History and exam
Key diagnostic factors
common
prostate pain
duration of pain ≥3 months
no other underlying pathology
rectal pain
perineal pain
Patients may report pain occurring in pelvic areas outside the prostate, such as the rectum, perineum, penis, testicles, abdomen, lower back, and the inguinal region.[4][6]
In a retrospective analysis of the clinical records of 1563 men with chronic prostatitis/chronic pelvic pain syndrome, perineal pain was the most prevalent pain symptom, occurring in 63% of patients, followed by the testicular pain (58%), pain in the pubic area (42%), and penile pain (32%).[43]
penile pain
Patients may report pain occurring in pelvic areas outside the prostate, such as the rectum, perineum, penis, testicles, abdomen, lower back, and the inguinal region.[4][6]
In a retrospective analysis of the clinical records of 1563 men with chronic prostatitis/chronic pelvic pain syndrome, penile pain was reported in 32% of patients.[43]
testicular pain
Patients may report pain occurring in pelvic areas outside the prostate, such as the rectum, perineum, penis, testicles, abdomen, lower back, and the inguinal region.[4][6]
In a retrospective analysis of the clinical records of 1563 men with chronic prostatitis/chronic pelvic pain syndrome, testicular pain was reported in 58% of patients.[43]
inguinal pain
prostate tenderness
pelvic floor tenderness
In men with PPPS, a pelvic examination may reveal tenderness which can be a sign of myofascial dysfunction.[4][6] If possible use a single digit when carrying out the pelvic examination to avoid causing excessive pain.[4]
Men with PPPS have been shown to have more muscle spasm and increased muscle tone, leading to pain on palpation of the pelvic muscles.[24] Persistent or repeated muscular overload may lead to activation of pelvic floor muscle trigger points.[4] One study showed that 51% of patients with prostatitis symptoms had muscle tenderness by comparison with only 7% of controls, with tenderness in the pelvic floor muscles being exclusive to the test group.[25]
dysuria
increased urinary frequency
Patients with PPPS may experience increased urinary frequency. Normal patterns of urination may vary considerably; however, adults generally void around 6 times daily, and no more than once during the night.[57] Frequent urination may occur due to bladder contraction when there is only a small amount of urine present.[6]
urinary urgency
Patients with PPPS may experience an inability to voluntarily delay urination. This may also be associated with urge incontinence in some patients.[6]
sexual dysfunction
Patients with PPPS may report pain during or after ejaculation and/or delayed or premature ejaculation. Patients may also experience erectile dysfunction. The prevalence of self-reported sexual dysfunction ranges from 46% to 92%.[58][59][60]
In a retrospective analysis of the clinical records of 1563 men with chronic prostatitis/chronic pelvic pain syndrome, pain during ejaculation was reported in 45% of patients.[43]
uncommon
Other diagnostic factors
uncommon
gluteal muscle tenderness
Trigger points can be located within the pelvic floor muscles and in adjacent muscles such as the abdominal and gluteal muscles. Pain is aggravated by pressure on the trigger point on examination.
Risk factors
weak
hormonal imbalance
There is evidence of adrenocortical hormone abnormalities in men with chronic pelvic pain syndrome compared with healthy controls, with increased progesterone, androstenedione, and testosterone, and reduced corticosterone and aldosterone.[27] This suggests reduced activity of CYP21A2 (P450c21), the enzyme that converts progesterone to corticosterone and 17-hydroxyprogesterone to 11-deoxycortisol.[27] The sex hormones can modulate both nociception and pain perception.
Significant early life events can change the development of the hypothalamic-pituitary-adrenal axis and therefore alter the chemicals released. Stress can induce long-term biological changes that may cause the relation between chronic pain syndromes and significant early life events.[34]
genetics
An individual who has one chronic pain syndrome is more likely to develop another, and family clusters of pain conditions have been observed.[35] Numerous genetic variations, including those that involve subtle changes in transmitters and their receptors, have been described that may be linked to incidence of chronic pain syndromes.[35]
history of other pain syndromes
An individual who has one chronic pain syndrome is more likely to develop another, and family clusters of pain conditions have been observed.[35]
childhood sexual abuse
A history of sexual abuse during childhood is a risk factor for PPPS in adults with persistent pain.[36][37] Although the evidence to support this risk factor in men is limited, one study found that men who reported having experienced sexual, physical, or emotional abuse as a child/adolescent had increased odds (3.3 vs. 1.7) for symptoms of PPPS.[36]
psychosocial factors
All pain syndromes are worsened in the presence of anxiety and/or depression and these appear to be significant risk factors for the development of chronic pelvic pain syndrome.[18] One study demonstrated that men under stress at home or work were 1.5-fold more likely to have PPPS than those who were not stressed.[38]
Beliefs about pain contribute to the experience of pain. One meta-analysis showed that many patients with chronic pelvic pain had associated psychosocial factors or psychiatric comorbidities, including a high level of pain catastrophisation.[19]
history of previous urinary tract infection
A history of previous urinary tract infection or ongoing inflammation may result in chronic pelvic pain in a small proportion of patients. In one study involving a large cohort of patients with acute bacterial prostatitis, 10.5% developed a form of chronic pelvic pain syndrome.[39] Another study of 2300 men showed that the number of previous urinary tract infections, particularly >3, was associated with symptoms suggestive of PPPS (P <0.01).[14]
history of sexually transmitted infection
Evidence has shown that men with PPPS are twice as likely to have had a previous sexually transmitted infection than men without PPPS.[15]
immune dysfunction
intra-prostatic urinary reflux
Intra-prostatic urinary reflux may be important both as a route of infection in bacterial prostatitis and as a cause of the inflammatory process in abacterial prostatitis.[26]
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