Chronic prostatitis (chronic pelvic pain syndrome (CPPS))

Chronic prostatitis (also known as chronic pelvic pain syndrome (CPPS) or primary prostate pain syndrome)

Chronic prostatitis (also known as chronic pelvic pain syndrome (CPPS) or primary prostate pain syndrome) should be considered separate from acute and chronic bacterial prostatitis and is not associated with active infection (1)

• CPPS
  • is defined as pelvic pain with variable associated urinary symptoms and sexual dysfunction for at least three months (1)
    
    
  • is characterised by pelvic or perineal pain in the absence of pathogenic bacteria in expressed prostatic secretions
    
    
  • is often associated with irritative and obstructive voiding symptoms including urgency, frequency, hesitancy, and poor interrupted flow
    
    
  • symptoms can also include pain in the suprapubic region, lower back, penis, testes, or scrotum and painful ejaculation (2)
    
    
  • is characterized by chronic pelvic pain symptoms and possibly voiding symptoms in the absence of UTI (urinary tract infection) (3)
    
    
  • CPPS may be inflammatory (white cells present in prostatic secretions) or non-inflammatory (white cells absent in prostatic secretions) (2)
    
    
  • relevant investigations in CPPS are stated to include (1)
    • mid-stream urine sample for microscopy and culture
    • sexually transmitted infection screening
    • prostate specific antigen (PSA) in appropriate patients:
      • PSA is indicated in patients with LUTS suggesting bladder outflow obstruction, in patients where there is suspicion of prostate cancer, or in patients who are concerned about prostate cancer
      • PSA may be falsely raised in patients with any type of prostatitis
      • PSA testing should be delayed for six weeks if the patient is being treated for urinary tract infection
      • ultrasound scan of the urinary tract to check for chronic urinary retention if the patient has a history of LUTS
      • testicular ultrasound scan is indicated if testicular pain is present
      • faecal immunochemical tests for occult blood in faeces in patients over 50 with unexplained abdominal pain or weight loss
        
        
  • management principles (1):
    • analgesia such as paracetamol and non-steroidal anti-inflammatory drugs.
    • consider
      • gabapentinoids or tricyclic antidepressants if neuropathic pain suspected (involvement of a pain specialist is indicated here)
      • a uroselective alpha blocker eg, tamsulosin
        • discontinue if no benefit is seen after six weeks
        • for treatment of LUTS or benign prostate enlargement:
          • 5-alpha reductase inhibitors may be useful in combination with an alpha blocker
    • offer a single 4-6 week course of a quinolone such as ciprofloxacin or levofloxacin to patients who have had symptoms for less than six months
      • noted that many patients without confirmed infection on urine culture respond to antibiotics
        • offer a repeat course if there was partial response or positive urine cultures, as this could be chronic bacterial prostatitis
        • avoid repeat courses if the patient sees no benefit and cultures are negative.
    • if the patient has pain on defecation then offer stool softeners
    • in patients with suspected pelvic floor dysfunction then consider physiotherapy
    • suggests discussion of stress management strategies or consider referring for counselling or cognitive behavioural therapy
    • majority will require a combination of these treatments aimed at the specific symptoms they have
      
      
  • criteria for referral to a a urologist
    • if the diagnosis is uncertain, if symptoms are severe, or if symptoms are refractory to treatment after four to six weeks (1)
    • urologist may perform the four or two glass test to determine whether the patient has chronic bacterial prostatitis
    • urologist may consider specialist diagnostics such as
      • uroflowmetry,
      • cystoscopy,
      • or prostatic imaging to exclude differentials such as bladder outflow obstruction, bladder cancer, prostate cancer, or prostatic abscess

Reference:

1. Healy R, Thorne C, Manjunath A. Chronic prostatitis (chronic pelvic pain syndrome) BMJ 2023; 383 :e073908 doi:10.1136/bmj-2023-073908
2. Bowen DK, Dielubanza E, Schaeffer AJ. Chronic bacterial prostatitis and chronic pelvic pain syndrome. BMJ Clin Evid. 2015 Aug 27;2015:1802. PMID: 26313612; PMCID: PMC4551133
3. Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. doi: 10.5489/cuaj.11211. PMID: 22031609; PMCID: PMC3202001.