Chronic Prostatitis Chronic Pelvic Pain Syndrome

Chronic prostatitis chronic pelvic pain syndrome is pain in the pelvic region for at least 3 months, with or without voiding symptoms, in the absence of urinary tract infection or another identifiable cause.

It is the commonest prostatitis syndrome, accounting for about 90% of cases.

It affects about 2 to 10% of men, mostly at 30 to 50 years, and it greatly reduces quality of life. Treatment is multimodal and based on the symptom pattern.

Pathophysiology. The cause is multifactorial and not settled. Proposed mechanisms:

• Pelvic floor muscle tension and myofascial trigger points.
• Neuroinflammation and central sensitisation.
• Prior or occult infection, autoimmune and inflammatory processes.
• Urinary reflux into the prostatic ducts.
• Psychological factors (anxiety, depression, catastrophising, stress), which both contribute to and result from pain.

Subtypes: inflammatory (leucocytes in prostatic secretions or semen) and non-inflammatory. The distinction has little effect on treatment.

The UPOINT phenotype sorts patients into six domains: urinary, psychosocial, organ specific (prostate), infection, neurological or systemic, and tenderness of muscles.

Pain in the perineum, suprapubic region, testes, penis, groin or lower back, worse with sitting, ejaculation or stress. Lower urinary tract symptoms (frequency, urgency, weak stream), sexual dysfunction (erectile dysfunction, painful ejaculation, reduced desire), and depression or anxiety. Examination: tender prostate in some, and tenderness and tight pelvic floor muscles on rectal examination.

Symptoms of infection, fever or retention indicate a different diagnosis.

• The diagnosis rests on exclusion of other causes.
• Urinalysis, midstream culture, first void urine nucleic acid tests for sexually transmitted infection, and the two glass or four glass test when bacterial prostatitis is suspected.
• Chronic Prostatitis Symptom Index (0 to 43): pain 0 to 21, urinary symptoms 0 to 10, quality of life 0 to 12. Total mild 0 to 14, moderate 15 to 29, severe 30 to 43.
• Digital rectal examination for prostate and pelvic floor tenderness.
• Uroflowmetry and post-void residual. Cystoscopy for haematuria, or when stricture or bladder pain syndrome is suspected.
• Transrectal ultrasound or MRI of the pelvis for atypical features. PSA only when indicated by age and risk.
• Screen for depression and anxiety (PHQ-9 and GAD-7, score of 10 or more).

Differential diagnosis.

• Chronic bacterial prostatitis
• Benign prostatic enlargement
• Bladder pain syndrome (interstitial cystitis)
• Urethral stricture or bladder neck obstruction
• Pelvic floor myalgia and pudendal neuralgia
• Chronic epididymitis or orchialgia
• Prostate or bladder cancer
• Anorectal, hernia, hip or lumbar spine disorders

• Explanation, reassurance and the aim of reducing symptoms and improving function.
• Lifestyle: avoid prolonged sitting and cycling (use a cushion), avoid caffeine, alcohol and spicy food if they worsen symptoms, regular exercise, and warm baths.
• Pelvic floor physiotherapy with myofascial release and relaxation training, 6 to 12 sessions.
• Alpha blocker for voiding symptoms and recent onset: tamsulosin 400 micrograms orally once daily after a meal, or alfuzosin 10 mg prolonged release once daily after a meal, for at least 3 months.
• Single antibiotic course when infection is suspected or the patient has had no antibiotics: ciprofloxacin 500 mg orally twice daily or levofloxacin 500 mg once daily for 4 weeks, reduced for renal impairment. Review at 2 weeks and stop if there is no response. Prolonged or repeated courses are not advised.
• Analgesia: ibuprofen 400 mg orally every 8 hours with food for up to 2 weeks. Avoid long term opioids.
• Neuropathic pain: amitriptyline 10 mg at night, increased to 50 to 75 mg, or gabapentin 300 mg at night, titrated to 900 to 1800 mg daily, or pregabalin 75 mg twice daily, titrated to 150 mg twice daily, reduced when eGFR is under 60.
• Sexual dysfunction: tadalafil 5 mg orally once daily, which also helps voiding symptoms.
• Psychological care: cognitive behavioural therapy and treatment of depression and anxiety, with specialist referral when severe.
• Second line options with limited evidence: low intensity extracorporeal shock wave therapy (4 to 6 weekly sessions), acupuncture, pelvic floor botulinum toxin, tibial or sacral neuromodulation, and pollen extract.
• Surgery has no role, and 5-alpha-reductase inhibitors help only men with an enlarged prostate.

Monitoring. Chronic Prostatitis Symptom Index at baseline, then at 6 and 12 weeks. A fall of at least 6 points is a meaningful response. Review adverse effects of neuropathic agents. Escalate when no improvement in 3 months.

Referral and escalation. Refer to urology or a pain service for persisting symptoms after 3 months, or to a pelvic pain clinic. Urgent referral for fever, retention, haematuria, a suspicious nodule or weight loss.