RU2692644C1 - Method for selecting therapeutic approach to chronic pelvic pain syndrome treatment - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to psychiatry and urology, and can be used to select a therapeutic approach to chronic pelvic pain syndrome. Total blood serotonin and daily dopamine excretion are analysed. If observing a decrease in the level of total serotonin and standard indices of daily excretion of dopamine, a course of antidepressant venlafaxine is prescribed. If observing the increased daily excretion of dopamine and standard or increased values of the total serotonin level, an atypical neuroleptic Quetiapine is prescribed. In case of combined disturbance of neurotransmitter systems with reduction of total serotonin level and increase of daily excretion of dopamine prescribe combination of preparations: antidepressant Venlafaxine and atypical neuroleptic Quetiapine. In case of normative indicators of total serotonin and daily dopamine excreting, cognitive-behavioural psychotherapy and hypno-concussive therapy with self-hypnosis and relaxation training are prescribed.EFFECT: method provides higher clinical effectiveness in chronic pelvic pain syndrome by selecting a differentiated therapeutic approach taking into account pathogenetic mechanisms.1 cl, 4 ex

Description

The invention relates to medicine, namely, to psychiatry and urology, and can be used in the treatment of patients suffering from chronic pelvic pain syndrome.

According to the definition of the European Association of Urology (EAU) chronic pelvic pain syndrome (CPPS) - persistent or intermittent recurrent pelvic pain, accompanied by symptoms of dysfunction from the lower urinary tract (NMP), intestine, genitals of a man or woman; there is no significant clinical pathology - there is no inflammation of infectious or non-infectious genesis, tumor processes, etc. (see Fall M., Baranowski A. R. et all. 2011. Chronic pelvic pain syndrome. European Association of Urology: 10-45 ).

The diagnosis of CPPS is established only by excluding any clinically significant, obvious diseases of the urogenital organs, the intestines, the nervous system, etc. that can cause existing pain (see Fall M., Baranowski AP et all. (2011) Chronic pelvic pain syndrome. European Association of Urology: 10-45).

CPPS is a common, poorly understood and difficult to treat disease (see Kessler TM (2016) Chronic pelvic pain syndrome: Europ. Urol. 69 (2): 298-299).

All manifestations of CPPS and the actual pain, which often reaches a rather high degree of severity, and associated symptoms, violate the quality of life of patients with CPPS, and this reduction is comparable to such diseases as myocardial infarction, coronary heart disease and Crohn's disease (see Wenninger K. , Heiman JR, Rothman I., Berghuis JP, Berger BE (1996) Sickness impact on chronic nonbacterial prostatitis and its correlates (J. Urol. 55: 965-968).

It is known that CPPS is characterized by a high frequency of comorbidity with a number of mental disorders:

- depression (see Mental health diagnoses in patients with interstitial cystotis / painful bladder syndrome and chronic prostatitis / chronic pelvic pain syndrome: a case / control study. J. Urol. 180 (4): 1378-1382);

- anxiety disorders (see Riegel, V. et al. (2014)), for example, in men-A systematic review. Psychosomatic J. Ch. Prostatitis / Chronic Pelvic Pain Syndrome (CP / CPPS) in men-A systematic review. Research 77: 333-350);

- post-traumatic stress disorder (see Riegel In et al. (2014)), in men-A systematic review. Psychosomatic Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP / CPPS) in men-A systematic review. J. Psychosomatic Research 77: 333-350);

- personality disorders (see Riegel, V. et al. (2014)), Systematic review. men. - A systematic review. J. Psychosomatic Research 77: 333-350).

Currently, it is proven that the pathogenesis of CPPS is based on neurobiological (regulatory) disorders.

Neuro-imaging studies (PET, brain MRI) of patients with chronic pelvic pain syndrome revealed activation of the central regulatory structures of the nociceptive system (somatosensory cortex of the cerebral hemispheres, cerebral cortex, islet, prefrontal cortex, talamus, contiguous nucleus (center of pleasure and reinforcement), amygdala). Functional activation in these structures correlates with the intensity of pain of CPPS (see Farmer, MA, Chanda ML, Parks EL, Baliki MN, Apkarian (2011). Brain functional / anatomical changes in chronic prostatitis / chronic pelvic pain syndrome. J. Urol. 186: 117-24). At the same time, these areas of the brain are involved in the formation of emotions, motivation, sensory

sensations, causing an emotional, cognitive and behavioral response to pain (see Farme, MA Brain Functional and Anatomical Changes in Chronicle Prostatitis / Chronicle Pelvic Pain Syndrome J. Urol. 186: 117-124).

