eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Chronic Pelvic Pain Syndrome and Prostatodynia: Differential Diagnoses & Workup

Author: Richard A Watson, MD, Chief of Ambulatory Urology, HUMC Department of Urology, Professor of Surgery (Urology), Department of Surgery, Division of Urology, UMDNJ New Jersey Medical School, Hackensack University Medical Center
Coauthor(s): Robert J Irwin, Jr, MD, Chair, Harris L Willits Professor, Department of Surgery, Division of Urology, University Hospital, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Jul 17, 2009

Differential Diagnoses

Other Problems to Be Considered

Tuberculous prostatitis
Sexually transmitted diseases
Congenital or acquired abnormalities of the urethra
Prostatic cyst
Prostatic abscess
Seminal vesiculitis
Myofascial pain syndrome
Reactive arthritis
Pelvic joint dysfunction
Coccydynia

These many differential diagnoses—and this list is by no means complete—reveal the conundrum of diagnosing prostatodynia. Because the diagnosis is one of exclusion, in theory, this diagnosis cannot be made until all of these alternatives have been definitively excluded. However, time, patience (the physician's and the patient's), limited medical resources, and/or the patient's finite financial resources preclude a categorical demonstration of the absence of each of these symptomatically related entities.

An archetypical example would be differentiating between prostatodynia and interstitial cystitis in the male. A detailed review of the diagnosis of interstitial cystitis is presented thoroughly in Interstitial Cystitis. The distinction between prostatodynia and interstitial cystitis is particularly challenging because both conditions are diagnoses of exclusion, ie, 2 separate "wastebasket" diagnoses. No diagnostic test can be used to definitively establish or to exclude the diagnosis of prostatodynia or interstitial cystitis.

If cystoscopy is planned as part of the workup, performing this study with the patient under anesthesia and including a bladder biopsy and hydrodistension to search for indicative signs is prudent and cost effective.⁶ However, the pathognomonic Hunner ulcer is as rare as it is classic. Additionally, the presence of glomerulations—not always an all-or-none observation—has been described in asymptomatic women.

At the 2001 convention of the American Urological Association, no fewer than 3 reports disparaged the utility of the once heavily promoted potassium sensitivity test. Conversely, Parsons and Albo (2002), who are leaders in the field of interstitial cystitis, found that the response to the potassium sensitivity test in 40 men with chronic prostatitis (CP) was comparable with that expected in women with interstitial cystitis. They concluded that prostatitis and interstitial cystitis in men may be part of a continuum of lower urinary dysfunctional epithelium.⁷

In 2004, urologic specialists at the University of Oklahoma reviewed a series of 92 men diagnosed with interstitial cystitis.⁸ This condition had been diagnosed according to standard National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD) criteria and confirmed by the presence of severe glomerulations or Hunner ulcers on the bladder wall after hydrodistension. These researchers caution that the symptoms of interstitial cystitis closely parallel those of CP/chronic pelvic pain syndrome (CPPS). (For further information, see Interstitial Cystitis.)

Most of the patients with interstitial cystitis in this series were referred for urological evaluation with an initial diagnosis of CP (54%) or of benign prostatic hyperplasia (23%). Their presenting symptom was most often only mild discomfort in the suprapubic area. However, their symptoms rapidly worsened; within less than 3 years, they had marked suprapubic pain, severe dysuria, and debilitating urinary frequency, during both daytime and nighttime. Sexual dysfunction was an issue for 60% of these men, with painful ejaculation being the most frequently expressed symptom. Low back pain, perineal pain, and testicular pain were reported by 50% of these patients. Symptoms were so severe that total cystectomy was performed as a last resort in 2 of these patients. (As a side note, these researchers observed an unusually high prevalence of interstitial cystitis among Native American [Cherokee] men.)⁸

The point at which the physician empirically recommends (for a given patient with prostatodynia) a trial of therapies specific for interstitial cystitis is based on the physician's judgment. For example, therapies such as pentosan sulfate (Elmiron) and intravesical instillations of dimethyl sulfoxide (DMSO) have yielded success in selected patients with prostatodynia. Details regarding the array and application of various interstitial cystitis therapies are beyond the scope of this article (see Interstitial Cystitis). Nonetheless, the frustrated diagnostician should keep this option for diagnosis in mind when further evaluating a patient with refractory prostatodynia. Similarly, other diagnoses also must be excluded.

