Chronic Pelvic Pain in Men Clinical Presentation

Updated: Mar 17, 2020
  • Author: Richard A Watson, MD; Chief Editor: Edward David Kim, MD, FACS  more...
  • Print


Symptoms parallel those experienced by persons with chronic bacterial and nonbacterial prostatitis. The typical patient is a young to middle-aged man with variable symptoms of chronic, irritative, and/or obstructive voiding accompanied by moderate to severe pain in the pelvis, lower back, perineum, and/or genitalia.

Erectile dysfunction is the symptom that initially brings many men to seek medical attention; however, the patient often waits until the end of the interview to mention the problem or he may avoid mentioning it at all unless the physician specifically inquires.

To facilitate history taking and to establish a more uniform standard, a National Institutes of Health (NIH) collaborative panel proposed the Chronic Prostatitis Symptom Index (NIH-CPSI). This index is calculated using a series of nine questions that contain 21 items used to assess patient history in a standardized and quantifiable format. The questions cover pain, urinary symptoms, and impact of symptoms on quality of life. Each category generates separate scores; a total score is also calculated.


Physical Examination

No physical examination finding in chronic pelvic pain syndrome (CPPS) is pathognomonic. Examination of the genitalia reveals normal results. Digital rectal examination may reveal a tight anal sphincter. When the anal sphincter tone is hyperactive, a verifiable spastic neuropathy must be excluded. The hyperactivity may otherwise indicate a spasmodic hyperirritability of the pelvic floor musculature, which may be amenable to medical and biofeedback therapies.

The prostate and adjacent tissues may be moderately to severely tender, and the gland itself may be slightly congested or boggy. However, the presence of a small, relatively firm gland does not exclude the possibility of CPPS type III. Extreme tenderness upon gentle palpation of the prostate should raise suspicion for acute bacterial prostatitis or even a prostatic abscess.

The value of this examination is to exclude other diagnoses, such as prostate cancer, chronic urethritis/meatitis, and granulomatous prostatitis.