Chronic Pelvic Pain Syndrome (men)

Overview

Chronic Pelvic Pain in Men

Chronic pelvic pain syndrome (CPPS) in men and chronic prostatitis (CP) (1) are terms often used to describe the same thing. 

CPPS/CP in men causes repeat feelings of genital pain over a period of months or years. Importantly these symptoms need to be there in the absence of infection.

Assessment should be framed in 4 symptom groups

1. LUTs
2. Erectile dyfunction / ejaculatory issues
3. Pain symptoms – perineal , inguinal scrotal also other pelvic organs with pain
4. Systemic symptoms such as lethargy etc

Treatment of CPPS/CP in men can be difficult and there is a lack of good evidence for certain treatments. This page therefore takes a pragmatic approach and has been developed with local clinicians (urologists, GPSI, meds management team)

Chronic Pelvic Pain in Women

Please go to the Persistent (Chronic) Pelvic Pain (women) page.

Red Flags

If any of the following are present, consider a diagnosis of prostate cancer:

• erectile dysfunction
• haematuria
• lower back pain
• bone pain
• weight loss, especially in the elderly

See the Urology 2WW page for indications for 2WW referral.

What to do before referral

Consider the following to exclude or treat underlying causes of pain:

• DRE to examine the prostate for malignancy or tenderness
• Urine dip to exclude haematuria.
• MSU should be considered if infection is suspected (even if dipstick is negative)
• Urine NAAT test to exclude sexually transmitted infection
• Blood tests to check PSA and exclude other infection (HIV, syphilis).

There are comprehensive guidelines published by Prostate Cancer UK (2) which has advice on management in primary care. These take a symptom-based approach using antibiotics at presentation (but avoiding repeated / long term use), alpha blockers, anti-neuropathic agents etc:

(2) Quick Reference Guide 

Management in Primary care

If there are no red flags and infections have been excluded or treated, then reassurance and management in primary care is appropriate initially. Treatment should be directed towards managing the symptoms. In addition consider the following:

• Provide an information leaflet: see Resources section below.
• Pelvic floor exercises for men: here 
• Painful episodes often respond to simple painkillers such as paracetamol or ibuprofen. A hot bath can also help to relax the pelvic muscles and relieve symptoms.
• If defecation is painful - advise an osmotic laxative or stool softener*
• Alpha blockers* – can help to relax the pelvic floor muscles and prostate - trial for 4-6 weeks particularly if there are significant lower urinary tract symptoms.
• Medication for neuropathic pain* – especially with symptoms that started recently these medications can be trialed although evidence is lacking. Amitripyline is usually advised first line.
• Screen and treat underlying anxiety /depression.
• Acupuncture and aerobic exercise may also be beneficial.
• Prostate massage is also sometimes suggested but there is no clear evidence.

*See BNSSG Formulary for formulary choices.

Antibiotics for Chronic Prostatitis/ CPPS

There are guidelines for treatment of acute prostatitis in the antibiotic guidelines of the BNSSG formulary, but no advice for use in patients with CPPS/CP once an acute episode or infection has been treated.

There is some evidence of effectiveness of antibiotics v placebo for use of fluroquinolones, and a 4 week course of ciprofloxacin 500mg bd is suggested in the Quick Reference Guide (2). CKS guidelines (1) also suggest a single course of antibiotics for 4-6 weeks (trimethoprim or doxycycline). However repeated or longer courses of broad spectrum antibiotics are not advised and should be avoided.

Referral

Most cases of CPPS/CP should be managed in primary care and referral to a urologist is rarely indicated.

For patients not responding to primary care management then referral options include:

• Urology Advice and Guidance via eRS
• Referral to sexual health clinic -  Unity  offers a specialist service for Chronic Pelvic Pain in men. This service is not open access and a referral from a GP is needed (not available via eRS).
• Urology referral via eRS if there are other urological symptoms that cannot be managed in primary care.
• NHS Talking Therapies for psychological support.
• Pain clinic if no cause has been found and above measures have not been effective.

Resources

(1) Prostatitis - chronic (CKS)

(2) Quick Reference Guide (pdf) from Prostate Cancer UK

Patient information:

Chronic Prostatitis (pdf)) from Patient UK at http://www.patient.info

Prostatitis (Prostate Cancer UK)

Pelvic Floor Muscle Relaxation for Men (Pelvic pain foundation of Australia)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.