Chronic prostatitis/chronic pelvic pain syndrome
Michel Pontari, MD
Section Editor
Michael P O'Leary, MD, MPH
Deputy Editor
David M Rind, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. |This topic last updated:Μαϊ 14, 2012.
INTRODUCTION — Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a clinical syndrome, defined primarily on the basis of urologic symptoms and/or pain or discomfort in the pelvic region. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms [1].
The clinical manifestations, evaluation, and management of CP/CPPS will be reviewed here. Acute prostatitis and chronic bacterial prostatitis are discussed separately. (See "Acute and chronic bacterial prostatitis".)
DEFINITIONS — A number of terms have been used to describe the syndrome now commonly called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). These include prostatodynia (painful prostate) and abacterial prostatitis.
A classification approach supported by the National Institutes of Health (NIH) to standardize definitions and facilitate research is the currently accepted categorization of prostate syndromes [2]. This schema defines the following categories:
•   I. Acute prostatitis
•   II. Chronic bacterial prostatitis
•   IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory
•   IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory
•   IV. Asymptomatic inflammatory prostatitis
Acute and chronic bacterial prostatitis (classes I and II, respectively) are discussed in detail elsewhere. (See "Acute and chronic bacterial prostatitis".)
Research guidelines define CP/CPPS as chronic pelvic pain for at least three of the preceding six months in the absence of other identifiable causes [3]. The inflammatory subset of CP/CPPS (class IIIA) includes patients with inflammatory cells in expressed prostatic secretions, postprostate massage urine, or seminal fluid. The noninflammatory CP/CPPS (class IIIB) subset includes the remainder of the patients with chronic prostatitis or pelvic pain. The distinction between inflammatory and noninflammatory CP/CPPS is generally for research purposes only, as there is no evidence that patients in the two subgroups have different symptoms or respond differently to therapy.
In contrast to the symptomatic patient presenting with CP/CPPS, asymptomatic inflammatory prostatitis (class IV) is typically diagnosed incidentally during prostate biopsy or an infertility or cancer work-up. This entity is not sufficiently studied to have an adequate understanding of its natural history, need for therapy, or response to treatment.
EPIDEMIOLOGY — Chronic prostatitis is a common condition worldwide, affecting approximately 2 to 10 percent of all adult men [4].
In one United States survey of 58,955 ambulatory visits to physicians by men over the age of 18 years, genitourinary tract symptoms accounted for 5 percent of all complaints, and prostatitis was listed as a diagnosis in nearly two million encounters annually [5]. Most men diagnosed with "prostatitis" have CP/CPPS rather than acute or chronic bacterial prostatitis [2].
In a large population-based Canadian study, 10 percent of the men had complaints compatible with chronic prostatitis, and 7 percent had moderate to severe symptoms [6]. The prevalence seems to peak in the fifth decade, but declines thereafter:
•   11 percent ages 20 to 39
•   13 percent ages 40 to 49
•   10 percent ages 50 to 59
•   9 percent ages 60 to 69
•   7 percent ages 70 to 74
ETIOLOGY — The etiology of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is unknown. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms [1].
Although bacterial infection has been suspected, particularly in the inflammatory subset of CP/CPPS, a bacterial etiology has not been consistently identified. Most experts believe that inflammatory and noninflammatory CP/CPPS are both noninfectious disorders [7,8]. Studies of Chlamydia, Mycoplasma, and Ureaplasma, which have all been implicated in chronic prostatitis, have generally concluded that they are not responsible for CP/CPPS [9-12]. Several investigators have performed polymerase chain reaction (PCR) testing looking for evidence of bacteria in prostatic tissues, but these have yielded negative results [13,14]. One study cultured prostatic biopsy specimens obtained via the transperineal approach from men with CP/CPPS and from normal volunteers [15]. There was no difference in the number of patients from whom bacteria were cultured (38 versus 36 percent, respectively).
Additionally, there appears to be little correlation between histologic prostatic inflammation and presence or absence of CP/CPPS symptoms [16]. Leukocytes can be found in the prostatic fluid of asymptomatic men, and there appears to be no correlation between the presence of leukocytes and symptoms [17].
Noninfectious etiologies have been proposed for CP/CPPS, but none has been proven [17]. These include inflammation due to trauma, autoimmunity, reaction to normal prostate flora or some other factor, neurogenic pain, increased prostate tissue pressure, and the interplay of somatic and psychologic factors [17-19]. Psychological stress, including anxiety and fear of severe illness, appears to be common in men with symptoms of CP/CPPS and may be a contributing factor [20,21].
