Prostatitis, Nonbacterial/Pelvic Pain Syndrome, Chronic

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 incompletely understood with symptomatology due to 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