Chronic Pelvic Pain Syndrome

CP/CPPS is a clinical syndrome in men defined by pain or discomfort in the pelvic region, for at least three of the preceding six months in the absence of other identifiable causes, often associated with urinary symptoms and/or sexual dysfunction. Despite the use of the term “prostatitis”, it is unclear to what degree the prostate is the source of symptoms.

Several other terms have been used to describe CP/CPPS, including “prostatodynia” (painful prostate) and “abacterial prostatitis.”

The best way to think about CP/CPPS is that it is like a “tension headache” in the pelvis. Almost all of us have stress, and it manifests in our bodies in different ways. Some get headaches, others have irritable bowel, others get neck and back aches.

For men with CP/CPPS, this tension is being held in their pelvic muscles. The pelvic muscles are involuntarily being clenched, causing long term spasm and discomfort. This affects the organs it supports, specifically the bladder, prostate, bowels, and penis.

Many men, particularly younger men with these symptoms, have been given the diagnosis of “chronic prostatitis”, implying that these symptoms are coming from some infection of the prostate. These patients often receive a large urologic work-up, including looking into the bladder and/or invasive bladder function studies. They are also put on multiple courses of antibiotics, which because of their anti-inflammatory effects, temporarily make them feel better but are not addressing the root of the problem.

Many of our patients have been told that there is nothing more that can be done for them, and that they will simply have to live with their symptoms. Fortunately, this is almost always not true.

CP/CPPS occurs worldwide and is far more common than you might think. However, because it presents in each man differently, has a variable time-course and affects so many organs and functions, it is often not identified correctly. This condition accounts for 1% of all primary care visits and 8% of visits to urologists. It’s more common in younger men, and the mean age at diagnosis is 42.

It is thought that up to 14% of all men will experience CP/CPPS.

Importantly, most men diagnosed with “chronic prostatitis” have CP/CPPS rather than acute or chronic bacterial prostatitis. They are thus mistreated with multiple, long courses of unindicated antibiotics whose anti-inflammatory effects make the men feel better temporarily, but not due to their anti-bacterial effects.

The cause of CP/CCPS is unknown, but it is most useful to think of it as tension held in the pelvis, causing pain and spasm, leading to the symptoms described above. Again, it is most useful to conceptualize it as “a tension headache in the pelvis.” It is very unlikely to be caused by actual infection of the prostate and in many cases does not involve the prostate at all.

The three main symptoms of CP/CPPS are:

• Pain
• Urinary Symptoms
• Sexual Issues

Most men will have flare ups of their symptoms, which can last from seconds to months. Sometimes the pain is very minor, and sometimes quite significant. The pain can vary in location as well.

Fortunately, it does tend to “burn itself out”; both the frequency of symptoms and their intensity often decrease over time. Flare ups seem to be caused by stress, sexual activity, and changes in lifestyle habits. Like any chronic pain syndrome, it often causes decreased quality of life and depression.

Pain

As suggested by its name, the primary symptom of CP/CPPS is pain, which may be felt in any of the following locations.

Perineum: The most common location (63%) is the perineum, the area between the pubic bone and tail bone (coccyx.).

Testes: 58% of men will have testicular pain.

Bladder/Suprapubic Area: 42% of men will have pain above the pubic bone, which is where the bladder is located.

Penis: 32% of men will have pain in the penis. It is the most common cause of pain in the penis after Peyronie’s disease. However, with Peyronie’s disease the pain is often accompanied by scar tissue (which can be felt), curvature, and/or a history of trauma. Also, the pain from Peyronie’s disease is usually worse with an erection. Thus, for a urology specialist, the diagnosis of Peyronie’s disease is an easy one to make. Other penile pain is CP/CPPS until proven otherwise!

What does the pain feel like?

The pain is usually dull but can be sharp for some. It is rarely “colicky” like a kidney stone. It can vary in duration, lasting minutes, hours, or days. Many men with CP/CPPS have chronic pain or discomfort in other parts of their body, like migraine headaches, irritable bowel syndrome, interstitial cystitis, chronic fatigue syndrome, and fibromyalgia.

Urinary Symptoms

In addition to pain, many men have urinary symptoms. The most frequent symptoms are:

• Frequency (needing to go to the bathroom too often)
• Urgency (needing to urinate right away when the urge hits)
• Nocturia (being woken up several times nightly to urinate)
• Dysuria (pain with urination)
• Painful bladder filling

These urinary symptoms are often what causes men to receive the wrong diagnoses of either having chronic prostatitis or an asymptomatic enlarged prostate.

Sexual Symptoms

Many men will develop sexual symptoms from CP/CPPS. These include:

Pain with Ejaculation

Painful ejaculation occurs in 58% of men with CP/CPPS, and of course, dramatically decreases sexual satisfaction. Some men find the pain worsens with frequent ejaculation while others find that the longer the interval between ejaculations, the more discomfort they have. This pain may occur every time a man ejaculates or intermittently. Ejaculation is an intense series of physical and neurological events, but should be pleasurable, not painful!