The distinction between chronic urethritis and CP/CPPS can prove problematic. This issue was discussed in a 2004 review from the University of Washington in Seattle.² Of the 7 symptoms evaluated in the NIH Chronic Prostatitis Symptom Index, 3 symptoms are common to both populations: penile pain, urinary frequency, and dysuria. The remaining 4 symptoms are typical of CP/CPPS alone: perineal pain, pain in the testicles, pain in the suprapubic area, and pain upon ejaculation. Conversely, urethral discharge was characteristic of nongonococcal urethritis (NGU) but was not specifically reported in cases of CP/CPPS. Urethral WBCs were identified in all patients with NGU and in 50% of those with CP/CPPS. For further information on NGU, see Urethritis.

Most importantly, any risk of underlying cancer must be addressed urgently. Transitional cell cancer and carcinoma in situ of the bladder are deadly masqueraders. Prostate cancer can also manifest as symptoms that suggest prostatodynia. Neoplasms of the rectum and GI tract and rare tumors of other pelvic organs have manifested as irritative prostatic symptoms. Benign prostatic hyperplasia and obstructive uropathy also manifest in this manner. See Prostate Hyperplasia, Benign. All of these possible diagnoses must be considered when diagnosing prostatodynia.

Older men who experience the symptoms of CPPS for the first time may understandably be concerned that these symptoms represent underlying cancer of the bladder or prostate, but they me be reluctant to openly voice this anxiety. Once the diagnosis of cancer has been firmly ruled out, the patient must be reassured that this possibility has been carefully considered and excluded.

Ignoring these possibilities in patients with prostatodynia may eventually prove to be a fatal mistake. However, to subject every patient to a physically and financially exhaustive gauntlet of tests and procedures is also clearly inappropriate. Tailoring the diagnostic workup to meet the needs of a specific patient is a skill that defies textbook codification. The art of medicine comes into play in deciding, together with the patient, which possibilities to pursue and how vigorously to pursue each of them.

Standard teaching has been that men with CPPS have no increased risk of prostate cancer. However, a study from Case Western Reserve reveals that patients who underwent an initial prostate biopsy that was negative for cancer but positive for CP were at higher risk of subsequently developing cancer than were men who underwent prostate biopsy that was negative both for cancer and for prostatic inflammation.⁹ The researchers do not recommend any change in current recommendations, pending confirmatory studies. Meanwhile, patients with CPPS should adhere strictly to standard recommendations for prostate cancer screening.

Workup

Laboratory Studies

• Urinalysis and culture
  • No tests exist for which the results unequivocally indicate the diagnosis of chronic pelvic pain syndrome (CPPS).
  • The presence of pyuria, bacteriuria, or both supports a diagnosis of bacterial prostatitis.
  • The presence of an inordinate number of WBCs in the expressed prostatic secretions (EPS) and/or bacteria on Gram stain and/or a heavy, nearly pure growth of a known bacterial pathogen on culture indicates a diagnosis of bacterial prostatitis. However, contamination from the urethra, an external site, or a source of infection in the upper urinary tract can lead to a false-positive result, while errors in collection or processing can lead to a false-negative result.
  • The NIH Chronic Prostatitis Cohort Study, in reviewing the screening results from 488 men with chronic prostatitis (CP), CPPS, or both, found (discouragingly) no reliable correlation between the leukocyte counts or the bacterial counts and the degree of symptomatology, whether the analysis was performed on the EPS, the postmassage voided urine (ie, third midstream bladder specimen [VB₃]), or the ejaculate. The authors concluded that factors other than leukocytes and bacteria must contribute to symptom development in men with CPPS.¹⁰
  • Stamey recommended the 3-glass urinalysis method, and, while this approach is widely taught, it is much less widely practiced by clinical urologists today. See Prostatitis, Bacterial for a detailed description of this examination. Nickel suggests that a simplified premassage and postmassage test may prove more efficacious.¹¹
• Prostate-specific antigen
  • The prostate-specific antigen (PSA) level is often elevated in men with acute bacterial prostatitis and may also be modestly elevated in those with CP/CPPS.
  • PSA testing in men with CPPS symptoms may be helpful in distinguishing between chronic bacterial prostatitis (ie, elevated PSA value) and prostatodynia (ie, PSA value within reference range)¹² ; however, this theory has yet to be tested in a well-controlled clinical trial.
  • Testing this theory presents problems because researchers would have to counsel large numbers of men who are younger than 40 years and who have an elevated PSA value secondary to benign prostatic inflammation that their elevated PSA test result is not an indication of prostate cancer.
• Urinary cytology: Voided urine cytologies, while not routine, should be readily considered whenever the index of suspicion is at all elevated—for instance, patients who have had a long history of smoking, who have had occupational exposure to known toxins, or who exhibit persistent microhematuria. When such a patient is undergoing cystoscopy, bladder-wash cytology should be obtained. Carcinoma in situ, at times, presents as a velvety patch of mucosa, but, often, it may be indistinguishable from normal urothelium.

