Chronic Pelvic Pain Syndrome - Male: Difference between revisions

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Chronic prostatitis (CP) is a male health issue commonly seen in adulthood and effects 2-6% of men. The etiology and pathophysiology of CP/CPPS remain largely unknown.<ref name=":2">Zhang J, Liang C, Shang X, Li H. [https://journals.sagepub.com/doi/full/10.1177/1557988320903200 Chronic prostatitis/chronic pelvic pain syndrome: a disease or symptom? Current perspectives on diagnosis, treatment, and prognosis.] American Journal of Men's Health. 2020 Jan;14(1):1557988320903200.</ref>
Chronic prostatitis (CP) is a male health issue commonly seen in adulthood and effects 2-6% of men. The etiology and pathophysiology of CP/CPPS remain largely unknown.<ref name=":2">Zhang J, Liang C, Shang X, Li H. [https://journals.sagepub.com/doi/full/10.1177/1557988320903200 Chronic prostatitis/chronic pelvic pain syndrome: a disease or symptom? Current perspectives on diagnosis, treatment, and prognosis.] American Journal of Men's Health. 2020 Jan;14(1):1557988320903200.</ref>


There has always been lack of insight into CPPS, which has led to an unsatisfactory management of patients in clinical practice. There are very few evidence-based studies with long-term follow-up on the effects of medical intervention on CP/CPPS patients and prognosis of the disease. Major difficulty in medical treatment of patients with CP/CPPS is extended time of therapy, uncertainty of outcomes, and relapse of the symptoms. <ref name=":2" />
There has always been lack of insight into CPPS, which has led to an unsatisfactory management of patients in clinical practice. There are very few evidence-based studies with long-term follow-up on the effects of medical intervention on CP/CPPS patients and prognosis of the disease. Major difficulty in medical treatment of patients with CP/CPPS is extended time of therapy, uncertainty of outcomes, and relapse of the symptoms. Knowledge of etiology and pathophysiology is not sufficient and therapeutic guidelines have not yielded acceptable outcomes and prognoses for both patients and care providers.  <ref name=":2" />


Chronic pelvic pain syndrome, usually affects young men (mean age 43 years) and presents with perineal and genital pain that can be unrelenting. The prevalence of CPPS in the United States is estimated between 2-16% while the prevalence in Asia is estimated between 2.7-8.7%.<ref name="Nguyen">Nguyen C, Shoskes D. Evaluation of the Prostatitis Patient. Chronic Prostatitis/Chronic Pelvic Pain Syndrome. 2008:1-16. doi:10.1007/978-1-59745-472-8_1.</ref><ref name="Suh">Suh L, Lowe F. Alternative Therapies for the Treatment of Chronic Prostatitis. Current Urology Reports. 2011;12(4):284-287. doi:10.1007/s11934-011-0188-y.</ref><ref name="Potts" />
Chronic pelvic pain syndrome, usually affects young men (mean age 43 years) and presents with perineal and genital pain that can be unrelenting. The prevalence of CPPS in the United States is estimated between 2-16% while the prevalence in Asia is estimated between 2.7-8.7%.<ref name="Nguyen">Nguyen C, Shoskes D. Evaluation of the Prostatitis Patient. Chronic Prostatitis/Chronic Pelvic Pain Syndrome. 2008:1-16. doi:10.1007/978-1-59745-472-8_1.</ref><ref name="Suh">Suh L, Lowe F. Alternative Therapies for the Treatment of Chronic Prostatitis. Current Urology Reports. 2011;12(4):284-287. doi:10.1007/s11934-011-0188-y.</ref><ref name="Potts" />
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== Physiotherapy Management  ==
== Physiotherapy Management  ==
An individualized multimodal treatment approach to cope with the course of the disorder is proposed by the physical therapist; alongside  emphasis on communications and personal/family/community supports, as it is a vital component in the therapeutic regime and rehabilitation of patients with CP/CPPS. The purpose of rehabilitation program is to improve comprehension on CP/CPPS and to help care providers and patients to achieve the goal of medical intervention—relieving associated symptoms of CP/CPPS and improving the quality of life.


