Chronic Pelvic Pain in Men Guidelines

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

In 2015, Prostate Cancer UK released consensus guidelines for the diagnosis and management of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The guidelines define early-stage disease as persistent, recurrent symptoms for < 6 months in antibiotic‐naïve men. In later-stage disease, patients experience persistent, recurrent symptoms for >6 months that are refractory to initial lines of pharmacotherapy. The recommendations for evaluation include the following [1] :

  • Use of reliable instruments, such as the National Institutes of Health Chronic Prostatitis Symptom Index (NIH‐CPSI), International Prostate Symptom Score (IPSS), and UPOINT system, should be considered to assess initial symptom severity, evaluate phenotypic differences, and monitor patients' response to therapeutic intervention.
  • Patients should be screened for psychosocial symptoms (eg, anxiety or stress) using either the psychosocial yellow flag system and/or Patient Health Questionnaire–9 (PHQ‐9) and/or Generalized Anxiety Disorder–7( GAD‐7) scales.
  • Referral to a mental health specialist (eg, psychiatrist, clinical psychologist) should be considered if clinically relevant levels of psychosocial symptoms are present.
  • Other concerns or differential diagnoses, including urological cancers and infertility, should be discussed with the patient to establish a full patient history.
  • Patients should be informed of the underlying causes of CBP and CP/CPPS to help improve their understanding. This may include an explanation of basic pelvic anatomy, the chronic pain cycle, and potential routes for pain (neuropathic vs nociceptive).

The guidelines include the following recommendations for treatment of CP/CPPS [1] :

  • Consider α‐adrenergic antagonists as an initial treatment option, although there is a lack of evidence to inform best practice for the use of these agents and they have a modest treatment effect regarding total, urinary symptom, pain, and quality of life (QoL) scores. 
  • Treatment with α‐adrenergic antagonists should be considered in patients who present with significant voiding lower urinary tract symptoms (LUTS; eg, slow urinary flow, hesitancy); if no relief from voiding LUTS or other symptoms is achieved within 4–6 weeks, treatment should be stopped and a different pharmacotherapy considered. Patients should be referred to specialist care if other approaches have been exhausted.
  • Due to the adverse effect profiles, consider uroselective α‐adrenergic antagonists (eg, tamsulosin, alfuzosin, silodosin) as first‐line treatment in patients who present with voiding LUTS.
  • Antimicrobial therapy may have a moderate effect on total, urinary, pain and QoL scores and should be considered as an initial treatment option  
  • Antimicrobial therapy should be guided by bacterial cultures and sensitivities, taking into consideration any drug interactions and/or contraindications  
  • For patients with early‐stage disease, a quinolone (eg, ciprofloxacin or ofloxacin) for 4–6 weeks may be offered as first‐line therapy.
  • A repeated course of antibiotic therapy (4–6 weeks) should be offered only if a bacterial cause is confirmed or if the patient has a partial response to the first course.
  • If a bacterial cause is excluded (eg, via urine dipstick or culture) and symptoms do not improve after antibiotic therapy, a different treatment method or referral to specialist care should be considered.
  • Multimodal/combined therapy should be individualized for each patient; depending on the symptoms at presentation; possible additions to first‐line antibiotic therapy include an α‐blocker and/or a nonsteroidal anti-inflammatory drug (NSAID), an agent targeting neuropathic pain (eg, pregabalin), or a 5-α‐reductase inhibitor (predominantly for patients with coexisting LUTS and benign prostatic hyperplasia).
  • Patients whose condition is refractory to treatment should be questioned about the possibility of any past trauma (including physical, emotional, or sexual abuse)
  • A multidisciplinary team should be utilized for treatment of refractory symptoms, with pharmacotherapy, physical, and psychosocial approaches integrated into an individualized treatment plan.
  • The multidisciplinary team may include urologists, pain specialists, nurse specialists, physiotherapist, general practitioners, cognitive behavioral/psychological therapists, and sexual health specialists.
  • There is insufficient evidence to recommend surgical techniques, including radical prostatectomy, transurethral resection of the prostate (TURP), high-intensity focused ultrasound (HIFU) or prostatic massage, except in the context of a clinical trial.
  • If non‐physical causes for symptoms have been excluded, physiotherapy may be considered.
  • After referral, a full assessment (eg, symptom score scaling, examination of the pelvic floor muscles) should be completed to guide the subsequent sequence of physiotherapy treatments.

The following physiotherapy treatment options may be considered:

  • Pelvic floor re‐education
  • Local pelvic floor relaxation
  • Biofeedback
  • General relaxation
  • Deep relaxation/mindfulness
  • Trigger point release
  • Myofascial release
  • Stretches
  • Exercise for pain management
  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture for trigger point release and pain management
  • Bladder retraining

The guidelines also include the following recommendations for pain management [1] :

  • In patients with early‐stage disease, regular paracetamol (acetaminophen) may be offered for management of pain symptoms.
  • NSAIDs should be offered only for short‐term treatment of pain, to patients with early‐stage disease whose symptoms are suspected to be due to an inflammatory process, or those judged to be experiencing an inflammatory flare. 
  • To prevent unwanted adverse effects, NSAIDs should be stopped within 4–6 weeks of treatment initiation if they do not reduce symptoms.
  • In patients with early‐stage disease, use of opioids for pain management should be avoided.
  • If pain is considered to be neuropathic in origin, consider treatment with a gabapentinoid (eg, pregabalin or gabapentin), a tricyclic antidepressant (eg, amitriptyline, nortriptyline, trimipramine) or a selective serotonin‐noradrenaline (norepinephrine) reuptake inhibitor (eg, duloxetine).
  • Consider referral to a pain specialist when pain is severe and refractory to treatment or is significantly impairing the patient's lifestyle and ability to participate in daily activities