Management of prolonged post-operative pelvic pain after transurethral prostate surgery: a clinical real-world survey and international comparison of therapy regimens

Abstract

AbstractSection Background

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Up to 50% of patients with benign prostate hyperplasia (BPH) face post-operative complications after transurethral prostate Surgery. This includes nearly 15% of patients suffering from prolonged post-operative pelvic pain (pPPP) consisting of dysuria and prostatodynia for sometimes several months post-surgery. This study elucidates and proposes a definition of the multi-dimensional nature of prolonged post-operative pelvic pain (pPPP) after transurethral prostate surgery by providing real-world data on therapeutic options and their efficacy.

AbstractSection Methods

German and international urologic practitioners participated in an online-survey after invitation via social media accounts and newsletters. The survey included questions on the amount of expertise, the therapeutic regimens for prolonged post-operative pelvic pain (pPPP) and the expected therapy outcome. Participation was voluntary and uncompensated. Chi-Square tests and Student’s t-tests were used for descriptive statistics.

AbstractSection Results

67 German urologists participated in a 9-question online Survey. 94,0% treated patients with lower urinary tract symptoms and 85,1% disclosed their therapeutic regime for prolonged post-operative pelvic pain (pPPP). The most common treatments included anti-inflammatory medication (69,6%), anti-cholinergics (53,6%), alpha-blockers (51,8%) and pelvic physiotherapy (50,0%). Over half of the patients responded to the therapeutic approach, but only 5,4% of urologists anticipated full pain relief after one year. These findings are closely aligned with a recent international survey (n=230). Notably, German urologists more frequently prescribed anti-cholinergics (53,6% vs. 28,7%, p = 0,0004), herbal remedies like saw palmetto (25,0% vs. 6,5%, p < 0,0001) and non-pharmacological therapies (82,1% vs. 49,1%, p < 0,0001), but less anti-inflammatory drugs (69,6% vs. 88,7%, p = 0,0003), gabapentin/pregabalin (8,9% vs. 42,2%, p < 0,0001) and opioids (0% vs 5,7%, p = 0,0221). Based on these results a structured definition and therapy plan for prolonged post-operative pelvic pain (pPPP) is proposed.

AbstractSection Conclusion

Prolonged post-operative pelvic pain (pPPP) is a common challenge for urologists. Despite various therapeutic options, treatment outcomes and practitioner confidence remain suboptimal. Further research and attention to prolonged post-operative pelvic pain (pPPP) are essential to develop evidence-based guidelines for effective patient management and prevention of chronic pain syndromes.

Introduction

Benign prostatic hyperplasia (BPH) affects approximately 50% of men over 50 years, increasing to 90% in men over 90, making it one of the most prevalent conditions in aging males [1, 2]. Many affected individuals develop significant lower urinary tract symptoms (LUTS), necessitating therapeutic interventions including transurethral surgical approaches such as transurethral resection of the prostate (TUR-P) or holmium laser enucleation of the prostate (HoLEP) [3]. Post-operative complications, including persistent or de-novo LUTS, occur in 20–50% of patients following transurethral prostate surgery [4].

A recent review concluded that up to 15% of patients experience prolonged post-operative pelvic pain (pPPP) including dysuria (defined by The International Continence Society as “complaint of pain, burning or other discomfort during voiding”) and pelvic pain in men/prostatodynia (defined by The International Continence Society as “complaint of pain, pressure or discomfort related to the pelvis but not clearly related to the bladder, urethra, scortum or perineum”) for several months post-surgery, regardless of the surgical technique employed [5]. While often transient and self-limiting after three months[5], pPPP can significantly impair quality of life and may evolve from occasional discomfort into a chronic pain syndrome with multidimensional somatic, psychological, and social implications [6].