CLINICAL MANIFESTATIONS — The symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) include pain (in the perineum, lower abdomen, testicles, penis, and with ejaculation), voiding difficulty (including bladder irritation and bladder outlet obstruction), and sometimes blood in the semen. Chronic prostatitis may also lead to problems with daily activities, depression, and overall quality of life [22]. CP/CPPS is also associated with erectile dysfunction and ejaculatory pain [23-25].
There is an association of chronic pelvic pain syndromes with other pain syndromes, such as irritable bowel syndrome (IBS), chronic fatigue syndrome, and fibromyalgia [26]. Given the overlapping innervation of the bowel and bladder [27], irritation of the bowel can result in lower abdominal pain and urinary symptoms as well. (See "Clinical manifestations and diagnosis of irritable bowel syndrome" and "Clinical features and diagnosis of chronic fatigue syndrome" and "Clinical manifestations and diagnosis of fibromyalgia in adults".)
The clinical course of CP/CPPS, with or without treatment, is not well-defined [28]. The patient usually will experience a relapsing-remitting pattern where the severity and frequency of flares decreases, usually over many months.
DIFFERENTIAL DIAGNOSIS — Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a diagnosis of exclusion.
The clinical presentation of CP/CPPS can be similar to that of chronic bacterial prostatitis, as both may present with urinary frequency, dysuria, and perineal pain. However, CP/CPPS does not present with low-grade fever, which can occur with chronic bacterial prostatitis. In patients with chronic bacterial prostatitis, the rectal examination may also demonstrate prostatic hypertrophy, tenderness, and edema, which does not occur in CP/CPPS. The evaluation of chronic bacterial prostatitis is discussed in detail elsewhere. (See "Acute and chronic bacterial prostatitis", section on 'Chronic bacterial prostatitis'.)
Other causes should also be considered prior to making a diagnosis of CP/CPPS [2]:
•   Urethritis (see "Infectious causes of dysuria in adult men")
•   Urogenital cancer (see "Clinical presentation, diagnosis, and staging of bladder cancer" and "Urethral cancer in men")
•   Urinary tract disease (see "Lower urinary tract symptoms in men")
•   Urethral stricture (see "Treatment of urethral stricture disease in men")
•   Neurologic disease affecting the bladder, such as spinal cord injury and lumbar spinal stenosis (see "Chronic complications of spinal cord injury", section on 'Urinary complications' and
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"Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis", section on 'Clinical presentation')
Unlike patients with these other disorders, patients with CP/CPPS are unlikely to have systemic or neurologic symptoms (eg, fever, weight loss, fatigue, incontinence).
EVALUATION — As chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a diagnosis of exclusion, the evaluation is designed to rule out identifiable causes of pelvic pain. The evaluation includes the history, physical examination, urinalysis, urine culture, and, in select cases, diagnostic imaging.
History — The clinician should ask about pain, urinary complaints, sexual function, depressive symptoms, and overall quality of life. The NIH developed and validated the Chronic Prostatitis Symptom Index (NIH-CPSI) which can be useful in the evaluation of patients presenting to general medicine and urology clinics [29]. The NIH-CPSI specifically assesses pain, voiding, and quality of life. The maximum possible symptom score is 43, where higher numbers indicate more severe symptoms.
Physical examination — The focused examination should evaluate areas of pain, search for unexpected masses, and assess for possible urinary tract abnormalities (including urinary retention).
The evaluation consists of an examination of the abdomen, including careful palpation of the groin, spermatic cord, epididymis, and testes. Clinicians should specifically search for hernias, testicular masses, and hemorrhoids.
On digital rectal examination, the prostate is usually not tender but may sometimes be mildly tender; severe tenderness suggests acute prostatitis. In addition to the prostate, the digital rectal examination should also assess for rectal masses and muscle spasm or myofascial tenderness by palpation of the perineum, pelvic floor, and pelvic sidewalls.
Laboratory studies — A urinalysis should be performed in any patient suspected of prostatitis [30]. A urine culture is also required to rule out urinary tract infection [30]. Patients with recurrent urinary tract infections should be evaluated for chronic bacterial prostatitis. (See "Acute and chronic bacterial prostatitis".)
Patients with hematuria should have an evaluation that includes urine cytology (looking for carcinoma in situ of the bladder), cystoscopy, and possibly upper tract imaging with intravenous pyelography or CT. (See "Etiology and evaluation of hematuria in adults".)
