Male Chronic Pelvic Pain Potentially Exacerbated by COVID-19 Infection 2023

Chronic pelvic pain syndrome (CPPS) is a multifactorial disorder in which patients typically present with pain or discomfort in the pelvic region, often accompanied by urologic symptoms or sexual dysfunction. The interplay of the neurological, endocrine, and immune systems is thought to influence the pathogenesis of CPPS.¹

Here, we present a case demonstrating the recurrence of chronic pelvic pain that may be related to infection with COVID-19.

The patient is a 51-year-old male with a medical history of prediabetes mellitus, possible chronic prostatitis, Grade 1 internal hemorrhoids, anal fissure, and nonobstructive nephrolithiasis. He complained of pelvic pain involving the rectum, perineum, and penile area for approximately 7 months. He described the pain as constant and exacerbated by sitting, urination, ejaculation, and defecation. He denied trauma to the pelvis and recent pelvic operations. He was evaluated by multiple specialists including urology, neurosurgery, colorectal surgery, infectious disease, and physical medicine and rehabilitation.

Physical examination was remarkable for tenderness of the levator ani muscle. Prostate exam and cystoscopy were normal. Due to initial urinalysis and seminal fluid culture showing extended-spectrum beta-lactamase-producing Escherichia coli and Enterococcus faecalis, he was treated with oral and intravenous antibiotics.

Following antibiotic therapy, however, his pain symptoms persisted. CT abdomen/pelvis and MRI of the thoracic and lumbar spine did not suggest other potential etiologies. He had a prior flexible sigmoidoscopy that showed an anal fissure, but follow-up colonoscopy was unremarkable.

Trials of NSAIDs, gabapentinoids, tricyclic antidepressants, skeletal muscle relaxants, a topical compounded local anesthetic and skeletal muscle relaxant mixture, pelvic floor exercises, and warm sitz baths were unsuccessful. He was then referred to the interventional pain clinic for further evaluation.

The decision to perform bilateral pudendal nerve blocks under fluoroscopic guidance was made with the patient’s consent. The patient was placed on the fluoroscopy table in the prone position with pillows under the abdomen. The back and gluteal regions were prepped and draped in the usual sterile fashion and sterile technique was adhered to during the entire procedure. Fluoroscopy was utilized to confirm needle and injectate localization.

Following the procedure and up until approximately 2 weeks post-procedure, the patient reported significant pain relief (pre-procedure VAS score: 7 out of 10, post-procedure VAS score: 1 out of 10). Due to improvement of pain symptoms, he was able to discontinue his oral pain medications.

Three weeks after the procedure, the patient developed COVID-19 and reported a return of his pelvic pain. He noted that the pain had been gradually increasing in severity (VAS score 6 out of 10) since the onset of respiratory symptoms related to COVID-19. He otherwise denied any other changes in his daily routine. After recovering from the infection, he was rescheduled for a repeat bilateral pudendal nerve block. Immediately following the procedure, he again reported significant pain relief (pre-procedure VAS score: 9 out of 10, post-procedure VAS score 1-3 out of 10 at 7-week follow-up).

Acute viral illnesses often present with fatigue, arthralgia, myalgia, and organ-specific dysfunction, as seen with influenza and coronavirus infections. Outcomes related to these infections are often focused on the acute response and the corresponding treatment rather than potential long-term sequelae. Although the literature is limited, recent studies have described the recurrence of chronic pain in the setting of COVID-19 infection mainly through the action of proinflammatory mediators.²˒³ In a small study of 22 patients infected with COVID-19, a chronic post-COVID syndrome consisting of fatigue, diffuse myalgia, and recurrence of chronic pain symptoms persisted after acute illness.⁴

A case series of 8 patients whose chronic pain symptoms returned after infection further provides some insight into the spectrum of chronic pain relapse.³ The importance of prompt testing and early treatment for COVID-19, as well as aggressive pain management interventions, is emphasized given the multidimensional impact of chronic pain on quality of life. Our patient was fortunate enough to fully recover from a mild COVID-19 infection and responded well to a repeat of his prior interventional pain procedure.

Although the COVID-19 vaccination has significantly reduced the number of new cases arising in the United States, there are still many individuals suffering from the long-term effects of prior COVID-19 infection. As such, the volume of patients presenting with chronic pain may be expected to rise in both the immediate and long-term.⁴ The optimal management of patients with chronic pain syndrome relapse remains unclear, but it is important to take into consideration that these patient presentations could be related to COVID-19.

Disclosure: As the case report is devoid of patient-identifiable information, it is exempt from IRB review requirements as per the University of Miami policy. Patient informed consent was obtained for submission. The authors have no conflicts of interest to disclose.

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