Chronic Pelvic Pain Syndrome

Chronic pelvic pain syndrome (CPPS) is a pelvic pain condition in men. It used to be called prostadynia. It is synonymous with chronic prostatitis and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis. Prostatitis is an inflammation of the prostate gland and causes pelvic pain.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common type of prostatitis. It is more common in young and middle-aged men. It can be classified as inflammatory or non-inflammatory. When CP/CPPS is non-inflammatory, there are neither infection-fighting cells nor bacteria in the prostatic fluid.

CP/CPPS tends to cause chronic discomfort or pain in the groin, genitals, perineum or bladder. Patients may complain of pain with urination and ejaculation as well.

But many cases show transient symptoms or may be asymptomatic altogether.

CPPS may actually represent an underlying pelvic floor dysfunction or muscle strain instead of actual prostatitis. There is a varying degree of sexual dysfunction in these men – many continue to be able to have sex as they did before, but it may be may be uncomfortable or painful at times. Therefore, taking a detailed sexual history is essential, and indeed, can be challenging given the sensitive nature of this topic. Patients should be assessed for the psychological impact of their symptoms using through proper screening for depression, and if they attribute their low mood to pain, psychologically based pain management should be considered.

Clinical exam includes a digital rectal exam to feel any abnormalities in the prostate gland. Urine and prostatic fluid samples are tested, along with blood tests, ultrasounds, MRIs, or biopsies as needed.

CP/CPPS can be difficult to treat, and it is sometimes incurable. Treatments include:

• Medications. NSAIDs are given for pain relief and to minimize inflammation. Muscle relaxants may be given as well. Alpha-blockers may also help, but their side effects should be accounted for, which include decreased or retrograde ejaculation, nasal congestion, dizziness, tiredness. If no symptom relief is seen with alpha-blocker within 4-6 weeks, an alternative alpha-blocker should be attempted. There is no clear evidence that antibiotics are effective for this condition.

• Heat. Taking a hot bath or applying a heating pad or hot water bottle to the affected area may provide some relief.

• Changes in diet. Patients are recommended to avoid spicy foods, caffeinated or acidic drinks as they can aggravate symptoms.

• Lifestyle changes. Activities such as bicycle riding may make the symptoms worse and are best avoided.

• Prostatic massages. These massages can provide some pain relief.

• Counseling. It is important to identify and address the psychological distress that comes with this condition. These men tend to have high levels of anxiety and getting psychological help from a counselor may help.

CP/CPPS can be refractory, and in severe cases, surgery needs to be considered, but the evidence for the usefulness of surgery is very limited.