Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Types of prostatitis

The US National Institutes of Health classifies prostatitis into four categories:

This page focuses on categories II and III. For the acute form, see prostatitis.

Symptoms

Pain

Pain or discomfort in one or more areas:

• the perineum (between the scrotum and anus)
• the testicles or penis, especially the tip
• above the pubic bone or in the lower back
• the rectum
• during or after ejaculation

Urinary symptoms

• frequent urination, including at night
• urgency
• burning or painful urination
• a weak or interrupted stream, or a feeling of incomplete emptying

Sexual and other effects

• pain with ejaculation
• erectile dysfunction and reduced libido
• anxiety, low mood and poor sleep, which can both result from and worsen pain

Symptoms often come and go in flares, triggered by stress, prolonged sitting, cycling, alcohol, spicy food or sexual activity in some men.

Causes

In most men, no single cause is found. Contributing factors include:

• pelvic floor muscle dysfunction: tight, tender muscles in the pelvis, often a major driver
• inflammation in the prostate without infection
• nerve sensitization: the nervous system amplifies pain signals over time
• previous infection that has resolved, or an undetected organism
• urine reflux into prostate ducts
• psychological stress, which tightens muscles and amplifies pain
• chronic bacterial infection in category II

Diagnosis

Diagnosis is based on symptoms and excluding other conditions. A urologist will:

• take a history, often using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) questionnaire to measure pain, urinary symptoms and quality of life
• examine the abdomen, genitals and perineum, and do a digital rectal exam to check the prostate and pelvic floor muscles for tenderness
• test the urine for infection and blood
• sometimes perform a two-glass test, collecting urine before and after prostate massage, to look for bacteria from the prostate
• check post-void residual urine and urine flow
• test for sexually transmitted infections if relevant

Other tests may be done to rule out conditions such as benign prostatic hyperplasia, urethral stricture, bladder stones, interstitial cystitis, hernia and, rarely, bladder or prostate cancer.

Treatment

Because several factors usually contribute, the most effective approach treats each man's specific symptom domains. Urologists often use the UPOINT framework: Urinary, Psychosocial, Organ-specific, Infection, Neurologic/systemic, and Tenderness of muscles.

Medicines

• Alpha-blockers (such as tamsulosin): relax the prostate and bladder neck, helping urinary symptoms, especially if started early.
• Antibiotics: for chronic bacterial prostatitis, usually a fluoroquinolone or trimethoprim-sulfamethoxazole for 4 to 6 weeks. A single trial may be offered in CP/CPPS of short duration, but repeated courses without evidence of infection are not recommended.
• Anti-inflammatories: short courses for pain and inflammation.
• Nerve pain medicines: such as amitriptyline, gabapentin or pregabalin in some men.
• Quercetin and pollen extract supplements have shown modest benefit in some studies.

Pelvic floor physical therapy

Myofascial release and relaxation techniques with a specialist pelvic floor physical therapist can significantly reduce pain when pelvic floor muscles are tight and tender. Kegel exercises that tighten the pelvic floor are generally not advised for CPPS.

Lifestyle and self-care

• warm baths or a heating pad
• avoiding long periods of sitting, and using a cushion with a cutout
• reducing triggers such as alcohol, caffeine and spicy food if they worsen symptoms
• regular aerobic exercise
• limiting cycling, or using a prostate-friendly saddle

Psychological support

Cognitive behavioral therapy, stress management and treating anxiety or depression reduce pain and improve quality of life.

Other options

Acupuncture has some evidence of benefit. Shockwave therapy is being studied.

Outlook

CP/CPPS can be frustrating and long-lasting, but it is not linked to prostate cancer or infertility in most men, and it does not damage the kidneys. Symptoms often improve gradually with a combined treatment plan, and many men have long periods with few or no symptoms.

Frequently asked questions

What is chronic prostatitis?

Chronic prostatitis usually refers to chronic prostatitis/chronic pelvic pain syndrome: pain in the pelvis, perineum or genitals for at least 3 of the past 6 months, often with urinary or sexual symptoms. Most cases are not caused by infection. A smaller group have chronic bacterial prostatitis.

Why don't antibiotics work for my prostatitis?

Most chronic prostatitis is not a bacterial infection, so antibiotics do not help and can cause side effects. Pelvic floor muscle tension, inflammation and nerve sensitization are more often to blame. Antibiotics are used when bacteria are found or for a single short trial early on.

Can chronic prostatitis be cured?

There may not be a quick cure, but symptoms can often be greatly reduced. Combining treatments such as alpha-blockers, pelvic floor physical therapy, pain relief and stress management works better than any single treatment. Many men improve substantially over months.

Does chronic prostatitis cause cancer or infertility?

Chronic prostatitis does not cause prostate cancer. It may cause temporary changes in semen but is not a common cause of infertility. It can raise PSA levels, so your doctor may take that into account when interpreting PSA tests.