In chronic pelvic pain, a decrease in the volume of the gray matter of the somatosensory cortex, islet and prefrontal cortex and hippocampus is detected, in these same structures the activation and loss of the gray matter in depressed patients is proven (see Mordasini L. (2012) Chronic Pelvic Pain Syndrome in Men is Cortulate Cortex Compared to Healthy Controls, Associated with Reduction of Relative Gray Matter, J. Urol. 188 (6): 2233-2237. Somatosensory and prefrontal cortex is activated in patients with hypothyroidism in the context of depression, and the cortex of the nucleus of the brain is in patients with anhedonia (a symptom of depression). At the same time, activation in these areas is significantly enhanced by the combination of chronic pelvic pain and depression in the clinical picture (see Kutcha J. at all. (2015). MAPP : Research Network Neuroimaging Study. Neurolmage Clin 8: 493-502).

Neurobiological theory explains the close relationship between chronic pelvic pain and affective disorders (depression and anxiety) by neurotransmitters common to pain and depression: in affective disorders, there is a deficiency of serotonin, norepinephrine and dopamine; at the same time, serotonin and norepinephrine neurons are involved in the transmission of pain impulses. Disruption in one of these systems leads to disorders in the other, which explains the combined development of chronic pelvic pain and affective disorders. Therefore, if with pain and affective disorders there is an imbalance of the same mediators, then it can be assumed that their correction can lead to success in the treatment of chronic pain.

The neurobiological hypothesis explains the coexistence of chronic pain and affective disorders by the fact that emotional reactions activate the sympathetic nervous system and the hypothalamic-pituitary-adrenal system, this activation through alpha 2 adrenoreceptors leads to the excitation of central nociceptors, from which, by the mechanism of retrograde activation, excitation is transmitted by peripheral peripheral peripheral peripheral peripheral peripheral stimulation of nociceptors. . Also, with psychoemotional stress, there is also a reflex tension of the muscles, in which at the same time algogens are synthesized, sensitizing the muscle peripheral nociceptors. As a result, peripheral nociceptors begin to send signals to the central nervous system, supporting its sensitization and thereby closing the vicious circle of activation of the nociceptive system as a whole (see Osipova VV. Psychological aspects of pain. Neurology, neuropsychiatry, psychosomatics. 2010, 2 (1 ): 4-9).

Thus, emotional disorders can be one of the factors responsible for the onset and maintenance of chronic pain (see Kukushkin M.L., Tabeeva EV, Podchufarova EV (2011) Clinical guidelines. Pain syndrome: pathophysiology, clinic, treatment. M .: IMA-PRESS, 72 p.).

Based on the foregoing, the approaches of various authors to the treatment of CPPS with the use of psychotropic drugs are understandable.

There is a method of treating CHPS with tricyclic antidepressant amitriptyline, which leads to a significant reduction in pain in 67% of patients with CPPS. Amitriptyline is prescribed in a dosage of 25 mg to 100 mg per day once a day, in the evening before bedtime. Therapy begins with a minimum dosage, gradually increasing to 100 mg per day using the minimum effective dosage (see Saarto T., Wiffen PJ (2005) Antidepressants for neuropathic pain. Cochrane Database Syst. Rev. Jul: 20-23; Ophoven A. , Pokupic S., Heinecke A., et al. (2004) A prospective, randomized, placebo controlled,

double-blind study of amitriptyline for the treatment of interstitial cystitis. J Urol 172 (2): 533-6).

The disadvantages of the described method include the lack of an algorithm for choosing this method of therapy and sufficient information about its differentiated effectiveness.

Selitsky G.V. et al. proposed a method for treating patients with CPPS with a selective serotonin and adrenaline reuptake inhibitor milnacipran at a daily dosage of 100 mg for 12 weeks. As a result of therapy, "a marked decrease in pain syndrome by 26.1% in the vast majority of patients, as well as a decrease in the degree of anxiety and depressive disorders to a mild degree" (see Selitsky GV, et al. (2007) Milnacipran (Ixel) in the treatment of anxiety-depressive and sexual disorders in patients with non-inflammatory chronic pelvic pain syndrome (5: 81-84).

The disadvantages of the described method include the lack of an algorithm for choosing this method of therapy and clear information about its effectiveness.

