Relatively common diagnosis – estimated prevalence up to 8 % depending on definition.
“Chronic pain or discomfort in the pelvic region for at least 3 of the last 6 months, variably associated with LUTS, psychological consequences or sexual dysfunction” – with other causes excluded.
Heterogenous condition with significant impacts on quality of life, and difficult to treat.
Pathogenesis
No clearly defined clear cause but several proposed possible contributors:
- Infection
- Bacterial or leukocytes often found during Stamey test – however 8% of healthy controls also culture uropathogens
- History of STI – 1.8 x risk of CPPS
- Often patients do have initial acute bacterial prostatitis episode
- Inflammation +/- autoimmunity
- Higher levels of inflammatory cytokines found in EPS cf. controls
- Higher mast cell tryptase levels in EPS
- However only a third of men with CPPS symptoms have inflammation demonstrated histologically on biopsy, and there seems to be no clinical differentiation in type 3a/3b prostatitis or correlation between level of inflammation and symptoms
- Neurological / central sensitisation
- Cardinal symptom is pain which is mediated through central nervous system
- Evidence for central sensitisation – continued nerve activity in the absence of stimulation/or very low level nociception – in men with CPPS
- There may also be peripheral nervous system sensitisation from products of inflammation
- Pelvic floor dysfunction
- Failure of pelvic floor muscles to relax associated with pain during micturition, defecation and sex
- EMG studies have shown greater resting tone and instability
- Definite pelvic floor muscle tenderness demonstrated in a set of CPPS patients
- Endocrinological
- Men with CPPS have higher cortisol rises and lower baseline ATCH – similar findings to other chronic overlapping pain conditions
- Psychosocial
- Psychosocial factors (baseline anxiety/depression, supports, adjustment behaviours) can alter the phenotype and severity of symptom/quality of life
Symptoms
The cardinal symptom is pain, of varying severities and locations.
Then there are urinary, sexual, psychological and other features which are all variable.
- Pain:
- Most commonly perineal
- May radiate or localise to scrotum, penis, rectum, lower back, abdomen or pelvis
- Accompanying dysuria, ejaculatory pain
- Pain may fluctuate, and have flares
- Urinary
- 50 – 60 % have LUTS – often obstructive
- Often an element of pelvic floor dysfunction
- Sexual
- Up to 40 – 70 % some form of symptomatology
- Substantial impact on quality of life
- ED, ejaculatory dysfunction and ejaculatory pain
- Psychological
- Anxiety and depression common – 2 x controls
- Catastrophising
- Overlap with other conditions such as IBS, fibromyalgia
Symptoms should be phenotyped using the UPOINTS system, which can also be used to guide treatments. Men with CPPS often fall into multiple domains.
Strongly consider the use of validated questionnaires for symptom assessment – i.e. NIH-CPSI +/- IPPS for urinary symptoms / SHIM for sexual symptoms.
Examination
Focussed urological examination including:
- Abdominal examination looking for other causes of pain
- Pelvic/genital exam
- DRE
- Examination for pelvic floor muscle tenderness
Investigations:
- Urinalysis and culture to exclude infection / haematuria
- Culture for atypical organisms if urethritis symptoms
- 2 – glass test if not previously done (differentiate class 2/3 prostatitis)
- Urine cytology, if appropriate
- Bloods if no baseline available, +/- PSA if suitable for screening and counselled
- No role for semen culture or analysis. Differentiation between category 3a and 3b prostatitis does not seem to have any clinical benefit.
- Ultrasound KUB with post void residual, esp if urinary symptoms
- Scrotal ultrasound if any scrotal pain
- Flow rate if voiding symptoms
- Urodynamics – may help clarify if obstruction responsible for symptoms, or allow diagnosis of pelvic floor dysfunction / DSD
- Cystoscopy – can exclude urethral stricture, assess for bladder outlet obstruction and exclude Hunner’s ulcers / interstitial cystitis
- MRI of the prostate may be useful for specific indications – e.g. haematospermia, elevated PSA
Management
Treatment of CPPS is a formidable task which is frustrating for both patients and clinicians. There is no effective monotherapy. Different patients respond to different treatments and there is evidence that using the UPOINTS phenotype based approach shows benefit (individualised treatment)
Using the NIH-CPSI validated questionnaire can help assess treatment response – a decrease in 6 points from baseline has been used in literature to be considered a positive therapeutic response.
Multidisciplinary approach helpful. Management of symptoms cf. cure.
Valid treatment options for men with CPPS, depending on phenotype and symptoms:
Things which evidence don’t support:
- Antibiotics, in the absence of demonstrable infection / chronic bacterial prostatitis
- 5-alpha reductase inhibitors – no benefit in RCT
- Pentosan polysulfate – no benefit in RCT
Things with limited evidence for support:
- Quercetin (bioflavinoid with anti-oxidative properties) 500 mg BD showed benefit cf. placebo in RCT
- Cernilton (standardised pollen extract) TDS showed benefit over placebo in RCT
- Physical therapy / aerobic exercise demonstrated a benefit