Investigations
1st investigations to order
clinical diagnosis
Test
There are no specific tests for primary prostate pain syndrome (PPPS). Investigations are directed towards identification and exclusion of specific diseases associated with pelvic pain, and may also be helpful for phenotypical description.
Result
history of persistent pelvic pain of at least 3 months’ duration centred around the prostate; 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
dipstick urinalysis
Test
Urine dipstick is recommended in all patients with pelvic pain symptoms to rule out differentials.
Result
negative
urine culture
Test
Urine culture (including culture for tuberculosis if sterile pyuria) is recommended in all patients suspected of having a pelvic pain syndrome to rule out infection.
Result
negative
STI screen
Test
Consider an STI screen, including a first pass urine for gonorrhoea and chlamydia nucleic acid amplification test (NAAT) and urethral swab for trichomoniasis, in sexually active men younger than 35 years, men with multiple sexual partners, or those who have had a recent partner change.
Result
negative
Investigations to consider
cystoscopy
Test
Cystoscopy with or without distention and biopsy (follow your local protocol) may be considered to rule out interstitial cystitis/primary bladder pain syndrome if signs and symptoms plus urine testing suggest this is a likely differential, and to exclude other bladder pathology (such as urethral stricture).[4][6]
Cystoscopy with or without the addition of bladder wash cytology should also be considered to help exclude bladder cancer in patients who are at higher risk of urethral malignancy (e.g., smoking history, previous bladder cancer, or those presenting with haematuria) as bladder cancer is diagnosed in around 1% of patients referred for PPPS.[50][61]
Result
no signs of bladder pathology
ultrasound imaging
Test
Ultrasound has only limited value for the assessment of patients with chronic pelvic pain but may reassure patients. Ultrasound may be performed to help rule out any underlying pathologies that may present with similar symptoms, as well as to aid phenotypical description.[4]
Result
no pathology detected
MRI
Test
Consider MRI if there is suspected pelvic malignancy (e.g., prostate cancer) or neurogenic aetiology of the pain; either pelvic or spinal MRI may be an option. Magnetic resonance neurography in specialised centres may be used for the diagnosis of the location and degree of nerve injury.
Result
no sign of pelvic malignancies or spinal abnormalities
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