History

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.

Differential Diagnoses

[Guideline] Rees J, Abrahams M, Doble A, Cooper A, Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015 Oct. 116 (4):509-25. [QxMD MEDLINE Link]. [Full Text].
Pontari MA, Ruggieri MR. Mechanisms in prostatitis/chronic pelvic pain syndrome. J Urol. 2004 Sep. 172(3):839-45. [QxMD MEDLINE Link].
Jain P, Ghosh A, Jana D, Pal DK. Chronic pelvic pain syndrome/chronic prostatitis: Is it related to human papillomavirus infection? A case-control study from Eastern India. Urologia. 2020 Jan 16. 391560319899848. [QxMD MEDLINE Link].
Krieger JN, Riley DE. Chronic prostatitis: Charlottesville to Seattle. J Urol. 2004 Dec. 172(6 Pt 2):2557-60. [QxMD MEDLINE Link].
Cohen RJ, Shannon BA, McNeal JE, Shannon T, Garrett KL. Propionibacterium acnes associated with inflammation in radical prostatectomy specimens: a possible link to cancer evolution?. J Urol. 2005 Jun. 173(6):1969-74. [QxMD MEDLINE Link].
Rudick CN, Berry RE, Johnson JR, et al. Uropathogenic Escherichia coli induces chronic pelvic pain. Infect Immun. 2011 Feb. 79(2):628-35. [QxMD MEDLINE Link]. [Full Text].
Soto SM, Smithson A, Martinez JA, Horcajada JP, Mensa J, Vila J. Biofilm formation in uropathogenic Escherichia coli strains: relationship with prostatitis, urovirulence factors and antimicrobial resistance. J Urol. 2007 Jan. 177(1):365-8. [QxMD MEDLINE Link].
Westesson KE, Shoskes DA. Chronic prostatitis/chronic pelvic pain syndrome and pelvic floor spasm: can we diagnose and treat?. Curr Urol Rep. 2010 Jul. 11 (4):261-4. [QxMD MEDLINE Link].
Penna G, Fibbi B, Maggi M, Adorini L. Prostate autoimmunity: from experimental models to clinical counterparts. Expert Rev Clin Immunol. 2009 Sep. 5(5):577-86. [QxMD MEDLINE Link].
Davis SN, Maykut CA, Binik YM, Amsel R, Carrier S. Tenderness as measured by pressure pain thresholds extends beyond the pelvis in chronic pelvic pain syndrome in men. J Sex Med. 2011 Jan. 8(1):232-9. [QxMD MEDLINE Link].
Miller JL, Rothman I, Bavendam TG, Berger RE. Prostatodynia and interstitial cystitis: one and the same?. Urology. 1995 Apr. 45(4):587-90. [QxMD MEDLINE Link].
Parsons CL, Albo M. Intravesical potassium sensitivity in patients with prostatitis. J Urol. 2002 Sep. 168(3):1054-7. [QxMD MEDLINE Link].
Forrest JB, Schmidt S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity. J Urol. 2004 Dec. 172(6 Pt 2):2561-2. [QxMD MEDLINE Link].
MacLennan GT, Eisenberg R, Fleshman RL, Taylor JM, Fu P, Resnick MI, et al. The influence of chronic inflammation in prostatic carcinogenesis: a 5-year followup study. J Urol. 2006 Sep. 176(3):1012-6. [QxMD MEDLINE Link].
Schaeffer A, Stern J. Chronic prostatitis. Clin Evid. 2002 Jun. (7):788-95. [QxMD MEDLINE Link].
Nickel JC. Practical approach to the management of prostatitis. Tech Urol. 1995 Fall. 1(3):162-7. [QxMD MEDLINE Link].
Pansadoro V, Emiliozzi P, Defidio L, Scarpone P, Sabatini G, Brisciani A, et al. Prostate-specific antigen and prostatitis in men under fifty. Eur Urol. 1996. 30(1):24-7. [QxMD MEDLINE Link].
Theodorou C, Konidaris D, Moutzouris G, Becopoulos T. The urodynamic profile of prostatodynia. BJU Int. 1999 Sep. 84(4):461-3. [QxMD MEDLINE Link].
Davis BE, Weigel JW. Adenocarcinoma of the prostate discovered in 2 young patients following total prostatovesiculectomy for refractory prostatitis. J Urol. 1990 Sep. 144(3):744-5. [QxMD MEDLINE Link].
Chung SD, Huang CC, Lin HC. Chronic prostatitis and depressive disorder: a three year population-based study. J Affect Disord. 2011 Nov. 134(1-3):404-9. [QxMD MEDLINE Link].
Nickel JC, Shoskes DA. Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome. BJU Int. 2010 Nov. 106(9):1252-63. [QxMD MEDLINE Link].
Davis SN, Binik YM, Amsel R, Carrier S. Is a Sexual Dysfunction Domain Important for Quality of Life in Men with Urological Chronic Pelvic Pain Syndrome? Signs "UPOINT" to Yes. J Urol. 2013 Jan. 189(1):146-51. [QxMD MEDLINE Link].
Samplaski MK, Li J, Shoskes DA. Clustering of UPOINT domains and subdomains in men with chronic prostatitis/chronic pelvic pain syndrome and contribution to symptom severity. J Urol. 2012 Nov. 188(5):1788-93. [QxMD MEDLINE Link].
