Chronic Pelvic Pain Syndrome / Chronic Prostatitis

Scope

  • Chronic Pelvic Pain Syndrome (CPPS), previously known as Chronic Prostatitis (CP)
  • Treatment should be based on symptoms of pain lasting at least 3 months
  • Presents with perineal, suprapubic, testicular, penile, low back, inguinal or rectal pain
  • The aetiology is largely unknown. An infectious cause is uncommon
  • It is difficult to diagnose, being a diagnosis of exclusion characterised by pain with associated urinary and psychological symptoms
  • Most commonly seen in 40-60 year olds
  • There is no indication to give more than one course of antibiotics

Please Note: Pre-Choice Triage is currently active for this specialty.

Out of scope

  • Management of male urinary tract infections
  • Management of acute and chronic urinary retention
  • Management of acute prostatitis (this is a rare diagnosis with an infective history and the patient is systemically unwell often requiring admission)

Assessment

Signs and Symptoms

Symptoms characteristic of CPPS include:

  • perineal or suprapubic pain, testicular pain, penile pain, low back pain, inguinal pain or rectal pain. Pain on ejaculation, urethral burning during and independent of micturition can also occur
  • Lower urinary tract symptoms (LUTS) voiding symptoms (hesitancy slow stream) and storage symptoms (dysuria, frequency, urgency). IPSS score can be helpful
  • erectile dysfunction / sexual dysfunction history. IIEF-5 can be useful
  • associated (irritable bowel syndrome) IBS and functional bowel symptoms
  • psychological including anxiety, stress and depression and quality of life (QoL). A mental health assessment tool such as PHQ-9 can be useful
  • take a sexual history and consider referral for sexually transmitted infection (STI) screening if appropriate

History and examination

  • A focused physical examination is important so that abnormalities of the abdomen, external genitalia and pelvic floor muscle dysfunction are not missed and left untreated
  • Digital rectal exam (DRE) The patient may have diffuse mild tenderness in the prostate/pelvic floor.
  • A DRE is possible during episodes of pain (unlike in acute prostatitis), and may reproduce the pain felt by the patient
  • There may be no objective clinical signs
  • If pyrexial consider alternative diagnosis

Differential Diagnosis

Acute bacterial prostatitis is very uncommon.

Signs of acute prostatitis may include:

  • signs localised to the prostate: an extremely tender, swollen and tense, smooth-textured prostate gland which is warm to the touch
  • DRE may not be possible because of extreme discomfort
  • signs of bacteraemia: patients with acute bacterial prostatitis are usually systemically unwell with pyrexia and tachycardia
  • consider acute prostatitis as an STI in younger adults

Does the patient have symptoms of UTI with signs LUTS? See Formulary chapter 5 - UTIs

Red Flags

Red Flag/Urgently refer patients if:

  • a suspicion of prostate or bladder cancer see 2WW referral
  • storage symptoms in a heavy smoker
  • chronic retention which may present as night time enuresis / over flow incontinence and/ or painless palpable bladder needs renal function checking and refer urgently

Investigations

  • Urine dipstick to exclude infection and red flags
  • Midstream urine sample (MSU) (ideally early morning sample) if dipstick suggests infection
  • Prostate specific antigen (PSA) to exclude alternative diagnosis or red flag

A description of neuropathic pain in the context of CPPS

Pain is experienced by the majority, if not all, people across a lifetime.

On most occasions, the pain experienced is in the context of an acute injury or inflammatory process. The body's natural response to pain is to try to protect the injured area, usually by altering posture or muscle tone around this area while the injury, inflammation or infection is healing. Once healing has completed, the pain resolves and any postural and muscular changes return to normal.

However, in a small proportion of people who suffer an injury, inflammation or infection, the sensation of pain continues, despite the resolution or healing of the underlying problem. This sometimes happens because the pain nerves themselves have been damaged by the original injury or inflammation and, as a result, have become sensitised. Other factors that increase the risk of this happening include genetic factors, psychological problems associated with the original injury (e.g. anxiety) and prior experience of pain in the injured or inflamed area. In these circumstances, the ongoing pain sensation is due to over-sensitisation of the pain nervous system that supplies the painful area. The pain experienced by the patient is very real, but no longer provides a useful purpose as the injury has already healed or the infection has already resolved.

Thus, in patients with CPPS, the original infective or inflammatory episode of 'prostatitis' has resulted in sensitisation of the pain nervous system that supplies the prostate and surrounding area. The sensation of pain (which may mimic the original 'prostatitis' pain) continues, despite the fact that, in the vast majority of patients, any underlying infection has completely resolved.

However, the human body will react to pain by trying to protect the painful area, irrespective of whether the signal is due to a genuine injury or an abnormality in the nervous system. If the pain experience is prolonged, these protection mechanisms become entrenched. In the longer term, the changes in posture and muscular function can lead to secondary pain problems, resulting in increased disability and worsening of the pain condition.

Referral

Referral criteria

  • History & examination
  • Investigations
    • Urine dipstick to exclude infection and red flags
    • MSU (ideally early morning sample) if dipstick suggests infection
    • PSA to exclude alternative diagnosis or red flag
  • Any treatments

If symptoms persist despite following suggested management and treatment then consider referral to Urology Pre-choice triage for further advice. If the problem is not specifically urological then consider referral directly to one of the following services:

  • Pain management
  • Mental Health for psychosocial symptoms following full assessment/management in primary care
  • Psychosexual counselling

Referral instructions

For referral to Urology

Refer using e-Referrals

  • Specialty: Urology
  • Clinic Type: Not otherwise specified
  • Service: DRSS-Northern-Urology- Devon CCG - 15N
For referral to Chronic pain service

Refer using e-Referrals

  • Specialty: Pain Management
  • Clinic Type: Pain Management
  • Service: DRSS-Northern-Pain Management- Devon CCG - 15N

Referral forms

DRSS Referral form

Supporting Information

Patient Information

Evidence

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Publication date: June 2020

Last updated: 08-06-2020

 

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