Approach

This topic covers chronic pelvic pain of nonbacterial origin localized to/centered around the prostate. Keep in mind, however, that chronic pelvic pain syndromes are closely linked and are difficult to separate in clinical practice. The term chronic pelvic pain syndrome is often used when pain is localized to more than one organ site in the pelvis (typically including perineal, suprapubic, testicular, or penile pain).[1] When pain is localized to a specific organ, some specialists use an end-organ term - such as primary prostate pain syndrome (PPPS) - where pain is localized to/around the prostate.[4] Note that some specialists also prefer not to subdivide pain syndromes by anatomy and instead refer to all patients with pain perceived within the pelvis, with no specific underlying disease process identified, as having chronic pelvic pain syndrome.

Conditions that are also considered to fall under the umbrella term of chronic pelvic pain syndromes and include signs and symptoms that may significantly overlap with PPPS include interstitial cystitis/primary bladder pain syndrome, primary urethral pain syndrome, and primary testicular pain syndrome. See Differentials.

Chronic pelvic pain syndromes are symptomatic diagnoses; the approach to diagnosing chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is therefore fundamentally based on history taking.

Suspect CP/CPPS if all three of the following criteria are present in a patient:[4]

  • A history of pelvic pain with its maximum in the region of the prostate (usually reproducible by prostate palpation)

  • Symptoms present for ≥3 months

  • Absence of other underlying pathology

    • Pelvic pain associated with a specific disease (such as bacterial infection, cancer, neurogenic disease, primary anatomic or functional disease) must therefore be ruled out.[4]

Evaluate the severity of disease using a validated symptom score in order to monitor disease progression and treatment response.[4][42]

As there is no definitive test to diagnose CP/CPPS, investigations should primarily be performed to rule out any underlying pathologies that may present with similar symptoms, as well as to aid phenotypic description (describing the condition in terms of its symptoms, signs, and investigation results).[4]

[Figure caption and citation for the preceding image starts]: ​Diagnostic algorithm for diagnosing chronic pelvic pain; *Specific disease-associated pelvic pain caused by bacterial infection, cancer, drug-induced pathology, primary anatomical or functional disease of the pelvic organs, and neurogenic disease must be ruled out​Adapted from Engeler DS et al. EAU guidelines on chronic pelvic pain. Edition 2023. European association of Urology. Nijmegen, The Netherlands (https://uroweb.org/guidelines/chronic-pelvic-pain); used with permission [Citation ends].com.bmj.content.model.Caption@3ef27b29

History

A detailed history is an important first step in the evaluation of CP/CPPS; this should include the type of pain experienced, the localization of the pain, and the duration. Although the patient may describe pelvic pain, which is felt mostly in and around the location of the prostate, pain may also occur in areas outside the prostate including one or more of the following locations:[4][6]

  • Perineum

  • Abdomen/abdominal muscles/subrapubic region

  • Testicles

  • Penis

  • Rectum

  • Lower back

  • Inguinal region

  • Pelvic floor/pelvic floor muscles

  • Gluteal region/muscles.

In a retrospective analysis of the clinical records of 1563 men with CP/CPPS, perineal pain was the most prevalent pain symptom, occurring in 63% of patients, followed by testicular pain (58%), pain in the pubic area (42%), and penile pain (32%).[43]

Patients may also present with associated lower urinary tract signs and symptoms and/or signs and symptoms of sexual dysfunction, such as:[4][6]

  • Dysuria/urethral pain

  • Urinary frequency

  • Urinary urgency (which may be associated with urge incontinence)

  • Poor stream

  • Nocturia

  • Erectile dysfunction

  • Pain on or after ejaculation

  • Hematospermia

  • Neuropathic pain.

Clarify progression of symptoms with the patient. In malignant disease, symptoms are usually progressive, whereas in chronic primary pelvic pain syndromes there is most often (97%) an undulating course with symptom flares.[44]

Ask about social, economic, and psychological factors.[4] Psychological factors have been shown to play a role in chronic pelvic pain syndromes.[4][45] Significant early life events and stresses can change the development of the hypothalamic-pituitary-adrenal axis and therefore alter the levels of hormones released; this may lead to long-term biologic changes. Furthermore, sex hormones can modulate both nociception and pain perception. These factors may help to explain the relation between chronic pain syndromes and significant early life events.

Screen all patients presenting with symptoms of pelvic pain for sexual abuse during history taking. Sexual abuse, and particularly childhood sexual abuse, is also a risk factor for CP/CPPS in adults with persistent pain.[46] In one study, men who reported having experienced sexual, physical, or emotional abuse as a child/adolescent had increased odds (3.3 vs. 1.7) for symptoms of CP/CPPS.[36] Conversely, patients who have experienced sexual abuse should be asked about pelvic pain.

Also ask about other risk factors for CP/CPPS, including a history of previous/recurrent urinary tract infections with or without intraprostatic urinary reflux, history of sexually transmitted infections, presence of irritable bowel syndrome, and personal or family history of other pain syndromes. It is also important to enquire about negative cognitive, behavioral, sexual, or emotional consequences associated with the patient’s symptoms during the consultation.[4]

Ask all patients about past medical history, including surgical history.