Physiotherapy provides a broad variety of techniques that are safe and effective for CPPS. The following are different modalities or techniques that are available under pelvic floor rehabilitation: <ref name="Nguyen" /><ref name="Suh" /><ref name="Shoskes" />  
Physiotherapy provides a broad variety of techniques that are safe and effective for CPPS. The following are different modalities or techniques that are available under pelvic floor rehabilitation: <ref name="Nguyen" /><ref name="Suh" /><ref name="Shoskes" />  

Revision as of 02:59, 18 March 2022

This article is currently under review and may not be up to date. Please come back soon to see the finished work! (18/03/2022)

Original Editor - Laura Ritchie, posting on behalf of Henry Chan, MPT Class of 2017 at Western University, project for PT9584.

Top Contributors - Laura Ritchie, Niha Mulla, Kim Jackson, Vidya Acharya, Evan Thomas and Nicole Hills

Definition[edit | edit source]

Chronic Pelvic Pain Syndrome (CPPS), previously known as chronic nonbacterial prostatitis is a condition with long-term pelvic pain without evidence of a bacterial infection.[1][2]

Description[edit | edit source]

Pain experienced varies from person to person in ranging severity, type and perpetuity. CPPS-related pain can spread to the buttocks, lower back, and thighs.[1]

Chronic prostatitis (CP) is a male health issue commonly seen in adulthood and effects 2-6% of men. The etiology and pathophysiology of CP/CPPS remain largely unknown.[3]

There has always been lack of insight into CPPS, which has led to an unsatisfactory management of patients in clinical practice. There are very few evidence-based studies with long-term follow-up on the effects of medical intervention on CP/CPPS patients and prognosis of the disease. Major difficulty in medical treatment of patients with CP/CPPS is extended time of therapy, uncertainty of outcomes, and relapse of the symptoms. Knowledge of etiology and pathophysiology is not sufficient and therapeutic guidelines have not yielded acceptable outcomes and prognoses for both patients and care providers. [3]

Chronic pelvic pain syndrome, usually affects young men (mean age 43 years) and presents with perineal and genital pain that can be unrelenting. The prevalence of CPPS in the United States is estimated between 2-16% while the prevalence in Asia is estimated between 2.7-8.7%.[4][5][6]

Clinically Relevant Anatomy[edit | edit source]

A good understanding of the genitourinary system and pelvic floor musculature is clinically crucial.

Signs and symptoms of chronic pelvic pain syndrome[edit | edit source]

There are many symptoms related to CPPS, including:[1][2] [4][5][6]

  • Pelvic floor pain/ perineal pain without evidence of urinary tract infection, lasting more than 3 months is the key symptom of CPPS.
  • Abdominal pain
  • Frequent urination
  • Genital pain
  • Lower back pain
  • Pain during or after sex
  • Post-ejaculatory pain
  • Pain while sitting
  • Erectile difficulty
  • Sexual dysfunction
  • Unexplained fatigue

Pain in patients suffering from CPPS can range from mild to debilitating, it can be dull or sharp at the same time constant or intermittent.

Causes of chronic pelvic pain syndrome[edit | edit source]

The exact cause of CPPS is unknown. However, there are several theories of causation.[1][2] [4][5][6]

  • Constipation
  • Enlarged spleen
  • Inflammation of the intestines
  • Kidney stones
  • Painful bladder syndrome
  • Pelvic floor dysfunction
  • Endocrine hormone abnormalities
  • Neurogenic inflammation
  • Bacterial infection
  • Interstitial cystitis

Risk factors of chronic pelvic pain syndrome[edit | edit source]

Pelvic Rehabilitation Medicine has mentioned the following risk factors of chronic pelvic pain syndrome [1]

  • Diagnosis of a-bacterial Prostatitis
  • Hip impingement
  • Pelvic floor muscle hypertonia
  • Joint hyper mobility
  • Labral tear
  • STD/UTI/Yeast infection history
  • Hernia
  • Over active bladder

Clinical Presentation[edit | edit source]