A recent international Survey of 230 urologists revealed that anti-inflammatory medications, alpha-blockers, and gabapentin/pregabalin are the most commonly prescribed treatments for pPPP [7]. Teoh et al. proposed a 6-step management approach emphasizing diagnosis (especially by ruling-out capsular perforation and urinary tract infection), therapy timing, and optimal treatment options, including pelvic physiotherapy and the aforementioned pharmaceutical options [7]. This study presents a similar online survey among German-speaking urologists, focusing on therapeutic strategies and expected outcomes for pPPP. The analysis and comparison of these two survey results should shed some light on the management of pPPP.

Currently, the condition of pPPP lacks a clear definition and structured diagnostic and therapeutic guidelines. Thus, this study aims to propose a conclusive clinical definition and practical therapy regimen of pPPP based on common clinical practice derived from the answers of experienced urologists in online surveys.

Materials and methods

German online survey

An online survey comprising nine questions in German was conducted using SurveyMonkey (SurveyMonkey Corporation, San Mateo, California, United States (US)) and distributed through the regular German Society of Urology (DGU) newsletter, ensuring broad representation within the German-speaking urological community. Participation was voluntary, anonymous and uncompensated. Table 1 presents the English translation of the questions, question types, and possible answers. The original German questionnaire is available in Supplementary Table 1.

Table 1 Questions of the German online survey in english translation

International online Survey [7]

A 5-question online survey was created using Google Form (Google LLC, Mountain View, California, US) and distributed via the #UroSeMe X platform (formerly: Twitter) in 2020 [8]. Participation was voluntary, anonymous and uncompensated. Table 2 displays the questions, question types, and possible answers.

Table 2 Questions of the international online survey[7]

Statistical analysis

Descriptive statistics were analysed using Microsoft Excel (Microsoft Corporation, Redmond, Washington, US). Comparisons between the two surveys were performed using Chi-Square tests and Student’s t-tests. P-values < 0.05 were considered statistically significant.

Results

German online survey

67 German-speaking urologic practitioners participated in the survey. Almost all participants (94.0%) treated LUTS patients within the last 24 months. Due to partial responses, the number of answers differs between the questions. 56.1% of participants were under 50 years and more than two-third identify themselves as male. More than 75% are board-certified urologists, while the others are residents. 42.1% of participants worked in private practice.

The majority prescribed anti-inflammatory drugs (69.6%), followed by anti-cholinergics (536%), alpha-blockers (51.8%) and pelvic physiotherapy (50.0%) in pPPP therapy. Furthermore, a substantial portion of participants recommended phytotherapeutics (25.0%) and sitz-bath (21.4%). Two participants included modern therapeutic modalities like digital mobile apps (especially Kranus Lutera [9]) and one urologist offered a multi-modal concept including psychotherapy. The importance of substantial diagnostics including cystoscopy and/or microbiological analysis was emphasized in free-text answers. Within the anti-inflammatory drugs, the respondents preferred oral NSAIDs (82.1%) over NSAID suppositories (21.4%) and oral corticosteroids (7.1%).

43,9% of participants considered four weeks adequate for therapy evaluation, while 17.5% only waited two weeks and 38.6% allowed eight weeks or more until considering the therapy as insufficient. The average expected therapy response was 5.53 out of ten patients. 5.4% of patients were considered to be pain-free and 48.9% to benefit by maximum 50% pain reduction after one year. Table 3 shows the detailed results of the German survey.

Table 3 Results of the German online survey

International online survey [7]

230 international urologists participated in the online Survey from 2020, of whom 80% were urology consultants, 9.6% urology fellows and 10.4% were urology residents. The majority (88.7%) prescribed anti-inflammatory drugs in pPPP therapy, followed by alpha-blockers (42.2%), gabapentin/pregabalin (40.4) and pelvic physiotherapy (39.6%). If anti-inflammatory drugs were used, oral NSAIDs (81.3%) were preferred over NSAIDs suppositories (17.0%) and oral corticosteroids (17.0%). 48.3% of the respondents accepted four weeks until therapy evaluation, while 22.2% only waited two weeks. Around 30% of participants allowed the therapy regimen to run at least eight weeks. Only 0.9% of the participants expected all of their patients to respond to therapy, while 39.6% assumed that less than half of their patients will respond. The average expected therapy response was 5.9 out of ten patients. Table 4 shows the detailed results of the international survey.