Premature Ejaculation (PE)

An estimated 30% have lifelong PE, making it the most common sexual issue affecting men generally.  However, many men with reasonable control over ejaculation can begin experiencing control problems with CP/CPPS.  64% of men with CP/CPPS complain of PE, many of whom did not have it before. Learn More

Erectile Dysfunction (ED)

15% – 40% of men with CP/CPPS will either develop or have worsening of their erectile dysfunction. In fact, we often diagnose CP/CPPS in men who present to us with ED. Learn More

CP/CPPS is considered a “diagnosis of exclusion.” In other words, to have it, a man must have the symptoms consistent with diagnosis, and other specific causes need to be ruled out. All men should have a thorough history taken, as well as a physical examination, and urinalysis. Based on the findings of the physical examination and the urinalysis, other testing may be indicated.

In some cases, other symptoms or physical findings may be discovered which will require a different evaluation than outlined here. These include blood in the urine, lower extremity tingling or pain, lymph nodes in the groin, hernias, or abdominal masses.

Urological Physical Examination

All men will need a urological examination, which will include a scrotal examination looking for tenderness or masses. (If any masses are seen, an ultrasound would be indicated, which is a simple procedure, causing no discomfort.)

Most men should have a digital rectal examination (unless acute prostatitis is suspected).

Urinalysis and Urine Culture

All men with a possible diagnosis of CP/CPPS should have a urinalysis. If the urinalysis shows evidence of infection (which would include white blood cells, bacteria, or other specific finding) a urine culture should be performed, ideally on the same specimen. The urine is sent to a lab to see if a significant number of bacteria can be grown out of it. If so, the specific bacteria growing are identified. Simultaneously, an evaluation of which antibiotics would best treat these bacteria is performed.

Clearly, an infection must be treated with antibiotics, and an evaluation must be done to look for underlying causes of the infection.

If the urinalysis shows red blood cells (indicative of bleeding somewhere) a more intense urologic work up may be indicated to rule out other issues, including cancer and kidney stones.

Urethral Discharge Culture

Occasionally, men with CP/CPPS will complain of a urethral discharge or drip. If so, the discharge should be examined under the microscope and cultured, for bacteria, chlamydia, and gonorrhea.

Testing for Urination Issues

If a man has significant urination issues, a basic, non-invasive evaluation is often indicated.

Men with symptoms consistent with not emptying their bladder completely, or with flow issues, will receive two simple non-invasive tests done at the same time.

Uroflow

While a man urinates into a funnel, the rate at which he empties his bladder and the total volume is measured.

Post Void Residual

After the man finishes urinating, a small ultrasound probe is placed on the skin over his bladder, and the amount of urine left in the bladder is measured.

If the above tests are abnormal, then further urologic testing and treatment are warranted. This may include a cystoscopy (looking in the bladder with a scope) or urodynamics (measuring pressure as the bladder fills and empties). However, we believe that these more invasive tests are done far too often and too early in the diagnosis and treatment of CP/CPPS.

Evaluation of Erectile Dysfunction

If a man has ED, then a full ED evaluation is performed. This will include a full sexual history, targeted physical exam, testing of penile sensation, assessment of night time erections, and measurement of blood flow in and out of the penis.

Often, CP/CPPS is only one of the contributing causes of ED.

The most important part of any treatment regimen for CP/CPPS is pelvic floor therapy. Though this may sound “new agey”, endless, and iffy, it is “none of the above”, and has a high rate of success. Again, we find that almost all men with CP/CPPS have very tight and chronically clenched pelvic floor muscles. This leads to spasm, tenderness, and discomfort. (Think of it almost as a headache in the pelvis.)

The treatment usually involves pelvic floor therapy, biofeedback, stretching, and postural work. We find that most of the time, the actual therapy of the pelvic floor is the most important part of the intervention.

We refer patients to physical therapists specializing in pelvic floor disorders/dysfunction. They often start making a significant difference in 6-8 sessions. We have identified and worked with pelvic physical therapists in most geographic areas where our patients reside.

This treatment is usually covered by most insurances, as it is considered standard of care by most of them.

Daily tadalafil is a treatment option for men with significant voiding symptoms and is frequently used in men with Lower Urinary Tract Symptoms (LUTS) from an enlarged prostate. How it works to help these symptoms is not clearly understood, but it seems to relax the pelvic floor and bladder outlet muscles.  We have found that it can help with many of the symptoms of CP/CPPS, particularly with pain and voiding symptoms.

We will often start men on tadalafil/5mg daily for several months. (Fortunately, it’s dramatically less expensive since going generic, and even if not covered by insurance, it’s available for less than one dollar a pill.) It is important to note that tadalafil, as well as all the medications in its class (PDE5 inhibitors), is not addictive (physically or psychologically) and has no long-term negative effects on health.