Xia D. at al. suggested treatment of chronic pelvic pain syndrome by a selective serotonin reuptake inhibitor fluoxetine. The method of treatment is as follows: patients with stable CHTB without a response to antibiotic therapy and beta-blocker therapy received a selective serotonin reuptake inhibitor fluoxetine at a dose of 20 mg / day for three months. As a result of this therapy, "69.05% of patients had a significant improvement in the subjective global assessment and 78.57% had a more than 50% reduction in the severity of urological symptoms at the end of therapy (week 12)", which the authors attributed to a decrease in depressive symptoms ( see Xia D, Wang P. at all. (2011) Fluoxetine ameliorates symptoms of refractory chronic prostatitis / chronic pelvic pain syndrome (Chinese Medical Journal 124: 2158-2161).

The disadvantages of the described method include the lack of an algorithm for choosing this method of therapy and insufficient information about its effectiveness.

Barulin AE, Kurushina V.V., Dumtsev V.V. suggest the appointment of the neuroleptic alimemazine tartrate: for CPPS, accompanied by anxiety, patients are prescribed alimemazine tartrate in a daily dose of 60-80 mg in three to four doses (see Barulin AE, Kurushina OV, Dumtsev VV (2016 ) Modern approaches to the treatment of chronic pelvic pain. Breast cancer 13: 847-850).

The disadvantages of the described method include the absence of an algorithm for choosing this method of therapy and information about its effectiveness.

Tripp D.A. He proposed cognitive behavioral therapy for CPPS, aimed at correcting psycho-social factors associated with CPPS. Cognitive-behavioral therapy sessions are held 1 time per week for 8 weeks. During the sessions, the patient’s disastrous effects are affected, the patient’s psychosocial support is provided, a change in the patient’s pessimistic thinking regarding the pain syndrome and health-oriented thinking and behavior is formed (see Tripp DA (2011) A feasibility trial of cognitive-behavioral symptom management chronic prostatitis / chronic pelvic pain syndrome (Canadian Urological Association 5: 5-7).

The disadvantages of the described method include the absence of an algorithm for choosing this method of therapy and information about its effectiveness.

We did not find any analogs of the method used by us, which envisage a clear choice of a specific approach to the treatment of CPPS, based on an assessment of the pathogenetic mechanisms of suffering.

The technical result of the invention is to increase the effectiveness of treatment of chronic pelvic pain syndrome by choosing

differentiated treatment tactics taking into account the pathogenetic mechanisms of suffering.

This goal is achieved by the fact that after clinical diagnosis of CPPS in the laboratory, studies of the level of total serotonin in the blood and the daily excretion of dopamine are performed using any method available for the laboratory. If a decrease in the level of total serotonin is detected, and the standard indicators of the daily excretion of dopamine, the patient is prescribed a course of the antidepressant Venlafaxine; when elevated daily excretion of dopamine is detected and standard or elevated levels of total serotonin are detected - an atypical neuroleptic Quetiapine; in the case of the normative indicators of the level of total serotonin and daily excretion of dopamine, cognitive behavioral psychotherapy and hypnosuggestive therapy with self-hypnosis and relaxation techniques are prescribed.

The invention "Method of choice of treatment tactics for chronic pelvic pain syndrome" is new, since it is unknown in the field of medicine.

The novelty of the invention lies in the fact that for the first time a simple technique has been proposed that allows one to choose differentiated treatment tactics based on an understanding of the pathogenetic mechanisms of suffering. The essence of the technique is that by performing the proposed biochemical studies, the leading neurotransmitter disorder is revealed (or its absence, which brings to the forefront the need for psychotherapy), and this allows you to choose a specific, pathogenetically oriented method of treatment. At the same time, the identified primary disorders in serotonin neuromediation are the basis for the choice of antidepressants, and the dominant

disorders in the catecholamine system (dopamine, in particular) suggest the choice of an antipsychotic.

The invention "Method of choosing the tactics of treatment of chronic pelvic pain syndrome" is industrially applicable, as it can be used in health care, medical institutions of urological, therapeutic, neurological, psychiatric profile.

The method of selection of tactics for the treatment of chronic pelvic pain syndrome is as follows.

After the examination and diagnosis of CPPS, the laboratory performs a study of the level of total serotonin in the blood and the daily excretion of dopamine using any method available for the laboratory. According to research results, 4 options are possible:

1. The level of total serotonin in the blood is below the limits of the norm established by the laboratory for this method of research, the indices of daily excretion of dopamine are normative. The patient is prescribed a course of antidepressants (Venlafaxine).

2. Daily excretion of dopamine exceeds the limits of the norms established by the laboratory, with regulatory or elevated levels of blood serotonin levels. The patient is prescribed therapy with an atypical neuroleptic (Quetiapine).

3. The combined violation of neurotransmitter systems (low content of total serotonin in the blood and increased daily excretion of dopamine). Prescribes a combination of base classes of drugs (the antidepressant Venlafaxine and the atypical neuroleptic Quetapine).