Table 4 Results of the international online survey [7]

Comparison

A comparison between the German and international surveys revealed several significant differences in therapeutic approaches and demographics with a higher proportion of urology residents in the German survey (21.1% vs. 10.4%, p = 0.0303).

Notably, a greater percentage of international respondents prescribed anti-inflammatory drugs (88.7% vs. 69.6%, p = 0.0003), gabapentin/pregabalin (42.2% vs. 8.9%, p < 0.0001), and opioids (5.7% vs. 0%, p = 0.0221). Conversely, German urologists showed a preference for anti-cholinergic medications (53.6% vs. 28.7%, p = 0.0004), herbal treatments like saw palmetto (25.0% vs. 6.5%, p < 0.0001), and non-pharmaceutical therapies (pelvic physiotherapy, sitz bath, low-intensity extra corporal shockwave therapy and electro stimulation: 82.1% vs. 49.1%, p < 0.0001). International respondents seem to also focus more often on the muscular aspect of pPPP and prescribed muscle-relaxing agents like baclofen (5.7% vs. 0.0%, p = 0.0686). These differences in treatment preferences between German and international urologists may reflect variations in clinical training, healthcare system structures, regulatory environments, and cultural attitudes towards pain management. The higher use of anti-inflammatory drugs, gabapentin/pregabalin, and opioids among international respondents may be influenced by broader prescribing practices and greater acceptance of pharmacological interventions for chronic pain in some countries. In contrast, the more conservative approach observed among German urologists - with a greater reliance on anticholinergic medications, phytotherapy (e.g., saw palmetto), and non-pharmaceutical therapies - may stem from a stronger emphasis on multimodal treatment strategies. Additionally, stricter regulations surrounding opioid prescription in Germany and greater caution regarding their long-term use may further explain the absence of opioid use among German respondents. Phenazopyridine is not approved in Germany, which explains its less frequent utilization compared to the results from the international survey (1.8% vs. 10.9%, p = 0.0340). Figure 1 shows the comparison of treatment strategies. Both groups favored oral NSAIDs over other forms (81.3% vs. 82.1%, p = 0.8849); however, German practitioners were more restrictive in their use of corticosteroids compared to their international counterparts (8.9% vs. 30.9%, p = 0.0009). This might be due to a higher emphasize on the long-term side effects of corticosteroids in the German speaking group.

Fig. 1

Comparison of treatment strategies indicating the percentage of participants that used the respective therapy option. *indicates statistical significance (p < 0.05)

The time frame for considering a therapy ineffective was similar between both groups, with international respondents favoring a maximum duration of two months for evaluation (87.3% vs. 77.2%, p = 0.0400). The expected response rates did not differ significantly between groups, with averages of 5.91 out of ten patients for international respondents compared to 5.53 out of ten for German respondents (p = 0.1869). All results are presented in Supplementary Table 2.

Discussion

Despite new developments in transurethral prostate Surgery, a Substantial portion of patients of 20–50% is left with bothering symptoms of dysuria, urgency, infections or pain after surgery [4, 5, 10]. While some cases have identifiable causes like infections or perforations, the pathophysiology remains unclear for many patients [5]. Pathophysiologic theories include chronic bladder damage from long-term bladder-outlet-obstruction with collagenisation [11, 12] and damage caused by the heat of energy sources like laser and/or electricity during the surgical procedure [13]. Different studies reporting the outcome of various surgical approaches, including new minimally invasive procedures such as Aquablation, Urethral Lift and Rezum [14, 15], suggest a potential influence of the surgical approach to the nature and the rate of postoperative pelvic pain. Heat free methods like Urethral lift and Aquablation might prevent pain due to tissue damage caused by the heat, which might not be noticeable intraoperatively. Patients should be informed preoperatively about the advantages and disadvantages of the respective surgical approach and an individual decision should be made when selecting the treatment strategy with the patients, potentially including e.g. ultrasound parameters to predict the potential surgical outcome [16]. A recent meta-analysis on postoperative pelvic pain one month post-surgery Suggests a disadvantage for ablation procedures showing a rate of postoperative pain of 9% for enucleation, 10% for TURP but 15% for prostatic ablation [14]. Minimally invasive or heat free methods were, however, not included in the analysis. Furthermore, no randomized clinical trials are available, investigating postoperative pain for different surgical approaches when it comes to transurethral prostate surgery and while data suggests that clinical outcome is in part related to the occurrence of residual prostatic tissue [17], further studies are necessary to investigate the influence of residual tissue on the postoperative pain. Additionally, the Post-Voided Residual Ratio (PVR-R) - which measures the proportion of urine left in the bladder after voiding relative to the total bladder volume - was recently studied and rejected as a potential preoperative predictor for favorable outcomes after TURP [18], but evidence on its influence on postoperative pain is still missing.

