Chronic pelvic pain syndrome (CPPS) and chronic prostatitis are long-term conditions that are poorly understood, difficult to treat and for which there is currently no cure. As well as causing a range of disruptive symptoms – including severe pain, erectile dysfunction and urinary and bowel problems – that patients often find difficult to cope with, they can have a deleterious effect on an individual’s psychological wellbeing.
Chronic pelvic pain syndrome
This non-malignant pain is perceived in structures such as the muscles and nerves of the pelvis that have been continuous or recurrent for at least six months – the minimum length of time for pelvic pain to be regarded as chronic. ‘Perceived’ indicates that the patient and clinician, to the best of their ability from the history, examination and investigations (where appropriate) have localised the pain as being felt in the specified anatomical pelvic area (Fall et al, 2010).
CPPS can encompass several conditions causing pain in the different anatomical structures around the prostate, including various muscle types, nerves and bony structures in the pelvis, abdomen and spine (Rees et al, 2015). The causes are not completely understood; CPPS is not thought to be caused by infection, but a number of other factors may be involved (Prostate Cancer UK, 2015). A range of genetic variations have been described that may explain chronic pelvic pain (Marszalek et al, 2009).
Prostatitis, which is a contributing factor to CPPS, is a set of symptoms thought to be caused by infection or inflammation of the prostate gland. It is common but poorly understood (European Association of Urology, 2014; Pavone-Macaluso, 2007), and a significant burden in terms of physical symptoms, emotional distress and financial costs (Schaeffer, 2008; Calhoun et al, 2004; McNaughton Collins et al, 2001). Men with prostatitis have a very poor quality of life: it is comparable to that of people with conditions such as unstable angina, inflammatory bowel disease or congestive heart failure.
The condition affects men of all ages but it is most prevalent in those aged 36-50 years. Its presentation in some older men may be due to normal prostate enlargement; it is known that increased detrusor pressure is needed to empty the bladder in obstructive voiding, which can predispose men to reflux of urine into the prostate gland (Kirby et al, 1982).
A systematic review found an 8.2% prevalence of prostatitis symptoms (range 2.2-9.7%) in a population of over 10,600 men (Krieger et al, 2008) while, between April 2016 and March 2017, the specialist nurse team at Prostate Cancer UK received 289 contacts from men seeking help about prostatitis.
The condition can be acute or chronic, bacterial or non-bacterial, and symptoms can occur with or without signs of infection. It is categorised as:
- Acute bacterial prostatitis;
- Chronic bacterial prostatitis (rare);
- Chronic non-bacterial prostatitis/CPPS;
- Asymptomatic inflammatory prostatitis (Krieger et al, 1999).
Chronic non-bacterial prostatitis is the most common type experienced (Daniels et al, 2007; Clemens et al, 2005) and is defined as urological pain or discomfort in the pelvic region associated with urinary symptoms and/or sexual dysfunction lasting at least three months (Krieger et al, 1999). Although it is a benign condition, it can severely reduce quality of life, as patients often experience considerable physical and psychological morbidity (PCUK, 2015).
Chronic prostatitis is related to CPPS due to the following possible causative factors:
- Urine entering the prostate gland (Kirby et al, 1982); the prostatic utricle cyst and dilated prostatic duct in the peripheral zone of the prostate should be recognised as prostate benign lesions and are involved in urine reflux into the prostate (Inamura et al, 2016);
- An infection that does not show in tests;
- Inflammation of the nerves around the prostate gland;
- Problems with nerves that send pain signals to the brain without physical cause;
- Stress and/or anxiety;
- Problems with, or previous damage to, the pelvic floor muscles.
Symptoms and Comorbidities
The hallmark of chronic prostatitis and CPPS is persistent and disabling pain (Kwon and Chang, 2013), but both conditions can cause a wide range of symptoms relating to pain, urinary function, quality of life and sexual dysfunction (Boxes 1 and 2). Each man is affected differently and symptoms can be constant or intermittent.
Symptoms of chronic pelvic pain syndrome
- Pain in the perineum
- Pain in the lower abdomen
- Pain in the penis, especially the tip, and the testicles
- Pain in the rectum and lower back
- Pain or burning during ejaculation
- Premature ejaculation
- Erectile dysfunction
- Urinary problems such as feeling that the bladder is not emptying properly, urinary frequency or urgency, and pain when urinating
- Bowel problems
- Mild discomfort or pain when urinating
- Blood in semen (haematospermia)
- Discomfort, pain or aching in the testicles, perineum or tip of the penis
- Discomfort, pain or aching in the lower abdomen, groin or back
- Urinary frequency or urgency
- Pain or stinging during or after urinating
- Feeling as though sitting on a golf ball
- Lack of libido
- Less common: erectile dysfunction, pain or burning during ejaculation, and premature ejaculation
Assessment and investigations
Clinical diagnosis of CPPS and/or chronic prostatitis relies on patient history and physical examination. Various investigations are conducted to detect signs and exclude other pathologies.
- Physical examinations
If CPPS and/or chronic prostatitis is suspected, an examination of the abdomen and external genitalia (Rees et al, 2015; National Institute for Health and Care Excellence, 2010) and a digital rectal examination (Rees et al, 2015) should be performed. This last may reveal a tender prostate on palpation; it will also allow the health professional to assess the pelvic floor muscles’ tenderness and ability to relax and contract.
- Tests to rule out other pathologies
- Urodynamic studies can demonstrate decreased urinary flow rates, incomplete relaxation of the bladder neck and prostatic urethra, and/or an abnormally high urethral closure pressure at rest (Shergill et al, 2010). To detect infection, common investigations include a urine dipstick test and/or an early morning urine specimen and expressed prostatic secretions for culture/microscopy (Rees et al, 2015).
- Screening for sexually transmitted infections should be considered, and a urethral swab and culture taken if urethritis is suspected (Rees et al, 2015).
- Uroflometry, retrograde urethrography and/or a bladder scan will help exclude urinary retention, while cystoscopy can be performed to exclude bladder outlet obstruction, bladder neck stenosis, bladder cancer or urethral stricture (Rees et al, 2015).
- Magnetic resonance imaging and computerised tomography are useful to rule out a prostate abscess (Venyo, 2011). A number of other tests can be useful; for example, if prostate cancer is a concern, a blood test to measure PSA levels can be undertaken.
The philosophy for the management of chronic pelvic pain is based on a biopsychosocial model. This is a holistic approach with patients’ active involvement. Single interventions rarely work in isolation and need to be considered within a broader personalised management strategy, including self-management. Pharmacological and non-pharmacological interventions should be considered with a clear understanding of the potential outcomes and endpoints. These may well include: psychology, physiotherapy, drugs and more invasive interventions.
Some therapy like extracorporeal shockwave therapy can be of help. A Cochrane review of non-pharmacological interventions for chronic pelvic pain reported a reduction in symptoms following treatment compared with control and concluded that extracorporeal shockwave therapy may improve symptoms without an increase in adverse events.