Chronic Pelvic Pain Syndrome in Men (CPPS) or Bacterial Prostatitis By Lori Montgomery, MD, CCFP and Magali Robert, MD, FRCSC
Introduction Chronic pelvic pain is the most common reason for men under 50 to visit a urologist. Yet it is very poorly understood. Doctors have called it prostatitis (say: pros-tuh-TIE-tis) for many years, mainly because when the doctor does the exam on a man with this condition, the prostate is very tender. “-itis” means inflammation. When you look at samples of an affected prostate under the microscope, there is no inflammation (swelling), so prostatitis is not a very good name. We have also traditionally treated this condition with antibiotics. It turns out that there are very rarely any bacteria involved, either.
Signs and symptoms •pain in the penis, testicles, or rectum (without an infection or other problem to explain the pain); sometimes pain in the lower abdomen •pain can be worse with voiding, bowel movements, or sex •pain is often made worse by sitting for long periods •erectile dysfunction (problems having or keeping an erection)
Causes We do not know what causes chronic pelvic pain syndrome (CPPS). Sometimes symptoms get better with medicines that modify nerve signals. Because of this, some people think it is a kind of neuropathic pain. Like vulvodynia (pain in the vulva) in women, it is often made worse by tension in the pelvic floor muscles. In fact, this may be why pressure on the prostate is so painful during the exam—because the exam involves pressure over some of the pelvic floor muscles.
Diagnostic tests A urine sample should be taken to make sure you do not have a bladder infection. A bladder infection can sometimes cause the same symptoms. Sometimes, a swab or a sample of prostatic fluid will be taken to look for signs of infection as well. Depending on your symptoms, your age, and your family history, you and your doctor may decide to screen for prostate cancer as well. If these tests are normal, there are no other diagnostic tests which help to make the diagnosis.
Treatment approaches Medicines •Even though there is most often no bacteria involved, the pain sometimes responds to antibiotics such as minocycline and erythromycin. This may be because aside from killing bacteria, antibiotics also reduce levels of chemicals in the body that promote inflammation (swelling). •Doxazosin is a blood pressure medicine that can also reduce muscle spasm, and is sometimes useful in CPPS. •The pain in CPPS often fluctuates. It may be best to use a mild pain medicine (like acetaminophen or ibuprofen) on most days, with a stronger medicine (like codeine or tramadol) for severe flares of pain. •If you also experience erectile dysfunction, there are medicines that can be helpful to treat this. PDE5 inhibitors are useful if erections do not make the pain worse. There are a number of medicines that are used to control nerve pain. Some patients with chronic pelvic pain may benefit from these. The research evidence to support them is limited:
•tricyclic antidepressants (such as amitriptyline or nortriptyline) •gabapentin or pregabalin •serotonin-norepinephrine reuptake inhibitors (such as venlafaxine or duloxetine)
Sacral nerve stimulators have been used for treating CPPS, but this is an invasive treatment. It is only useful if you know that the sacral nerve is the source of the problem. This is not very common. Surgery to remove part or all of the prostate has also been tried. There is no good evidence to support this practice. The side effects include incontinence and permanent erectile dysfunction.
Non-drug therapies Physiotherapy with a therapist trained to work with the muscles of the pelvic floor can be useful. Sometimes, the pain around the genitals causes the muscles of the pelvic floor to become tense and sore. This causes pain itself. It makes chronic pelvic pain worse. It also makes sex more difficult. There is a list of pelvic physiotherapists elsewhere on this site. Some patients find things like acupuncture or transcutaneous electrical nerve stimulation (TENS) helpful as well.
Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:
•relaxation •meditation •activity pacing •cognitive behavioural therapy These self-management strategies can help you to improve your function so you can do more and enjoy life more.
For more information •Neuropathic Pain •Vulvodynia or Pudendal Neuralgia •Pain Medications •Physical Therapies •Self-management Web sites Pain.com www.pain.com
American Pain Foundation www.painfoundation.org
Urologyhealth.org (American Urological Association Foundation) www.urologyhealth.org
References Pontari M, Ruggieri M, Mechanisms in prostatitis/chronic pelvic pain syndrome [review]. Journal of Urology. 2004;172 (3) 839-45.