A prostate specific antigen (PSA) test is not indicated for the assessment of CP/CPPS, and if a PSA is measured and found to be elevated, the elevation should not be ascribed to CP/CPPS [31]. (See "Measurement of prostate specific antigen".)
The classic "four glass test" (examining and culturing the first void, midstream, and post-massage urine samples along with expressed prostatic secretions) is no longer routinely performed.
Diagnostic imaging — Imaging studies are appropriate in certain patients:
•   Patients with concomitant abdominal pain may require imaging with CT to exclude an intra-abdominal process. (See "Diagnostic approach to abdominal pain in adults".)
•   Testicular pain should be evaluated with a scrotal ultrasound. (See "Evaluation of nonacute scrotal pathology in adult men".)
•   A bladder ultrasound or catheterization may be performed to check a post-void residual in patients who report a sensation of incomplete bladder emptying. (See "Diagnosis of urinary tract obstruction and hydronephrosis".)
•   Lumbar radiculopathy can produce pelvic pain, so patients with signs and symptoms suggesting radiculopathy (eg, lower extremity paresthesias or weakness) may require imaging of the spine with MRI. (See "Diagnostic testing for low back pain".)
MANAGEMENT — A number of therapies are available for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); however, there is no uniformly-accepted treatment regimen. Alpha blockers and antibiotics are the main first-line agents for treatment of CP/CPPS, and can be used in combination. Physical therapy and psychological support are also used in certain cases of CP/CPPS.
The NIH chronic prostatitis symptoms index (NIH-CPSI) can be used to follow symptoms (ie, pain, voiding, and quality of life) and measure response to treatment [32].
In primary care practice, patients suspected of having acute or chronic bacterial prostatitis will frequently receive an empiric trial of an antibiotic (such as ciprofloxacin), and the diagnosis of CP/CPPS will only be entertained in those patients who relapse or do not respond to such therapy. (See "Acute and chronic bacterial prostatitis".)
Medical treatment — Alpha blockers, antibiotics, and finasteride (a 5-alpha-reductase inhibitor) are the most efficacious medications for treatment of CP/CPPS.
In a meta-analysis including 23 randomized trials of patients with CP/CPPS, several treatments were found to reduce NIH-CPSI scores compared to placebo, including alpha blockers (-11.0, 95% CI -13.9 to -8.1), antibiotics (-9.8, 95% CI -15.1 to -4.6), and finasteride (-4.6, 95% CI -8.7 to -0.5) [33]. The overall decrease in symptom scores was relatively small for each of the medications and likely of modest clinical significance. The greatest improvement in NIH-CPSI score occurred with combination alpha blocker and antibiotic treatment compared with placebo (-13.8, 95% CI -17.5 to -10.2). Symptomatic improvement with combination alpha blocker and antibiotic treatment was significantly greater than for each of the other treatments alone.
The choice of treatment in clinical practice may vary based on etiology of CP/CPPS and specific symptoms (eg, alpha blockers for those with pain and voiding symptoms, antibiotics for those with a history of urinary tract infection). However, given these data, we suggest the use of combination alpha blocker and antibiotic as initial treatment. An alpha blocker (either receptor specific or non-specific) plus a quinolone for six weeks initially is a reasonable option (tamsulosin 0.4 mg daily and ciprofloxacin 500 mg twice daily). If initial treatment is not effective, patients should be referred to a urologist for further evaluation and management.
Some clinicians decide to continue initial treatment despite lack of response. It is reasonable to continue an alpha blocker in patients with continued pain and voiding symptoms. Patients should be reevaluated after three months of continued alpha blocker therapy. We suggest not administering further antibiotics if the first course is ineffective and subsequent urine cultures are negative. Several antibiotic classes such as quinolones and tetracyclines (two of the most commonly-used antibiotics for CP/CPPS) are considered anti-inflammatory drugs and may improve symptoms regardless of infection [34]. Thus, in the absence of fever and positive urine culture, the patient does not likely have an infection, particularly if a patient feels better on antibiotics and feels worse the day after stopping them.
Finasteride, anti-inflammatory medications, and phytotherapies may have modest, but lesser, benefits in patients with CP/CPPS [33]. Finasteride is common treatment for older men with urinary symptoms, but is not recommended in young men who are still trying to have children given the effects on semen volume. Most of the anti-inflammatory medications studied for CP/CPPS treatment include cyclooxygenase-2 inhibitors (eg, celecoxib) and glucocorticoids (eg, prednisolone). Anti-inflammatory medications are generally given when pain is not controlled with initial therapy. Other medications found to be effective include phytotherapies and medication for neuropathic pain (eg, pregabalin). Specific phytotherapies found to be effective include cernilton (pollen extract) and quercetin (bioflavonoid) [35,36].