The primary and most commonly reported symptom in CPPS is pain. The traditional presentation of CPPS is a patient who has pelvic, perineal, or genital pain associated with voiding and/or sexual dysfunction, characterized by a relapsing, remitting course. Patients with CPPS, however, can have very variable presentations with many different signs and symptoms associated with the syndrome that often overlap with other urological disorders.[4] [6] [7]

There are four cardinal symptom categories of CPPS:

  • Perineal/pelvic pain
  • Voiding symptoms
  • Sexual dysfunction
  • Systemic conditions

The onset of pain is usually sudden with a duration that must be present for at least three of the last six months. The intensity of pain can be quite severe and is most often located at the perineal and genital region but can manifest to other regions such as lower abdomen, penis, scrotum, rectum, and lower back. Urinary symptoms, both obstructive and irritable, are common. Ejaculatory pain is also a common symptom. Systemic symptoms include myalgia, arthralgia, and unexplained fatigue. CPPS symptoms commonly wax and wane with inconsistent remissions and exacerbations.[4] [6][7] Review discusses the cause, diagnosis, and management of chronic scrotal content pain, a common but poorly understood condition.[8]

Differential Diagnosis[edit | edit source]

The following are conditions that can mimic CPPS: [4]

  • Granulomatous prostatitis
  • Various abscesses and cysts
  • Prostatic infections
  • BPH
  • Fistulae from adjacent organs
  • Prostatic urethral stricture
  • Varicocele
  • Seminal vesiculitis/obstruction
  • Bladder/prostatic calculi
  • Ureteral lithiasis
  • Tumours of the prostate
  • Urinary tract infection
  • Interstitial cystitis
  • Overactive bladder
  • Radiation cystitis
  • Bladder cancer
  • Urethral diverticulum
  • Bacterial urethritis
  • Diabetes mellitus
  • Pudendal nerve entrapment
  • Chronic Scrotal Content Pain[8]

Diagnostic Procedures[edit | edit source]

A physical pelvic examination will provide a good scan of the genitourinary system such as the penis, scrotum, perineum, prostate, and inguinal areas. A physical examination can be used to exclude other disorders such as inguinal herniation, nerve entrapment, or musculoskeletal inflammation. Suprapubic tenderness may be presented in some men with CPPS. The most important part of the examination is the digital rectal examination (DRE) which is used to assess the size, consistency, symmetry, and tenderness of the prostate. Most patients with CPPS will present with a normal DRE. Internal pelvic musculature should be palpated to examine muscle trigger points that can cause muscle spasm or pain. Often, patient report that symptoms can be reproduced by palpation of these trigger points.[4] [7] Laboratory studies are useful in characterizing the type of prostatitis and to use to rule out other pathologies such as urinary tract infection and chronic bacterial prostatitis. Voiding studies are useful in those that complain of voiding symptoms.[4] Imaging of the pelvis such as ultrasound, CT scan, and MRI is often not warranted but may be useful in ruling out conditions such as various abscesses and cysts, cancers, and prostatic calculi.[4]

Outcome Measures[edit | edit source]

The NIH Chronic Prostatitis Symptom Index (NIH-CPSI) is used to quantify signs and symptoms and their impact on quality of life.[4][7]

Physiotherapy Management[edit | edit source]

An individualized multimodal treatment approach to cope with the course of the disorder is proposed by the physical therapist; alongside emphasis on communications and personal/family/community supports, as it is a vital component in the therapeutic regime and rehabilitation of patients with CP/CPPS. The purpose of rehabilitation program is to improve comprehension on CP/CPPS and to help care providers and patients to achieve the goal of medical intervention—relieving associated symptoms of CP/CPPS and improving the quality of life.