4. Regulatory indicators of total serotonin levels and daily excretion of dopamine. Cognitive-behavioral psychotherapy and hypnysuggestive therapy with self-hypnosis and relaxation techniques are prescribed.

A course of antidepressant therapy is carried out as follows.

Patients with CPPS are assigned a selective serotonin and noradrenaline reuptake inhibitor - Venlafaxine - in the initial dose of 75 mg per day in two doses (37.5 mg twice a day). Next, the dose is titrated (gradual increase) of venlafaxine to therapeutically effective and tolerable, first up to 150 mg per day, then up to 225 mg per day with an interval of increasing the dose of venlafaxine in 2 weeks. When clinically necessary and in connection with the severity of symptoms, the interval for increasing the dose of Venlafaxine may be shorter, but not less than 4 days.

When a therapeutically effective and tolerable dose of Venlafaxine is reached, maintenance therapy is carried out in the minimum effective dosage of Venlafaxine for at least 6 months, followed by gradual withdrawal of Venlafaxine.

A course of neuroleptic therapy is carried out as follows.

Patients with CPPS are prescribed the neuroleptic Quetiapine in an initial dose of 100 mg per day in a single dose. Next, the dose is titrated (gradual increase) of Quetiapine to therapeutically effective and tolerable, but no more than on day 1 — 100 mg, day 2 — 200 mg, day 3 — 300 mg, day 4 — 400 mg. If necessary, the dose of Quetiapine is increased to 800 mg per day, but not earlier than by the 6th day of therapy, while the increase in the daily dose of Quetiapine should not exceed 200 mg per day.

When a therapeutically effective and tolerable dose of Quetiapine is reached, maintenance therapy is carried out at the minimum effective dosage of Quetiapine for at least 6 months, followed by gradual withdrawal of Quetiapine.

The course of combined therapy is carried out as follows. Patients with CPPS are prescribed a selective serotonin and norepinephrine reuptake inhibitor Venlafaxine in the initial dose of 75 mg per day.

a day in two doses (37.5 mg 2 times a day). Quetiapine in the initial dose of 100 mg per day in a single dose.

Next, the dose is titrated (gradual increase) of Venlafaxine to 150 mg per day, then to 225 mg per day with an interval of increasing the dose of Venlafaxine in 2 weeks or more. When clinically necessary and in connection with the severity of symptoms, the interval for increasing the dose of Venlafaxine may be shorter, but not less than 4 days.

At the same time, the dose of Quetiapine is titrated to 200-400 mg per day, not more than on day 1 — 100 mg, day 2 — 200 mg, day 3 — 300 mg, day 4 — 400 mg. If necessary, the dose of Quetiapine is increased to 800 mg per day, but not earlier than by the 6th day of therapy, while the increase in the daily dose of Quetiapine should not exceed 200 mg per day.

Titration of doses of Venlafaxine and Quetiapine is carried out to therapeutically effective and tolerable, upon reaching which maintenance therapy is conducted with Venlafaxine and Quetiapine, in the minimum effective dosage not less than 6 months, with subsequent gradual withdrawal of drugs.

A course of psychotherapy is carried out as follows.

10-15 sessions of cognitive-behavioral psychotherapy are held for patients with CPPS, during which, together with the psychotherapist, dysfunctional attitudes regarding the nature of CPPS and the possibilities of its therapy are detected and corrected. Also, with the use of hypno-suggestive therapy with self-hypnosis training and relaxation techniques, the skill of relaxation is reconstructed, which is lost during CPPS in order to relieve the patient’s emotional and muscular tension, as well as to teach the patient how to apply this skill independently.

Examples of the application of the “Method for choosing the tactics of treatment of chronic pelvic pain syndrome” in patients.

Example number 1. Patient L., 36 years old.

Anamnesis from the words of the patient, the patient’s spouse, medical records: it was not possible to identify the psychopathological burden. The patient's mother is hospitable, friendly, "economic", the father is "a master of all trades, stingy, hard-working." The patient's parents worked on the collective farm, the father was a combine operator, the mother was a worker on the farm, both were front-rank workers. The patient does not have data on pregnancy, birth of the mother, his early period of childhood. Born in 1980 as the youngest child in a structurally and functionally complete family. The patient has four older sisters (two half-sisters and two single uterine 1961, 1969 born from previous parent marriages). Quickly enough after the birth, the mother went to work, the patient was “nursed by the sisters”, with whom she had a warm relationship. I attended kindergarten, willingly. I went to school at the age of 7. He studied mostly satisfactorily, his favorite subject was mathematics. He spent his free time after school on the street with friends, his favorite games were mobile. Grew up a sociable, obedient, impressionable child. Puberty at 13-14 years, proceeded without features. The first alcohol test at age 17, in the company of friends. I tried marijuana several times. Throughout his life, he used alcohol culturally, but quite often, on a weekly basis (mostly beer, up to 2.0 liters), no dependence was found. He graduated from 9 classes of secondary school, then a college in the specialty "welder". He passed military service from 1998 to 2000. After demobilization, he worked in his specialty. In 2001, he married, in 2002, the patient had a daughter. He characterizes her marriage as “good, happy”, mutual understanding with her wife as a whole. In 2007, the patient had a second daughter. In 2008-2009 he works as a driver, he loves his job. According to his wife, according to the nature of “calm, phlegmatic, non-conflicting, impressionable, attentive to her health, suspicious”.

