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 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