Building on our current findings, it is important to address the current lack of a clear definition for pPPP. To fill this gap, we propose a clinical definition of pPPP grounded in our survey data, based on the following three key criteria:

• a Complex of symptoms: pelvic and/or perineal pain, dysuria and pollakisuria;

• b Timeframe after transurethral prostate surgery and duration: burden of symptoms for at least two consecutive weeks minimum two weeks post-surgery;

• c Absence of post-operative complications (especially perforation or sphincter injury) and/or urinary tract infection (i.e. no bacteriuria).

This study with two online surveys among urologists shows that urologists frequently encounter pPPP patients based on the aforementioned definition. The therapeutic strategies mainly include symptomatic therapy focusing on pain and inflammation (including anti-inflammatory drugs and/or opioids) and addressing bladder emptying issues (alpha-blockers and/or anti-cholinergics), but also include non-pharmacological options (pelvic physiotherapy and sitz bath) or even multi-modal approaches aligned with the bio-psycho-social pain model [19]. Additionally, antibiotics are frequently used, when a postoperative infection is suspected. A recent study, investigating the role of the urinary microbiome in benign, non-infectious urological conditions [20], suggests that the microbiome is associated with symptom prevalence and severity of chronic pelvic pain syndrome, suggesting a potential influence on pain. Specifically, in chronic pelvic pain syndrome (CPPS), certain microbial taxa have been identified as linked to the condition. Some studies report reduced microbial diversity in patients with CPPS, indicating possible dysbiosis. Although no data currently exist on the postoperative microbiome and its impact on postoperative pain, the findings from this analysis strongly suggest a potential influence that warrants further investigation. Understanding this relationship could also reshape our approach to antibiotic use, as indiscriminate application may further disrupt the microbiome.

These findings align with existing literature on the use of NSAIDs [21, 22], oral corticosteroids [23, 24] and gabapentin [25] for pelvic pain management. Additional therapies such as wrist-ankle acupuncture [26], phosphodiesterase type 5 inhibitor [27] and transperineal botulinum toxin injection [28] have shown promise in early postoperative stage to help patients with pain or catheter-discomfort after transurethral prostate surgery. Systematic reviews support acupuncture and extracorporeal shockwave therapy [29], but find limited evidence for pharmacological interventions like anti-inflammatories, alpha-blockers or phytotherapy with a risk of side effects [30]. This structure is also followed in the European Guideline on chronic pelvic pain [31].

Fortunately, pPPP is self-limiting for a majority of cases, but some men develop a prolonged or chronic pain syndrome similar to chronic pelvic pain syndrome. This condition often includes psychosocial, emotional and sexual dysfunction [6, 32]. Latest at this point it is necessary to evaluate multi-disciplinary and multi-dimensional therapy options including psychotherapy [6, 31, 32].

No matter, how long the symptoms bother the patients; all of these patients need effective and evidence-based therapy. Therefore, we propose a sequential therapy concept for men reporting of bothersome symptoms including pain and dysuria after transurethral prostate surgery based on the aforementioned definition of pPPP:

• 1. Rule out post-operative complications like capsular/bladder perforation by ultrasound (and cystoscopy if needed).

