Chronic Pelvic Pain in Men Differential Diagnoses

Diagnostic Considerations

The many differential diagnoses associated with prostatodynia reveal the conundrum of diagnosing this condition. 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.

Conditions to consider in the differential diagnosis of chronic pelvic pain syndrome (CPPS) include the following:

• Inflammatory bowel disease
• Nonbacterial prostatitis
• Acute bacterial prostatitis
• Prostate cancer
• Tuberculosis of the genitourinary system
• Urethral cancer
• Urethral diverticula
• Urethritis
• 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
• Chronic urethritis
• Interstitial cystitis
• Carcinoma in situ of the urinary bladder

CPPS versus interstitial cystitis

An archetypical example would be differentiating between prostatodynia and interstitial cystitis in the male. 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 hydrodistention to search for indicative signs is prudent and cost effective.^[9] 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 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.^[10]

In 2004, Forrest and Schmidt reviewed a series of 92 men diagnosed with interstitial cystitis, most of whom had been referred for urologic evaluation with an initial diagnosis of either CP (54%) or benign prostatic hyperplasia (23%).^[11] Interstitial cystitis had been diagnosed in these patients 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 hydrodistention. Forrest and Schmidt cautioned that the symptoms of interstitial cystitis closely parallel those of CP/chronic pelvic pain syndrome (CPPS).

The patients’ 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 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.)^[11]

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. 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.

CPPS versus chronic urethritis

The distinction between chronic urethritis and CP/CPPS can prove problematic, an issue discussed by Krieger and Riley.^[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.

CPPS versus cancer

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. 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 revealed 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 for cancer and for prostatic inflammation.^[12] However, the researchers did not recommend any change in current recommendations, pending confirmatory studies. Meanwhile, patients with CPPS should adhere strictly to standard recommendations for prostate cancer screening.

Differential Diagnoses

• Anal Fissure
• Bladder Cancer
• Colovesical Fistula
• Cystitis, Nonbacterial
• Fistula-in-Ano
• Gonococcal Infections
• Hemorrhoids
• Infertility