In the spring of 2012, a patient developed an autochthonous depressive somatized episode with pronounced senesthopathies in the area

of the chest that lasted no more than two weeks and ended also autochthonously: in the spring of 2012, for no apparent reason, the patient developed “shortness of breath” - the feeling that “there is not enough air, he could not breathe completely, as if he was pinching something in his chest », Accompanied by weakness, drowsiness, yawning, steadily decreased mood, after 1.5-2 weeks, these phenomena disappeared without a trace.

A repeated depressive episode developed a year later, in the spring of 2013, also autochthonously and became protracted; in the structure of the second depressive episode, senesthopathy in the chest area (similar to the first episode) came to the fore: in the spring of 2013, “dyspnea” in a patient for no apparent reason recurred and became constant - “all the time was choking”, there was a feeling of incomplete inhalation "," A lump in the chest ", which was accompanied by a yawn, a pronounced weakness," did not want to do anything during this period of time, did not care. " Dyspnea was observed only in the daytime, slept well at night. In the same period appear persistent low mood, longing, anhedonia, vigor, activity, and the patient's performance began to decline. He was examined by internists, there was no clinically significant pathology, the prescribed treatment did not bring relief.

In the winter of 2014, the patient's father died, that the latter suffered “very hard”, became depressed, gloomy, did not open up in his experiences - “kept everything in himself,” the emotional state worsened after the death of his father: anguish increased, emotional pain increased, the mood became more depressed, "There was no power."

By January 2015, the sensation of shortness of breath was gone. However, the feeling of sadness, heartache, “my heart was not good,” remained, I felt weak, lack of strength, joylessness, “I didn’t want to do anything, nothing was interesting.”

This condition improved somewhat in the summer months of 2014 and 2015, but did not go to full health. In March 2016 on the background

the patient continued to experience emotional disorders after hypothermia, increased urination (up to 8-10 times a day), to which, after two weeks (late March-early April 2016), there was a feeling of incomplete emptying of the bladder, constant urge to urinate, expressed pain over the bosom, pain in the perineum. Passed inpatient treatment in the GB №1 them. Semashko in the urology department from 04/21/2016 to 04/30/2016 with a diagnosis of chronic bacterial prostatitis. At the same time, the patient's mood dropped even more (the reduced depressed mood became noticeably dear), the patient became more gloomy, moody, withdrawn, less sociable, stopped joking and smiling, "could not rejoice at anything", became not as bright as before , emotions, increased feeling of weakness, fatigue.

After a complete adequate course of treatment of prostatitis, in spite of the normalization of laboratory parameters, the pain in the patient in the pelvic region not only persisted, but also increased in intensity and duration, began to be senestoalgic in nature, dysuric disorders increased; the severity of both pain and dysuric disorders had a daily dynamics (with worsening in the morning), pain over the bosom, in the perineal region there was a paroxysmal pattern for several days, then a day or two passed, but at that time “there was still some unpleasant feeling in the perineum, persistent urge to urinate and frequent urination; gradually pains in the bladder, perineum (in the prostate) became constant, up to 5 points out of ten, periodically increasing to 8-10 points; there was a burning sensation after urinating along the urethra, "even tried to endure and not urinate for a long time, so as not to experience this unpleasant, oppressive burning sensation", when he suffered pain, he felt painful, "I hold urine constantly, my brain started to boil"; I felt a “bladder” getting bladder after drinking liquids, while