• 2. Rule out urinary tract infection by urine dipstick and urine microbiology. Present bacteriuria (even if asymptomatic) should be treated with targeted antibiotics.

• 3. Offer symptomatic treatment from the beginning including pharmacological pain therapy (primarily NSAID and/or herbal therapeutics) and non-pharmacological therapy (pelvic physiotherapy, extracorporeal shockwave therapy and/or acupuncture).

• 4. Consider modifying the therapeutic regimen without symptomatic improvement after two weeks in a sequential manner. Explore second-line options like alpha-blockers, anti-cholinergics, corticosteroids or gabapentin/pregabalin, but keep in mind the potential side effects.

• 5. Consider pain specialist or psychologist consultation for multi-modal therapy after three months without improvement.

This easy-to-follow sequential therapy plan can sensitize urologists for pPPP and help patients to receive individual and effective therapy as soon as possible to minimize morbidity and limitation of quality of life. This might have a positive impact not only on the patient’s individual health but also for the healthcare system by reducing multiple hospital stays or visits of different practitioners and the economy by bringing the patients back to work earlier.

Comparison to EAU guidelines

As outlined above, most urologists manage pPPP in alignment with the structure and principles of the EAU guidelines on chronic pelvic pain syndrome. Our suggested approach in this manuscript also aligns with these guidelines, while being specifically designed for men with persistent pain after transurethral prostate surgery. Therefore, a stronger emphasis is put on typical postoperative complications and proactive antibiotic treatment even for asymptomatic bacteriuria. Additionally, we propose a shorter, two-week window before escalating therapy, given the higher likelihood of a clinically relevant infection in the immediate postoperative period. In contrast to the EAU guidelines, we recommend postponing early multidisciplinary interventions - such as psychological support - since, in this context, the patient’s symptoms are more likely to be directly related to the surgical procedure rather than to psychosomatic or chronic pain mechanisms.

Limitations of this study

Due to the small sample size, the results cannot be considered representative of the broader urologist population. However, the data nonetheless provide valuable preliminary insights. These findings can serve as a foundation for future larger-scale studies and help guide initial clinical considerations and hypothesis generation in this emerging area of research. Also, the findings are based on physicians’ perceptions and self-reported practices, which may not necessarily reflect real-world clinical outcomes or patient experiences. While survey-based studies offer valuable insights into current trends and expert opinions, they are inherently subjective and may be influenced by individual biases. Furthermore, using an online survey as the primary method of data collection may introduce a selection bias, as it is more likely to attract responses from younger, more digitally engaged urologists. This could potentially lead to an underrepresentation of older or less tech-savvy professionals, thereby influencing the generalizability of the result. However, by choosing the newsletter distributed by the German Association of Urology (DGU) for promoting this survey, we believe that our approach effectively targeted a broad and representative audience. The questionnaires lacked a clear definition of pPPP, which may have led participants to consider a variety of conditions. Additionally, the questionnaire used in this study is not a validated or standardized assessment tool. It was identical to a previously conducted survey, with the sole modification being its translation. This approach was chosen to enable a direct comparison with the results of the earlier published English-language survey. While this does not imply formal validation of the questionnaire, it does demonstrate that the tool has been successfully employed to collect relevant data in prior research.

Conclusion

Prolonged post-operative pelvic pain (pPPP) is a common challenge for urologists, yet it remains a complex condition to treat effectively. Despite the availability of various therapeutic options, both the evidence base for successful outcomes and clinician confidence in treatment efficacy remain low. This study highlights the need for increased research focus and clinical attention on pPPP to improve patient care.

Moreover, there is no clear definition based on high-level evidence. Our proposed definition and consensus-based therapy plan, derived from comprehensive survey data of common clinical practice, aim to provide a foundation for standardized management and future research. By offering a structured approach to pPPP diagnosis and treatment, we hope to enhance clinical outcomes, facilitate earlier interventions, and ultimately improve quality of life for affected patients. This work serves as a stepping stone towards developing evidence-based guidelines and fostering further investigation into this challenging post-surgical complication.