For all men, tadalafil can help with erectile function. For men who are not having ED issues, it will make their erections (during nighttime, masturbation, and sex) better, which is an added benefit. However, if a symptom of CP/CPPS is ED, we will evaluate and treat this simultaneously. Tadalafil/5mg daily is often not strong enough to manage a man’s ED. We can get anyone an erection, even if he has CP/CPPS.

We use alpha-blockers in most men with CP/CPPS. Alpha blockers are a first line medical therapy for men with voiding symptoms due to an enlarged prostate. They work by relaxing smooth muscles in the bladder neck (which has to relax and let the urine into the urethra), in the capsule around the prostate (which surrounds the urethra), and in the part of the urethra going through the prostate itself.

We have found them to be a useful adjunct to pelvic floor therapy and daily tadalafil/5mg in our patients with CP/CPPS. Since voiding symptoms are not being caused by an enlarged prostate in our CP/CPPS patients, often they can discontinue them as treatment progresses.

The main two side effects are decreased blood pressure and ejaculation issues.

The medication is usually taken at night, so the decreased blood pressure, if it happens, is while sleeping.  Men should get up slowly at night when they first start the medication so that their blood pressure can equilibrate. They should also go up on the dosage slowly.

Alpha blockers can also temporarily but significantly affect ejaculation. Rarely, men will be unable to ejaculate while on the medication. It can delay ejaculation, making it hard for a man to reach an orgasm with sex. (We sometimes use this side effect and specifically prescribe an alpha-blocker, silodosin, to help men with premature ejaculation last longer.) It can also cause retrograde ejaculation; the ejaculate instead of being propelled forward and out of the tip of the penis, goes backwards into the bladder. The semen is then urinated out with the regular urine during the man’s next void. This is in no way dangerous, but most men enjoy the feeling of ejaculating semen forwards during orgasm. All these symptoms are reversible once the medication is discontinued.

We usually start with tamsulosin 0.4mg, at bedtime, for six weeks. It can be increased to two pills (a total of 0.8mg) after 4-6 weeks if needed.

Since it is thought that CP/CPPS has an inflammatory component, anti-inflammatory medications can be helpful. We will often start patients on ibuprofen (Advil, Motrin) 400mg three times a day for three weeks. It must be taken with food to minimize stomach ulcers and bleeding.

Shockwave therapy, which is actually a pressure wave, was originally used in high intensity dosages to treat kidney stones. When used at a low intensity, these pressure waves can increase blood flow, which is why we use it for the treatment of ED.

It can also decrease soft tissue pain and is in fact FDA approved for plantar fasciitis which is an inflammation causing pain in the bottom of the foot.

Its proven efficacy in myofascial pain syndromes (like plantar fasciitis) and soft tissue pain has led to its use for CP/CPPS. Though there have been relatively few studies, the results of a few excellent ones have been positive, particularly in decreasing pain and increasing quality of life.

Is it Safe?

Yes. Fortunately, safety is not an issue. There is no evidence of any short- or long-term negative effects of treatment.

What is the Treatment?

You will receive four treatments, one per week for four weeks.

The probe will be placed against the skin of your perineum (the area between your testes and anus.) Pressure waves or impulses are generated by the probe and penetrate through the skin and into the underlying structures, particularly the fascia, muscles, tendons, and prostate.

A total of 3000 pressure waves will be used, at a rate of 4 per minute. Thus, the treatment lasts for 13-15 minutes.

You will be able to continue all your normal activities for the day, both before and after the treatment.

Does it Hurt?

Most patients describe a sense of pressure but no pain.

Most Importantly: Does it Work?

The data in various studies all indicate significant improvement from treatment. These improvements are seen in decreased pain, improved urinary symptoms, and quality of life.

Unfortunately, there are still not a lot of studies or data available. In the studies that exist, men were only followed for 3 months post treatment, so it unknown how long symptomatic improvements last.

Fortunately, there are no negative side-effects seen and the treatments are painless.

At What Point in My Treatment Should LI-ESWT be Used?

Like all the non-specific treatments for CP/CPPS, pressure wave treatment can be utilized at any point in your treatment.

In an ideal world, it would be started simultaneously with all the other non-specific treatments in this section.

As we have indicated, the symptoms of CP/CPPS are different in virtually every man who has it. Thus, there are both generalized treatments, including tadalafil 5mg daily, pelvic floor therapy, alpha blockers, and anti-inflammatories which most men receive, as well as specific treatments for ED and PE.

Erectile dysfunction can always be managed. We do not wait for the general treatments for CP/CPPS to be effective but evaluate and treat the ED, which is often what disturbs men the most.

Likewise, if a man develops premature ejaculation, this is also simultaneously managed.