his penoscrotal junction. He describes having a history of prolonged sexual arousal practices prior to this incident. During the traumatic event, he experienced what he describes as a 'blocked sensation' and attempted to achieve ejaculation despite difficulty maintaining erection, applying additional perineal pressure. Since this incident, he has developed a constellation of symptoms affecting his pelvic floor, sexual function, and overall quality of life.

Initial Assessment

The patient presents as a 24-year-old male from Dhaka, weighing 75kg with height 5'10". He reports multiple symptom categories including: genital/sexual dysfunction (weak ejaculation, sensation of trapped semen, altered penile sensitivity), pelvic floor tension (chronic muscle tightness, involuntary contractions), neurological symptoms (tingling in legs, burning sensations), autonomic symptoms (bowel urgency post-ejaculation), and significant psychological distress including depression, anxiety, and body disconnection.

The Diagnostic Journey

The patient has undergone extensive evaluation including consultations with multiple urologists who found no structural abnormalities. Pelvic MRI revealed mild anal canal inflammation and coccyx narrowing, but normal pelvic musculature and ejaculatory ducts. He was diagnosed with chronic pelvic pain syndrome (CPPS) by a physiotherapist. Treatment attempts included three sessions of shockwave therapy without significant improvement. He has not yet consulted with a neurologist despite neurological symptoms.

Final Diagnosis

Primary diagnosis: Chronic Pelvic Pain Syndrome (CPPS) with secondary psychological components. The condition appears to be multifactorial, involving pelvic floor dysfunction, possible neuropathic elements, and significant psychological overlay including anxiety and depression related to sexual function.

Treatment Plan

Current self-directed treatment includes CPPS-specific exercises, yoga-based hip opening routines, regular gym attendance, dietary modifications, and additional pelvic floor rehabilitation techniques. A multidisciplinary approach is recommended including: continued pelvic floor physiotherapy, psychological counseling or psychiatric evaluation for associated mental health symptoms, possible pain management consultation, and consideration of neurological evaluation for persistent neuropathic symptoms.

Outcome and Follow-up

The patient continues to experience symptoms despite ongoing self-treatment efforts. He reports increasing depression related to his condition and persistent concerns about recovery. Medical consultation suggested that psychiatric evaluation may be beneficial given the significant psychological component of his presentation. Long-term prognosis for CPPS varies, with many patients experiencing improvement through comprehensive, multidisciplinary treatment approaches addressing both physical and psychological aspects of the condition.