there was pain in the bladder; when he sat down on something, "as it gave an unpleasant feeling, not pain, but disgusting, as if by nerves in the scrotum, rectum, tail bone." During intercourse, pain in the penis appeared, “as if nerves were irritated there,” after the completion of coitus, pain passed, erection decreased, premature ejaculation appeared, the patient avoided prolonging sexual intercourse due to pain, and also reduced the number of sexual contacts to 1 , rarely 2 per week (3-4 before illness). I felt the worst in the morning hours, by the evening the pains could be somewhat relieved. Periodically, during urination, there was a feeling that “he cannot urinate, like some kind of spasm, the urine does not flow, one has to push it out of oneself,” which was accompanied by panic, a sensation of heat. Constantly "he listened to himself, to his body, thought only about pain, what happened to me, why it hurts so much." From October 2016, early awakenings appeared, sleep became shallow, the feeling of rest after sleep disappeared; the patient began to cope with work because of his state of health, became withdrawn, immersed in experiences, began to communicate even with relatives. A scrupulous examination by a urologist in 2016, a neurologist did not reveal any significant organic cause that would explain the duration and severity of persistent pain syndrome and dysuric disorders (microscopic and cultural examination of urine, prostate secretions, ejaculate which did not detect microorganisms, leukocytosis as signs of inflammation Uroflowmetry 07.10.2016 - the bladder is normal, with normal elasticity, with normal contractility. Transrectal ultrasound of the prostate gland and seminal pu Ultrasound angiography on 10/01/2016: moderate diffuse changes in the prostate parenchyma. Urination diary, July 2016: urination 4 to 7 per day, volume from 150 to 300 ml; MRI of the lumbar spine: CT scan of osteochondrosis spine

first degree. Consulted by a neurologist in September 2016 - no neurological pathology was identified).

The patient's urologist was diagnosed with chronic pelvic pain syndrome. The patient's condition did not improve, and when the urologist re-examined a somatically significant pathology, it was not possible to identify the patient, he was referred for a consultation with a psychiatrist.

The patient was conducted laboratory research methods (from 05.03.2017):

Blood serotonin (total) - 46 ng / ml (at a rate of 50-220)

Urine catecholamines (daily excretion):

Adrenaline - 16 mcg / day (at a rate of 0-25)

Norepinephrine - 47 mcg / day (at a rate of 15-70)

Dopamine - 176 mcg / day (at a rate of 65-500)

The patient was diagnosed with clinical and psychopathological methods on the basis of complaints, anamnesis and laboratory research methods: chronic pelvic pain syndrome. Recurrent depressive disorder, the current episode of moderate degree with somatic symptoms (larpi depression).

Considering that the laboratory study of the patient's neurotransmitter systems revealed a decrease in the level of total serotonin and regulatory indicators of dopamine excretion, in accordance with the “Method for choosing the tactics of chronic pelvic pain syndrome”, the patient was prescribed Venlafaxine at a dose of 75 mg per day in two doses. The dose of Venlafaxine was gradually increased to 225 mg per day with an interval of increasing the dose of Venlafaxine at 2 weeks, during which drug remission was achieved: all pains in the pelvic region, impatient urge to urinate, discomfort during urination, senestoalgia in the penis in coitus, were relieved. Restored to a euthymic mood, brightness of emotions, anhedonia were stopped, pathological fixation on his well-being, sleep disturbances, sexual function was restored,

vigor, activity, performance; the patient became again sociable, cheerful, began to cope at work, he felt completely healthy.

Further, maintenance therapy was carried out at this dosage (Venlafaxine 225 mg per day in two doses) for 7 months, followed by gradual abolition of Venlafaxine and the patient's release into clinical remission.

Example number 2. Patient K., 35 years old.

Anamnesis according to the patient: heredity is burdened by the abuse of alcohol by the patient’s father. Born from a normal pregnancy, term labor without features. Grew and developed in accordance with psycho-physiological standards. From 3 years old I attended kindergarten. By the nature of the formed sociable, mobile, vulnerable, good-natured child. Favorite games - mobile. At the age of 7 I went to school, in the children's team I adapted without features. He studied mainly on "satisfactory", without interest. Puberty at 13-14 years, without features. Upon completion of the 9th grade, he entered the road technical school, after which he served urgent service. He worked as a security guard at the factory. He married at the age of 25, at the age of 26 the son was born to the patient.

Since 2013 (30 years), the patient has pain in the perineum, testicles, in the inguinal areas, pain in the penis during ejaculation. These pains were periodic at the beginning - they were observed for several hours 2-3 times a week, they could be provoked by psycho-emotional stress, “aching, nasty”, “they move - it hurts now in the prostate, now in the scrotum, now in the groin”. Also, since 2013, since the onset of pain, the patient has slightly, but his mood has steadily decreased, the “pleasure from life” has disappeared, apathy and anhedonia have appeared, and the physical tone has decreased. Efficiency, decreased appetite - "lost 15 kg in 3 months," the process of falling asleep was extended, sleep

became superficial. Since 2014, pain in the perineum, testicles, and inguinal areas became constant, by 3-4 points out of 10, periodically increased to 7-8 points out of 10, had daily and seasonal dynamics. Repeatedly examined by a urologist - no dynamics, clinically significant urological, neurological pathology was found, turned to a psychiatrist with a urological diagnosis "Syndrome chronic pelvic pain III A, remission."