Physiotherapy provides a broad variety of techniques that are safe and effective for CPPS. The following are different modalities or techniques that are available under pelvic floor rehabilitation: [4][5][7]

  1. Biofeedback: helpful modality to teach the patient to avoid unnecessary increased resting muscle tone. Patients in weekly and biweekly physical therapy up to six to eight treatment sessions found significant improvement as shown by a decrease in the NIH-CPSI as well as improved resting tone.[9]
  2. Myofascial trigger point release: neuromuscular therapy aimed to reduce the tone of connective tissue and restoring mobility of the muscle fascia. In a group of patients treated for at least one month, about half experienced improvement associated with 25% or greater decrease in symptom scores.[10]
  3. Acupuncture: insertion of needles at specific points of the body. In a 10-week study, CPPS patients were randomized into acupuncture versus sham acupuncture groups. after which those in the acupuncture group improved twice as much in their NIH-CPSI symptom scores versus the sham group.[11] CPPS patients treated with a weekly session of acupuncture for six weeks showed more than 50% decrease in their NIH-CPSI score from baseline.[12]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Shrikhande AA. CHRONIC PELVIC PAIN SYNDROME (CPPS). Pelvic Rehabilitation Medicine. 2021\ Available from: https://www.pelvicrehabilitation.com/conditions/chronic-pelvic-pain-syndrome-cpps/#:~:text=Chronic%20Pelvic%20Pain%20Syndrome%20(CPPS)%20is%20a%20condition%20involving%20ongoing,%2C%20lower%20back%2C%20and%20thighs.\
  2. ↑ 2.0 2.1 2.2 Chronic pelvic pain syndrome. Wikipedia. Wikimedia Foundation; 2008 . Available from: https://en.wikipedia.org/wiki/Chronic_prostatitis/chronic_pelvic_pain_syndrome
  3. ↑ 3.0 3.1 Zhang J, Liang C, Shang X, Li H. Chronic prostatitis/chronic pelvic pain syndrome: a disease or symptom? Current perspectives on diagnosis, treatment, and prognosis. American Journal of Men's Health. 2020 Jan;14(1):1557988320903200.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Nguyen C, Shoskes D. Evaluation of the Prostatitis Patient. Chronic Prostatitis/Chronic Pelvic Pain Syndrome. 2008:1-16. doi:10.1007/978-1-59745-472-8_1.
  5. ↑ 5.0 5.1 5.2 5.3 Suh L, Lowe F. Alternative Therapies for the Treatment of Chronic Prostatitis. Current Urology Reports. 2011;12(4):284-287. doi:10.1007/s11934-011-0188-y.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Potts J. Physical Therapy for Chronic Prostatitis /Chronic Pelvic Pain Syndrome. Chronic Prostatitis/Chronic Pelvic Pain Syndrome. 2008:131-141. doi:10.1007/978-1-59745-472-8_11.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Shoskes D. Therapy for Category III Prostatitis: A Synthesis. Chronic Prostatitis/Chronic Pelvic Pain Syndrome. 2008:265-271. doi:10.1007/978-1-59745-472-8_20.
  8. ↑ 8.0 8.1 Ziegelmann MJ, Farrell MR, Levine LA. Evaluation and Management of Chronic Scrotal Content Pain—A Common Yet Poorly Understood Condition. Reviews in urology. 2019;21(2-3):74.
  9. ↑ Cornel E, van Haarst E, Schaarsberg R, Geels J. The Effect of Biofeedback Physical Therapy in Men with Chronic Pelvic Pain Syndrome Type III. European Urology. 2005;47(5):607-611. doi:10.1016/j.eururo.2004.12.014.
  10. ↑ Anderson R, Wise D, Sawyer T, Chan C. Integration of Myofascial Trigger Point Release and Paradoxical Relaxation Training Treatment of Chronic Pelvic Pain in Men. The Journal of Urology. 2005;174(1):155-160. doi:10.1097/01.ju.0000161609.31185.d5.
  11. ↑ Lee S, Liong M, Yuen K et al. Acupuncture versus Sham Acupuncture for Chronic Prostatitis/Chronic Pelvic Pain. The American Journal of Medicine. 2008;121(1):79.e1-79.e7. doi:10.1016/j.amjmed.2007.07.033.
  12. ↑ Tugcu V, Tas S, Eren G, Bedirhan B, Karadag S, Tasci A. Effectiveness of Acupuncture in Patients with Category IIIB Chronic Pelvic Pain Syndrome: A Report of 97 Patients. Pain Medicine. 2010;11(4):518-523. doi:10.1111/j.1526-4637.2009.00794.x.

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