Imaging Studies

• Because no diagnostic finding has proven definitive, all imaging studies (eg, kidneys, ureters, and bladder radiography; intravenous pyelography; videocystourethrography; CT scanning; MRI; ultrasonography of the scrotum; transrectal ultrasonography of the prostate) are aimed at excluding the presence of other, more definable and treatable causes of the patient's symptoms.
• None of these studies warrants universal application.
• A cost-effective diagnostic algorithm should be individualized for each patient suspected of having CPPS, incorporating only laboratory tests and radiographic procedures that are appropriate to that specific patient's problem.

Procedures

• Prostatic massage (diagnostic) and 3-glass urinalysis
  • Massaging the prostate produces EPS.
  • The finding of high colony counts of bacterial pathogens and/or a significant excess of WBCs suggests the presence of a treatable infectious agent, particularly if these findings can be reproduced after a second massage.
  • Because eliminating urethral contaminants from these specimens is impractical, the clinical reliability of these findings is subject to challenge.
  • Most men find this process distinctly unpleasant, and many patients find the procedure greatly difficult or impossible to tolerate.
  • In many cases, no prostatic secretion flows from the meatus after massage. In these cases, Stamey recommends obtaining the first 10 mL of voided urine immediately following massage, a VB₃, and submitting that specimen for Gram stain and culture as a substitute for the EPS.
• Videourodynamics
  • Videourodynamic evaluation often reveals evidence of a spastic dysfunction of the bladder neck and prostatic urethra.
  • Beyond helping detect occult neuropathies, urodynamic evaluation of patients with CPPS type III may lead to a better understanding of the underlying voiding dysfunctions peculiar to select subsets of patients with this condition. Nickel contends that dysfunctional voiding and intraprostatic reflux of urine may be initiating factors in the onset of CPPS type III.¹¹ Additionally, by subcategorizing patients with CPPS type III based on the presence and the nature of abnormal urodynamic findings, an improved rationale for case-specific therapies may be forthcoming.¹³
  • Incomplete relaxation of the bladder neck and abnormal narrowing of the prostatic urethra occur on voiding views.
  • These findings alone might not clearly justify the expense and discomfort associated with the procedure.
  • The main role of urodynamic studies is to rule out another underlying, unsuspected, but well-defined neuropathy amenable to treatment.
• Flow rate
  • A formal flow rate study often shows intermittency of flow and weakening of the urinary stream with a diminished peak urinary flow rate.
  • The urethral pressure profile typically shows a high maximum urethral closing pressure.
• Cystoscopy
  • Although the study results may be entirely normal, cystoscopy, at most, reveals only nonspecific findings of minimal-to-mild inflammation and congestion in the area of the trigone and prostatic urethra.
  • The main purpose of this intervention is, as with uroradiography, to help rule out the presence of other causes of the patient's symptoms.
  • Cystoscopy can be performed in an outpatient setting after urethral injection of lidocaine (Xylocaine) jelly. However, cystoscopy under general or regional anesthesia or under conscious sedation offers several advantages, as follows:
    • As a rule, patients with CPPS tend to be hypersensitive with a low pain tolerance. When the patient is unable to cooperate fully, endoscopic inspection is compromised.
    • General or regional anesthesia allows for more comfortable performance of cold-mucosal cup biopsies to rule out carcinoma in situ and for hydrodistension of the bladder to rule out interstitial cystitis.
    • Minor pathology, such as an annular stricture of the urethra or a prostatic polyp, can be treated at the same time.
• Anal sphincter electromyography and/or sphincter function profiles (microtip catheter)
  • With these studies, the reflex reactivity during cystometrography is recorded, and findings indicate the presence of hypertonicity and failure of the pelvic floor musculature to relax. These are signs of an underlying myofascial pain syndrome.
  • Overall pelvic floor activity during cystometrography can also be monitored via an intra-anal surface electrode.
  • While such experimental evaluations are not yet part of the standard urological armamentarium, they are available at select centers.⁵

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