The patient was conducted laboratory research methods (from 06.24.2017):

Blood serotonin - 197 ng / ml (at a rate of 50-220); Urinary catecholamines (daily excretion): adrenaline - 8 mcg / day (at a rate of 0-25), noradrenaline - 24 mcg / day (at a rate of 15-70), dopamine - 512 mcg / day (at a rate of 65-500)

Clinical diagnosis: moderate depressive episode with somatic symptoms.

Since the daily excretion of dopamine exceeded the limits set by the laboratory, the blood serotonin level was within the normal range, the patient received therapy with the atypical neuroleptic Quetiapine according to the indicated method: Quetiapine with an initial dose of 100 mg per day was titrated to 200 mg per day in a single dose. 100 mg per day in a single dose. After stabilization of the condition and the period of maintenance therapy for 7 months, Quetiapine was gradually canceled.

Example 3. Patient F., 38 years old.

Anamnesis from the patient's words: heredity is burdened by the psychopathological abuse of alcohol by the father, uncle, grandfather in the line of the father. Born from a normal pregnancy, urgent delivery. Grew up and developed in accordance with psycho-physiological standards. I did not attend kindergarten, I was with my mother. I went to school at the age of 7, adapted without features. He studied “well” and “satisfactorily”, without much interest, but he attended school with pleasure - “I liked communication in a team”. Was restless

active, held leadership positions. Also attended the section of basketball, tourism. Pubert 14-15 years, without features. He graduated from 11 classes in 1997, then received a higher education in engineering. In 2000 (20 years old) he married, in February 2001 a son was born to a patient. In the fall of 2001 (21 years old), the patient had a feeling of nausea, tingling "in the kidney area", decreased mood, dramatically decreased appetite, significantly decreased body weight, a feeling of weakness, fatigue, "it was all the time bad, but what happened to me unclear". Against the background of this condition, he suffered an exacerbation of prostatitis, was treated by a urologist, however, after the relief of prostatitis symptoms, the above listed complaints persisted. By the spring of 2002, the state gradually began to improve and by the autumn of 2002 it was fully restored to full health. In the spring of 2017, against the background of exacerbation of chronic prostatitis, the patient developed weakness, lethargy, decreased strength, mood gradually decreased, joylessness, apathy, anxiety appeared, interest in something was lost, appetite was upset, body weight decreased by 10 kg, "disappeared" feeling of rest after sleep, confusion and loss of concentration, “inability to concentrate”, feeling of “fog in the head, dry mouth, feeling of constant pulsation in the body,” distraction, anxiety, feeling of trembling, chills throughout the whole body, Corollary feelings of relaxation after sleep. About 3 months ago decreased potency, libido. Since spring 2017, after a successfully treated exacerbation of hr. Prostatitis, the imperative unexpressed urge to urinate, persistent pain and discomfort in the perineal area, up to 3-4 points out of 10, are aggravated by the evening (clinically significant urological pathology has not been identified). Because of the “bad state of health”, the patient struggled to cope at work and with housework, raising his son.

He turned to a psychiatrist with a urological diagnosis of chronic pelvic pain syndrome III A, remission.

The patient was conducted laboratory research methods (from 04.08.2017): blood serotonin - 34 ng / ml (at a rate of 50-220); urine catecholamines (daily excretion): adrenaline - 6 mcg / day (at a rate of 0-25), noradrenaline - 39 mcg / day (at a rate of 15-70), dopamine - 546 mcg / day (at a rate of 65-500).

Clinical diagnosis: recurrent depressive disorder, the current episode of moderate degree with somatic symptoms.

Since the patient was found to have a combined disorder of the neurotransmitter systems - low blood serotonin levels and increased daily excretion of dopamine, the patient was treated with antidepressant Venlafaxine in combination with the atypical antipsychotic Quetiapine 100 mg per day. Titration of the doses of Venlafaxine and Quetiapine was carried out to therapeutically effective and tolerable (Venlafaxine 337.5 mg per day, Quetiapine 100 mg per day), after which maintenance therapy with Venlafaxine and Quetiapine was carried out for 10 months, followed by gradual withdrawal of the drugs.

Example 4. Patient K., 29 years old.

