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For further information, see CMDT Part 23-03: Genitourinary Tract Infections

Key Features

Essentials of Diagnosis

  • Irritative voiding symptoms

  • Perineal or suprapubic discomfort, similar to that of chronic bacterial prostatitis

  • Positive white blood cells from expressed prostatic secretions, but negative culture

General Considerations

  • Nonbacterial chronic prostatitis and chronic pelvic pain syndromes are caused by an interrelated cascade of inflammatory, immunologic, endocrine, muscular, neuropathic, and psychologic mechanisms

Clinical Findings

Symptoms and Signs

  • Chronic perineal, suprapubic, or pelvic pain is the most common presenting symptom

  • Men may complain of pain in the testes, groin, and low back

  • Pain during or after ejaculation is one of the most prominent and bothersome symptoms

  • Psychosocial factors (depression, anxiety, catastrophizing, poor social support, stress) also likely play an important role in the exacerbation of chronic pelvic pain symptoms

  • The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) (https://www.prostatitis.org/symptomindex.html) has been validated to quantify symptoms of chronic nonbacterial prostatitis or chronic pelvic pain syndrome

Differential Diagnosis

  • Chronic bacterial prostatitis

  • Bladder cancer

Diagnosis

  • Diagnosis is usually one of exclusion

  • Increased numbers of leukocytes are typically seen in expressed prostatic secretions, but cultures of both expressed prostatic secretions and postprostatic urine specimens are negative

Treatment

  • Multimodal therapy is recommended according to the various phenotypes of patient presentation

  • Voiding symptoms are managed with an α-blocker (tamsulosin, alfuzosin, silodosin)

  • Psychosocial disorders are treated with

    • Cognitive behavioral therapy

    • Antidepressants

    • Anxiolytics

  • Neuropathic pain is treated with

    • Gabapentinoids

    • Amitriptyline

    • Neuromodulation

    • Acupuncture

  • Pelvic floor muscle dysfunction may respond to

    • Diazepam

    • Biofeedback techniques

    • Pelvic floor physical therapy (eg, kegel exercises)

    • Pelvic shock wave lithotripsy

    • Heat therapy

  • Sexual dysfunction with pain symptoms is treated with sexual therapy and phosphodiesterase-5 inhibitors (eg, sildenafil, tadalafil, vardenafil)

  • Surgery is not recommended for chronic prostatitis

Outcome

Prognosis

  • Annoying, recurrent symptoms are common, but serious sequelae have not been identified.

  • Quality of life is greatly decreased for many patients

When to Refer

  • Patients who do not respond to psychosocial therapy should be referred to a mental health specialist

  • Patients who do not respond to pain therapy should be referred to a pain management specialist

References

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Franco  JV  et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev. 2018 Jan 26;1:CD012551. Update in: Cochrane Database Syst Rev 2018 May 12;5:CD012551.
[PubMed: 29372565]  
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Holt  JD  et al. Common questions about chronic prostatitis. Am Fam Physician. 2016 Feb;93(4):290–6.
[PubMed: 26926816]  
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Magistro  G  et al. Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. Eur Urol. 2016 Feb;69(2):286–97.
[PubMed: 26411805] ...

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