Chronic nonbacterial prostatitis (chronic pelvic pain syndrome)

Current options for dealing with the most common form of prostatitis

Published: August, 2007

Chronic nonbacterial prostatitis (also known as chronic pelvic pain syndrome) is an all-too-common male genitourinary condition characterized by episodes of pain and discomfort that come and go unpredictably. It may also involve inflammation and difficulties with urination. Chronic pelvic pain syndrome degrades the quality of a man's personal and work life and leaving him confounded and depressed.

Of the four categories of prostatitis defined by the National Institutes of Health (see Table 1), chronic pelvic pain syndrome is most common, accounting for about 90% of all cases. It's also notorious for being the most difficult type of prostatitis to live with. A major difficulty is that in most instances, doctors are unable to definitively diagnose the condition and confidently identify a causative agent. Not surprisingly, with so little to go on, treatment is empiric "" guided by a doctor's clinical experience and instincts rather than hard evidence of what actually works. When they have prescribed standard treatments only to have patients experience little or merely temporary relief, many practitioners don't know what to do next for chronic pelvic pain syndrome, other than to keep cycling through the same standard treatment options.

Table 1: NIH classifications of prostatitis

Category

Definition

Symptoms

Comments

Type I

(acute bacterial prostatitis)

Acute infection of the prostate, identified by an increased white blood cell count and bacteria in urine that can be cultured in the laboratory (grown in sufficient quantities to be studied)

Chills, fever, body aches, fatigue, pain in the lower back and genital area, urinary frequency and urgency (often at night), burning sensation or painful urination and ejaculation

Rare, but responds well to antibiotics

Type II

(chronic bacterial prostatitis)

Recurrent infection of the prostate; similar to type I in that bacteria can be identified, but infection does not respond to initial antibiotic therapy and requires additional treatment

Same as above, but symptoms are often less pronounced

More common and usually treatable with antibiotics, although the infection can be persistent, requiring several courses of therapy

Type III

(chronic nonbacterial prostatitis/chronic pelvic pain syndrome "" the subject of this article)

No demonstrable bacterial infection

  • IIIA (inflammatory): white blood cells in urine, prostate secretions, and semen, but no evidence of an infectious agent
  • IIIB (noninflammatory): no white blood cells in urine or prostate secretions, and no evidence of infection

Pain in the lower back and genital area (perineum), urinary frequency and urgency (often at night), burning or painful urination and ejaculation

Represents more than 90% of all cases of prostatitis; no known cause or clinically proven treatments

Type IV

(asymptomatic inflammatory prostatitis)

White blood cells are present, but usually found during tests for another medical condition such as infertility

None

Treatment usually unnecessary

Adapted from Executive Summary: Chronic Prostatitis Workshop, National Institute of Diabetes and Digestive and Kidney Diseases, December 1995.

Many men with this syndrome resort to fending for themselves as they move from doctor to doctor and from one online chat group to another in the hope that someone will be able to help them (for example, see "A patient's story").

A patient's story (a real story but name changed to protect his privacy)

Jack Smith is a 36-year-old man who has chronic pelvic pain syndrome. His flare-ups follow the same pattern. "I get a cramping in my lower right-hand side and know it's going to hurt like heck tomorrow," Mr. Smith says. The pain begins as a dull ache, a pressure in the perineal area, behind his testicles. After a day or so this pressure lessens but the pain intensifies. "It's like you have a golf ball in your rectum," says Mr. Smith.

Mr. Smith also developed urinary symptoms: voiding urgency, a hesitant stream, and what he describes as "dribbles" after he thought he was finished voiding. The fear of dribbling urine "" especially when he was at work "" heightened his distress.

In spite of a two-year medical odyssey to various practitioners, Mr. Smith never received a conclusive diagnosis. He has been prescribed five separate courses of antibiotics (even though tests never revealed the presence of bacteria), pain medication ranging from over-the-counter drugs to a narcotic analgesic, nonsteroidal anti-inflammatory drugs, a muscle relaxant, a series of chiropractic treatments, and dietary restrictions (no caffeine, spicy foods, or alcohol). Finally, his new doctor prescribed an antidepressant that did bring more lasting relief from his symptoms. Mr. Smith also practices relaxation techniques and exercises to stretch his pelvic floor muscles.

For the first time in two years, his pain, although not gone completely, is under control. "I don't want pain to affect my whole life. If I can get up, go to work, have a normal day, and not worry about it, then being a bit uncomfortable once in a while is fine."

Diagnosing chronic pelvic pain syndrome

Chronic pelvic pain syndrome causes three types of symptoms: pain (including pain upon urination), urinary "voiding" difficulties, and sexual dysfunction. Of course, some of these symptoms may also occur in other urologic disorders, such as benign prostatic hyperplasia (BPH). Pain, however, is the predominant feature of chronic pelvic pain syndrome "" and that usually helps your doctor to differentiate it from BPH (see Table 2). If you experience painful or burning urination or pain in the pelvic area, your doctor will look for signs of inflammation and infection by performing a digital rectal examination, getting a urine sample, and perhaps testing your prostate's secretions.