Anamnesis according to the patient: psychopathological heredity is not burdened. Born from the second normally proceeding pregnancy, urgent delivery. Grew up and developed in accordance with psycho-physiological standards. Grew up a quiet, thoughtful, independent child. I attended kindergarten from 4 years. From 7 years old I went to school, I studied perfectly well, with interest. Engaged in a chess club. Puberty at 15-16 years old, leaked smoothly. After graduating from school, he studied at the university in the specialty "programmer", who graduated mostly perfectly. Doing business in the service sector. Not married, but about 4 years dating a girl.

In 2016, in the winter, for no apparent reason, the patient experienced pain in the scrotum, perineum region, “pulling” in nature, “annoying with its presence”, intensity at 3 points out of 10. This pain was associated with

varicocele, for which he underwent surgery in the spring of 2016. For one and a half months after the operation, he did not feel pain, but by the beginning of summer 2016 the previous pain in the perineum and scrotum had returned, was observed daily, mostly in the evening, by 3 points from 10, in the afternoon, when he was busy, “pays less attention to pain”. Reports that since the beginning of the summer of 2016, since the onset of pain after the operation, the mood slightly decreased, the range of interests gradually decreased, events and phenomena that brought joy earlier, stopped causing a bright emotional response, emotions became muffled, “frozen”, physical and mental strength, increased apathy, "indifference to everything", decreased appetite, sleep stopped bringing a feeling of rest, periodically became intermittent, but at work the patient coped, the state, including pain syn core deteriorated in the evening. Repeatedly examined and treated by a urologist without dynamics. Appealed to a psychiatrist with a urological diagnosis of Chronic Pelvic Pain III B Syndrome.

The patient was conducted laboratory research methods (from 14.11.2017): Blood serotonin - 182 ng / ml (at a rate of 50-220); Urinary catecholamines (daily excretion): adrenaline - 14.7 µg / day (at a rate of 0-25), noradrenaline - 19 µg / day (at a rate of 15-70), dopamine - 186.4 µg / day (at a rate of 65- 500).

Clinical diagnosis: a mild depressive episode with somatic symptoms.

Taking into account the normative indicators of neurotransmitter systems, in accordance with the claimed method, the patient underwent a course of cognitive-behavioral psychotherapy from 15 sessions with the adjustment of dysfunctional attitudes regarding the nature of CPPS, formed during the period of the disease; the patient was taught self-hypnosis and relaxation techniques. Therapy had a positive trend with relief of pain and recovery of emotional background.

The proposed method was treated 58 patients suffering from CTPS.

Of these, 16 (27.5%) showed a decrease in the level of total serotonin and regulatory indicators of dopamine excretion, these patients were prescribed a course of the antidepressant Venlafaxine according to the claimed method;

12 (20.8%) showed increased daily excretion of dopamine with standard or elevated levels of total serotonin, patients received a course of quetiapine neuroleptic according to the claimed method;

19 (32.8%) patients showed a decrease in the level of total serotonin and increased daily excretion of dopamine, in this case, patients received a combination of the antidepressant Venlafaxine and the antipsychotic Quetiapine according to the claimed method;

11 (18.9%) patients had no violations in the neurotransmitter systems studied, these patients underwent cognitive-behavioral psychotherapy and hypnosuggesting therapy with self-hypnosis training and relaxation techniques in accordance with the claimed method.

Persistent remission was achieved in 22 (37.9%) cases, a persistent, marked improvement in the condition in 31 (53.4%) patients. Therapy was ineffective in 5 (8.6%) patients.

Technical and economic efficiency of the "Method of choice of tactics for the treatment of chronic pelvic pain syndrome" is that the use of the method allows to significantly increase the effectiveness of therapeutic and preventive measures, giving them a pathogenetic orientation.

Claims (1)

A method for choosing the tactics of treating chronic pelvic pain, including psychopharmacotherapy and psychotherapy, characterized in that studies of the level of total serotonin in the blood and the daily excretion of dopamine are performed, and when a decrease in the level of total serotonin is detected and the standard indicators of the daily excretion of dopamine, the patient is prescribed a course of the anti-depressant Venlafaxine; when elevated daily excretion of dopamine is detected and standard or elevated levels of total serotonin are detected - an atypical neuroleptic Quetiapine, in the case of a combined violation of neurotransmitter systems while reducing the level of total serotonin and increasing the daily excretion of dopamine, a combination of drugs is prescribed: Venlafaxine and an Atypical pattern. in the case of the normative indicators of the level of total serotonin and daily excretion of dopamine, cognitive behavioral psychotherapy and hypnosuggestive therapy with self-hypnosis and relaxation techniques are prescribed.