Strange Vibes - Novel Presentation of Prostatitis.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has significant variability in its presentation. In this study, we present 2 novel cases of prostatitis in which "buzz" is described as the primary pain symptom. These cases describe patients with the primary complaint of "cell phone-like buzzing" within the perineum, with accompanying urinary symptoms consistent with prostatitis. CP/CPPS is a multifactorial disease within which psychological, inflammatory, neurologic, and neuromuscular etiologies are at play. As in other disease descriptions, a buzzing sensation represents the interaction of multiple pathways that have significant overlay with CP/CPPS. As such, we believe buzzing might represent a new symptom of CP/CPPS.

Introduction

Genital pain is a common urologic complaint. It can arise from a myriad of etiologies, including infectious, inflammatory, neurologic, immunogenic, and psychosomatic. The pain can provide a difficult diagnosis and thus treatment dilemma for urologists, particularly in those patients with chronic complaints.

The 1999 National Institute of Health consensus statement redefined chronic prostatitis as a pelvic pain syndrome (category 3) to encompass what is the primary unifying component—pain. Although multiple etiologies have been suggested, the neuromuscular component plays a prominent role in symptomatology. Pain, particularly in the perineum, and urinary symptoms are typical presenting features of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Discomfort in other regions such as the inguinal area, testes, and suprapubic region has also been reported. Paresthesias are common in a variety of neuromuscular disorders such as multiple sclerosis and peripheral neuropathies (eg, diabetic). A buzzing sensation has been used as a descriptor for some of these paresthesias. This symptom has not been described in prostatitis. Rarer paresthesia symptoms of CP/CPPS previously described include numbness, tingling, and sensation of sitting on a foreign object (eg, golf ball). In this study, we describe a novel symptomatology of suspected prostatitis with chronic cell phone–like vibratory buzz sensation. To the best of our knowledge, this has not been previously described.

Retrospective review was conducted on the medical records of 2 patients who presented to an outpatient academic urology practice with complaints of perineal/scrotal “buzzing.” Extensive PubMed review of the literature was performed to determine other similar descriptions. Terms such as dysuria, lower urinary tract symptoms, prostatitis, chronic prostatitis, vibration, and buzz failed to yield any similar descriptions or information pertinent to our cases. With little literature yield, search was extended to include Google search.

Case presentation

Case 1

A 54-year-old man with no significant past medical history presented to the outpatient urology office in June 2012 complaining of 3-4 weeks of a vibratory sensation under the base of his scrotum. The patient noted that this had occurred 4-5 times over this period, with each episode lasting 30-60 minutes. The symptoms were exacerbated by sitting, and there were no identifiable alleviating factors. The patient denied any numbness, pain, lower extremity weakness, or relation to voiding or ejaculation. He did report baseline nocturia with need to void 2-3 times per night and had an American Urological Association symptom score of 7. None of his urinary symptoms had changed over the period. He had no history of urinary tract or sexually transmitted infection.

The physical examination was significant for a tender prostate approximately 15 g in size. Vital signs, general appearance, and the remainder of the genitourinary examination were unremarkable. Midstream clean-catch urine culture was negative. At follow-up approximately 6 weeks later, he noted full resolution of symptoms, and vibratory symptoms had completely subsided. On physical examination, his prostate was no longer tender.

Case 2

A 71-year-old man with genitourinary history significant for recurrent prostatitis, benign prostatic hyperplasia, and elevated prostate-specific antigen with 2 previous negative prostate biopsies presented to the office with complaints of “vibrating in the groin.” The patient specifically described the sensation as akin to the vibration of a cellular telephone and pointed just posterior to the scrotum as the primary location of bother. This “buzzing” was temporally related to worsening urinary frequency and nocturia.

On physical examination, his prostate was without nodules and approximately 35 g in size. There was no discrete tenderness or fluctuance on digital rectal examination. The remainder of his examination was otherwise benign.

In the past, the patient has had dysuria, frequency, and feelings of incomplete emptying as his primary complaints during prostatitis flares. On this occasion, he had 0RBC and 26-50WBC on his urinalysis, but epithelial cells were present, and culture was negative. The vibratory sensation resolved over the coming weeks, and the gentleman returned to his baseline voiding habits.

Discussion

The etiology of CP/CPPS has been demonstrated to be multifactorial with interaction between psychologic factors and immunologic, neurologic, and endocrinologic dysfunction. This interplay results in the vast array of symptoms and the variable degree of symptomatology that CP/CPPS patients display.

The term “buzzing” has been used extensively to describe auditory symptoms, for example, tinnitus. Tinnitus, however, refers to an auditory impression and not a physical sensation as described in these cases. Underlying pathways, however, might be related. There are multiple disease states with tinnitus as a symptom and multiple potential etiologies to its occurrence. All the theories related to the etiology at least in part have underlying neurologic dysfunction. In addition, in cases of somatic tinnitus in which symptoms are altered by body position, psychosomatic features are thought to play a distinct role. In behavioral medicine literature, ear ringing and/or buzzing alone has been a somatic symptom correlated to anxiety, depression, and psychological distress.

Psychological factors stressors are an important contributor in CP/CPPS, as men are more likely to have a history of depression or anxiety. In a small study of medical interns who experienced “phantom vibrations,” interns who reported severely bothersome phantom vibrations also had higher depression and anxiety scores than those who reported subclinical phantom vibrations.

“Buzz” has also been used anecdotally to describe the sign of L'Hermmittee sign in multiple sclerosis patients—an electrical sensation running down the back and legs that occurs when patients flex their neck. This symptom occurs early in the disease process, a disease characterized by demyelination of the central nervous system. In this setting, the buzz is clearly neurologic in origin. Comparisons with other disease states such as diabetic neuropathy do not adequately characterize the symptoms presented by these 2 cases. Diabetic neuropathy commonly presents with a broad range of positive symptoms typically described as “pins and needles” and prickling or tingling.

Conclusion

Our patients presented with a novel complaint of vibratory sensation in the perineum. In both cases, the associated symptoms and physical examination findings support a diagnosis of prostatitis. “Buzzing” has been used as a descriptor in multiple other disease states with multifactorial etiologies similar to those proposed for CP/CPPS and might represent a novel description within the vast prostatitis symptomatology. It is clearly necessary for more research to be completed as to the pathogenesis of prostatitis and its symptoms, and we hope these data allow clinicians to better recognize and manage patients with this disorder.

Conflict of interest

Moldwin R: Taris Biomedical-investigator, medical advisory board; Afferent Pharmaceuticals–investigator; Urigen Pharmaceuticals–investigator, medical advisory board.