Nickel JC. Lower urinary tract symptoms associated with prostatitis. Can Urol Assoc J. 2012 Oct. 6(5 Suppl 2):S133-5. [QxMD MEDLINE Link]. [Full Text].
Smart CJ, Jenkins JD, Lloyd RS. The painful prostate. Br J Urol. 1975. 47(7):861-9. [QxMD MEDLINE Link].
Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005 Jul. 174(1):155-60. [QxMD MEDLINE Link].
FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2009 Aug. 182(2):570-80. [QxMD MEDLINE Link].
Wise D, Anderson RU. A Headache in The Pelvis: A New Understanding and Treatment. Occidental, CA: National Center for Pelvic Pain Research; 2003. [Full Text].
Sayed D, Kallewaard JW, Rotte A, Jameson J, Caraway D. Pain relief and improvement in quality of life with 10 kHz SCS therapy: Summary of clinical evidence. CNS Neurosci Ther. 2020 Feb 22. [QxMD MEDLINE Link].
Iacovelli V, Bianchi D, Pletto S, Pacini P, Fede Spicchiale C, Finazzi Agrò E. The role of glycosaminoglycans in the management of chronic pelvic pain: a systematic review. Minerva Urol Nefrol. 2020 Mar 16. [QxMD MEDLINE Link].
Anderson RU, Wise D, Sawyer T, Chan CA. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol. 2006 Oct. 176(4 Pt 1):1534-8; discussion 1538-9. [QxMD MEDLINE Link].
Lee JH, Lee SW. Relationship between Premature Ejaculation and Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Sex Med. 2014 Dec 5. [QxMD MEDLINE Link].
Sadeghi-Nejad H, Seftel A. Sexual dysfunction and prostatitis. Curr Urol Rep. 2006 Nov. 7(6):479-84. [QxMD MEDLINE Link].
Kaplan SA, Santarosa RP, D'Alisera PM, Fay BJ, Ikeguchi EF, Hendricks J, et al. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. J Urol. 1997 Jun. 157(6):2234-7. [QxMD MEDLINE Link].
Lee SH, Lee BC. Electroacupuncture relieves pain in men with chronic prostatitis/chronic pelvic pain syndrome: three-arm randomized trial. Urology. 2009 May. 73(5):1036-41. [QxMD MEDLINE Link].
Küçük EV, Suçeken FY, Bindayi A, Boylu U, Onol FF, Gümüs E. Effectiveness of Acupuncture on Chronic Prostatitis-Chronic Pelvic Pain Syndrome Category IIIB Patients: A Prospective, Randomized, Nonblinded, Clinical Trial. Urology. 2015 Jan 9. [QxMD MEDLINE Link].
Anderson RU, Sawyer T, Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol. 2009 Dec. 182(6):2753-8. [QxMD MEDLINE Link].
Anderson RU, Wise D, Sawyer T, Nathanson BH, Nevin Smith J. Equal Improvement in Men and Women in the Treatment of Urologic Chronic Pelvic Pain Syndrome Using a Multi-modal Protocol with an Internal Myofascial Trigger Point Wand. Appl Psychophysiol Biofeedback. 2016 Jun. 41 (2):215-24. [QxMD MEDLINE Link].
Meares EM Jr. Prostatitis. Med Clin North Am. 1991 Mar. 75(2):405-24. [QxMD MEDLINE Link].
Meares EM Jr. Non-specific infections of the genitourinary tract. Tanagho EH, McAninch JW, eds. Smith's General Urology. 14th ed. Appleton & Lange: Norwalk, Conn; 1995. 231-4.
Meares EM Jr. Prostatitis and related disorders. Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998. 285-6.
Lee JC, Muller CH, Rothman I, Agnew KJ, Eschenbach D, Ciol MA, et al. Prostate biopsy culture findings of men with chronic pelvic pain syndrome do not differ from those of healthy controls. J Urol. 2003 Feb. 169(2):584-7; discussion 587-8. [QxMD MEDLINE Link].
Lowentritt JE, Kawahara K, Human LG, Hellstrom WJ, Domingue GJ. Bacterial infection in prostatodynia. J Urol. 1995 Oct. 154(4):1378-81. [QxMD MEDLINE Link].
Taylor BC, Noorbaloochi S, McNaughton-Collins M, Saigal CS, Sohn MW, Pontari MA. Excessive antibiotic use in men with prostatitis. Am J Med. 2008 May. 121(5):444-9. [QxMD MEDLINE Link].
Barbalias GA, Nikiforidis G, Liatsikos EN. Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. 1998 Mar. 159(3):883-7. [QxMD MEDLINE Link].
Berger R. Editorial comment: Urological survey--infection and inflammation in the genitourinary tract. J Urol. Jan 2009. 181:135.
Pontari MA, Krieger JN, Litwin MS, et al. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: a randomized controlled trial. Arch Intern Med. 2010 Sep 27. 170(17):1586-93. [QxMD MEDLINE Link].
Schaeffer AJ. Editorial: Emerging concepts in the management of prostatitis/chronic pelvic pain syndrome. J Urol. 2003 Feb. 169(2):597-8. [QxMD MEDLINE Link].

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