A small randomized trial suggested some benefits with mepartricin, an antifungal agent that lowers estrogen levels in the prostate [37]. Mepartricin is not available in the United States.
Psychological support — As CP/CPPS is associated with depression and a poor quality of life [38], behavioral counseling may be beneficial in select patients with concomitant psychosocial problems. A cognitive behavioral program specifically targeting CP/CPPS can improve both symptoms and quality of life [39]. This approach addresses approaches to pain, urinary difficulties, depressive symptoms, social support, sexual functioning, and overall quality of life issues. Prior to widespread use of behavioral counseling, further studies are needed to determine which patients with CP/CPPS might benefit from this type of program.
Other — A few other treatments may be helpful in managing CP/CPPS:
•   Small randomized trials have found that acupuncture is more effective than sham acupuncture [40].
•   Physical therapy aimed at achieving myofascial trigger point release may have benefit in patients with pelvic floor muscle spasm [41,42]. This therapy is usually performed by a physical therapist, rather than a urologist or primary care clinician. (See 'Physical examination' above.)
•   Small randomized trials have found that transurethral microwave thermotherapy of the prostate may be effective in reducing symptoms of CP/CPPS [43,44]. Further trials are needed to document long-term efficacy and safety of thermotherapy, in comparison to medical therapy.
•   Sitz baths have anecdotally been reported to provide some relief, although there have been no studies on efficacy for chronic symptoms.
Surgical intervention for CP/CPPS is reserved only for those patients with a specific indication (eg, urethral stricture, bladder neck obstruction) [45].
Transurethral needle ablation of the prostate is not more effective compared to sham treatment in patients with CP/CPPS [46].
Referral — Patients whose symptoms persist despite initial treatment, or who are found to have abnormalities such as hematuria or an elevated PSA, should be referred to a urologist.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
•   Basics topic (see "Patient information: Prostatitis (The Basics)")
•   Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a clinical syndrome, defined primarily on the basis of urologic symptoms and/or pelvic pain. It is the most common diagnosis in men presenting with prostatitis; acute and chronic bacterial prostatitis are less common. (See 'Definitions' above and "Acute and chronic bacterial prostatitis".)
•   The etiology of CP/CPPS is unknown. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms. (See 'Etiology' above.)
•   CP/CPPS is a diagnosis of exclusion. Patients should have a physical examination directed at identifying other etiologies of pelvic pain. Any patient suspected of prostatitis should also have a urinalysis and urine culture. Diagnostic imaging is used in selected patients. (See 'Differential diagnosis' above and 'Evaluation' above.)
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•   In patients with CP/CPPS, we suggest initial treatment with combination alpha-blocker and antibiotic therapy (Grade 2B). We use tamsulosin 0.4 mg daily and ciprofloxacin 500 mg twice daily. After initial treatment, we suggest NOT repeating a course of antibiotics unless there is a subsequent positive urine culture (Grade 2C). (See 'Medical treatment' above.)
•   Anti-inflammatory medications, finasteride, and phytotherapies also appear to have modest, but lesser, effects on symptoms. Physical therapy aimed at myofascial release may have benefit in patients with pelvic floor muscle spasm. A cognitive behavioral treatment program may be beneficial in some patients with concomitant psychosocial problems. (See 'Management' above.)
•   Patients whose symptoms persist despite these initial treatments, or who are found to have abnormalities such as hematuria or an elevated PSA, should be referred to a urologist. (See 'Referral' above.)
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Όπως βλέπετε σημαντική θέση έχουν Alpha1-Blockers, όπως δηλαδή το omnic tocas ή το Xatral OD μία φορά την ημέρα. Εμένα γνωστός ουρολόγος που πρότεινε να πάρω OMNIC TOKAS. Το ξεκίνησα και βλέπω μάλιστα αποτελέσματα.
Κανένας που να το έχει πάρει για να μας πει τις εντυπώσεις του;;;;
στοματικο με υποπτη που ειχε φαρυγγαλγια. Ουρηθριτιδα μετα απο μερικες ημερες. Πηρα 2gr Sir Zithromax εφαπαξ.  Μικρη βελτιωση και μετα 10 ημερες πονος στο περινεο ιδιαιτερα όταν ημουν καθιστος. Ηλθε λοιπον η προστατιτιδα.