Pain assessment and validated symptom-scoring instruments

Determine the severity of pain and associated symptoms, its progression, and treatment response using a reliable and validated symptom-scoring tool.[42][47]

The most reliable methods for the assessment of pain severity are:

  • A 5-point verbal scale (none, mild, moderate, severe, very severe pain)

  • A visual analog scale (VAS) score from 1 to 10

  • An 11-point numerical scale from 0 (no pain) to 10 (extreme pain).

For CP/CPPS, the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) [ NIH Chronic Prostatitis Symptom Index Opens in new window ] and the International Prostate Symptom Score (I-PSS) [ Prostatism Symptom Score Opens in new window ] are reliable and valid indices of symptoms and quality of life.[48][49]

The urinary, psychosocial, organ-specific, infection, neurological/systemic, and tenderness (UPOINT) scale can be used to stratify patients into specific symptom-led phenotypes.[4][6] The clinical domains assessed are urinary symptoms, psychosocial dysfunction, organ-specific findings, infection, neurologic/systemic routes, and tenderness of muscles.[5] Note that the UPOINT scale also covers aspects of physical exam and investigation findings.

[Figure caption and citation for the preceding image starts]: Phenotyping of pelvic pain using the UPOINT classificationAdapted from Engeler DS et al. EAU guidelines on chronic pelvic pain. Edition 2023. European association of Urology. Nijmegen, The Netherlands (https://uroweb.org/guidelines/chronic-pelvic-pain); used with permission [Citation ends].com.bmj.content.model.Caption@116b82cc

Screening for psychosocial symptoms that may impact quality of life such as anxiety, depression, and stress should be carried out using one or more validated/standardized questionnaires or scales wherever possible.[4][6][50] These may include:[6]

  • Psychosocial yellow flag system

  • Patient Health Questionnaire-9 (PHQ-9)

  • Patient Health Questionnaire-2 (PHQ-2)

  • Generalized Anxiety Disorder-7 (GAD-7)

  • Hospital Anxiety and Depression Scale (HADS).

Physical exam

Carry out a physical exam to:[4]

  • Identify and exclude specific diseases associated with pelvic pain

  • Aid phenotypic description (describing the condition in terms of its symptoms, signs, and investigation results).

Perform abdominal, pelvic, and external genitalia exams to exclude gross pelvic pathology and identify sites of tenderness.[4][6][51][52] Carry out a broad musculoskeletal (tender point) evaluation, including muscles outside the pelvis, which helps to diagnose myofascial pain aspects of pelvic pain to aid phenotyping pelvic pain patients.[4][6][52]

  • Men with CP/CPPS have been shown to have more muscle spasm and increased muscle tone, leading to pain on palpation of the pelvic muscles.[24] One study showed that 51% of patients with prostatitis symptoms had muscle tenderness compared with only 7% of controls, with tenderness in the pelvic floor muscles being exclusive to the test group.[25]

  • Palpate the superficial pelvic floor muscles and perineum externally to look for signs of abnormalities in muscle function (myofascial dysfunction) and aid phenotyping.[4][6][53] This may include assessing for muscle tenderness and trigger points (which may be found in the pelvic floor muscles as well as adjacent muscles, including the abdominal and gluteal muscles, with pain being aggravated by pressure on the trigger point) as well as assessing the ability to contract and relax these muscles.[4]

  • The bladder may be palpable if the patient has urinary retention.[6]

  • Gentle palpation of the scrotum, penis, and urethra should be carried out to exclude masses and may elicit tenderness.

  • Pelvic floor testing may be carried out by a doctor or physical therapist with appropriate training in pelvic assessment.[4]

A general neurologic exam should also be performed, assessing for sensory problems, sacral reflexes, and muscular function.[4][5]

Carry out a digital rectal exam to:[4][6]

  • Help exclude pathologies of the rectum

  • Identify tenderness of the prostate (mild tenderness can typically be elicited on palpation of the prostate in patients with CP/CPPS)

  • Identify prostate abnormalities, which may indicate an underlying pathology other than CP/CPPS

  • Assess the deep pelvic floor muscles (rectal exam is a good way to test the pelvic floor function in men).[54]

Investigations

CP/CPPS is a clinical diagnosis. There is no specific diagnostic test to confirm the diagnosis. An experienced physician can make the diagnosis with a high degree of certainty based only on a thorough history and physical exam. However, it is important to exclude specific diseases with similar symptoms, and further investigations may be used for phenotyping once a diagnosis of chronic pelvic pain syndrome has been made.[4]

Consider performing the following investigations as part of the initial workup to exclude underlying pathology (see Differentials):

  • Urinalysis

  • Urine culture

  • Testing for sexually transmitted infections to rule out bacterial infection

  • Cystoscopy to rule out interstitial cystitis/primary bladder pain syndrome as well as bladder malignancy.[50]

Once CP/CPPS has been confirmed, imaging may also be of use to further aid phenotypic diagnosis.

The following optional investigations may help to identify neuropathic types of pain, which may be concomitant or isolated findings:

  • An injection of local anesthetic and corticosteroid at the site of nerve injury or differential block of the pudendal nerve

    • Provides information in relation to the site where the nerve may be trapped.[55]

  • Electrophysiologic studies

    • May reveal signs of perineal denervation, increased pudendal nerve latency, or impaired bulbocavernosus reflex.[56]

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