Table 2: Distinguishing chronic pelvic pain syndrome from BPH

One analysis found that most men with chronic pelvic pain syndrome see a doctor because of urinary or pelvic pain, while men with BPH seek medical attention because of urinary problems, and not pain.

Primary symptom that prompted a doctor visit

Chronic pelvic pain syndrome

BPH

Pain (including pain during urination and pain in abdomen, lower back, rectum, and genital area)

20%

3%

Urinary symptom (including weak urinary stream, problems voiding, incontinence, and nighttime awakenings)

18%

32%

Sexual dysfunction (including erectile dysfunction, pain with ejaculation, and loss of interest)

0.6%

1.4%

Your doctor should also do a simple urine test to check for bacteria and excessive white blood cells, which indicate an infection. If urinalysis reveals bacteria and white blood cells, your condition is probably a bacterial form of prostatitis. If only white blood cells are discovered, as is usually the case, you may have one of the nonbacterial forms of prostatitis.

Why the condition develops

Many researchers now believe that chronic pelvic pain syndrome develops after a complex series of interconnected events that somehow build on one another, giving rise to the signature symptoms of genitourinary and pelvic pain and urologic and ejaculatory dysfunction.

The initiating event may be an undetectable infectious agent or a physical trauma that causes inflammation or nerve damage in the genitourinary area. Over time this causes damage to organs and tissues in the area "" bladder, ligaments, pelvic floor muscles, and so forth "" that takes on a life of its own in susceptible individuals. If not controlled quickly enough, this damage and the body's response to it can lead to a heightened sensitivity of the nervous system. In other words, for some men with chronic pelvic pain syndrome, the pain sensitivity "switch" more readily flicks to the "on" position. Stress and tension can exacerbate this response.

Reassessing the "three A's" of treatment

The traditional treatments of chronic pelvic pain syndrome, known collectively as the "three A's" are antibiotics, anti-inflammatory medications, and alpha blockers.

Antibiotics

The use of antibiotics "" medications that eradicate bacterial infections "" remains controversial. For starters, only a very small percentage of men with chronic pelvic pain syndrome test positive for bacterial infection. This suggests that antibiotics would not be effective for most men. Randomized clinical trials bear this out.

Some researchers argue, however, that a negative test for bacteria doesn't mean bacteria aren't present. The best explanation for why this might be so is that bacteria can be present in the glands or stroma (connective tissue) of the prostate without entering into the urine. Another is that the bacteria can't be detected with current methods. To further complicate matters, although a positive test indicates bacteria are present, it doesn't necessarily mean that bacteria are the cause of that individual's prostatitis. Where do these uncertainties leave men affected with the condition?

At the time of diagnosis, even when a culture does not reveal bacteria, most researchers still recommend that men newly diagnosed with chronic pelvic pain syndrome take an antibiotic for a limited time, lasting not more than four weeks. This strategy may help some men even when their symptoms are not caused by a bacterial infection, but rather by inflammation. Some antibiotics have anti-inflammatory properties, yet work in a different way from nonsteroidal anti-inflammatory drugs (NSAIDs).

But repeat courses of antibiotics are probably not helpful. Although antibiotics have few side effects, they are not completely without risk. They can cause problems such as nausea and diarrhea, and interfere with medications for other conditions. Use of quinolone antibiotics "" the type prescribed for chronic pelvic pain syndrome "" increases the chance of suffering an Achilles' tendon rupture, for reasons that are not completely understood.

Anti-inflammatory medications

Anti-inflammatory medications, notably aspirin or NSAIDs such as ibuprofen, help some men cope with the pain of chronic pelvic pain syndrome. However, these medications are not usually helpful on their own. NSAIDs can help decrease pain, but then possible they should be used at the lowest possible dose for a short period of time. The best evidence suggests it is better to combine NSAIDs with another medication, such as an alpha blocker, that may actually address an underlying problem in chronic pelvic pain syndrome.

Alpha blockers

Alpha blockers are used primarily to treat BPH. However, they may also be prescribed for chronic pelvic pain syndrome because they relax muscles in the urinary tract, allowing urine to flow more freely "" and thus alleviating urinary dysfunction. The research indicates that these medications are not only effective treatments for chronic pelvic pain syndrome, but should be used more often, and in a more targeted way, for greater effect. For example, a review published in Urologia Internationalis looked at 10 studies of alpha-blocker therapy. The authors concluded that men who were newly diagnosed with chronic pelvic pain syndrome were more likely to respond to alpha blockers than were men who'd been dealing with the condition for years. They also concluded that an extended course of treatment (three to six months) was more effective than a shorter course.

Be persistent

Chronic pelvic pain syndrome develops for a number of reasons "" and each likely requires a different management strategy. There is no single cure-all for this condition.

It's important to keep abreast of research and work with your doctor to find an individualized treatment plan. And if your doctor seems reluctant to work with you, find another doctor.

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