Chronic Prostatitis is Chronic Pelvic Pain Syndrome

Chronic prostatitis is pelvic or perineal pain without evidence of urinary tract infection lasting longer than three months. The National Institutes of Health (NIH) classifies prostatitis into four syndromes. This article discusses the four prostatitis syndromes listed in the medical research and by the NIH.

Graph of pelvic pain symptoms associated with prostatitis.

Prostatitis affects half of all men 

Prostatitis is a common condition affecting  almost half of all men during their lifetimes.  Prostatitis accounts for over two million outpatient visits every year. One percent of all primary care visits in the United States is for prostatitis.

Prostatitis – the “wastebasket of clinical ignorance”

Prostatitis has been called the “wastebasket of clinical ignorance.”

Stamey, Thomas Alexander, 1989, “Pathogenesis and Treatment of Urinary Tract Infections,” Lippincott, Williams and Wilkins
3D Man with prostate pain, dyspareunia
3D Man having some pain down there. Dyspareunia. Prostatitis

Historical confusion – the many names of Prostatitis 

Prostatitis is referred to by several different names, some are proper and some describe slightly different conditions such as:

  • pelvic pain,
  • anorectal pain,
  • levator ani syndrome,
  • unspecified anorectal pain,
  • proctalgia fugax,
  • interstitial cystitis,
  • bladder pain syndrome,
  • chronic prostatitis,
  • chronic pelvic pain syndrome,
  • prostatitis,
  • proctalgia, and
  • prostatodynia.
Graph symptoms of office worker syndrome
Office syndrome infographic. Prostatitis and hemorrhoids are listed as signs of office worker syndrome.

 Physicians tend to manage patients with prostatitis based on a patchwork of what they learned during residency, experience, the last paper on the subject they read, and perhaps a touch of evidence.

National Institute of Health Consensus Conference –  CP/CPPS Defined – 1995

The National Institute of Health Consensus Conference 1995 in Bethesda, VA initiated a field change in our attitude regarding prostatitis and changed the direction of clinical research in the prostatitis field.

A major advance was to define the group of patients with chronic pelvic pain but no infection as Category iii Chronic Prostatitis/Chronic Pelvic Pain Syndrome.

Pelvic Pain yellow road sign - blue sky
chronic prostatitis / chronic pelvic pain syndrome, blue sky ahead

Chronic Prostatitis Collaborative Research Network – 1995

The National Institute of Health effort was via the Chronic Prostatitis Collaborative Research Network (CPCRN).

NIDDK revised definition in 1995

In 1995, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) also revised the definition of prostatitis and categorized prostatitis into distinct entities:

  • Acute bacterial prostatitis,
  • Chronic bacterial prostatitis, and
  • Asymptomatic inflammatory prostatitis.

For more information from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored by the National Institute of Health, you can check out the following informative link: https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostatitis-inflammation-prostate 

Illustration of normal prostate and acute prostatitis
normal prostate and acute prostatitis.

The National Institutes of Health (NIH) classifies prostatitis into four syndromes

  1. Acute bacterial prostatitis (ABP);
  2. Chronic bacterial prostatitis (CBP)
  3. Chronic nonbacterial prostatitis (CNP) also called Chronic pelvic pain syndrome (CPPS);
  4. Asymptomatic Inflammatory Prostatitis (formerly known as Prostatodynia) 

“The greatest number of cases of prostatitis have no known cause, despite chronic inflammation.” 

Meares, E.M., Prostatitis and related disorders. In: Walsh PC, Gittes, RF, Perlmutter, AP, Stamey, TA, Eds., Campbell’s Urology. Philadelphia Penn, WB, Saunders Co., 1986:868-85

1.  Acute Bacterial Prostatitis (ABP) 

Acute Prostatitis is when your prostate gland becomes enlarged and tender suddenly.  Acute Prostatitis is usually caused by the same bacteria that cause urinary tract infections or sexually transmitted diseases.  Acute bacterial prostatitis is treated with antibiotics.

“Some men with acute bacterial prostatitis require hospitalization.”  

J. Jurtis Nickel, M.D., FRCSC, Prostatitis Syndromes, “A Continuing enigma for the family physician,” Canadian Family Physician, Vol. 37: April 1991

Patients with Acute Bacterial Prostatitis have:

  • sudden onset of urinary frequency (abnormally frequent urination);
  • urgency (a sudden urge to urinate);
  • nocturia (urination more than two times during the night);
  • and dysuria (painful urination) associated with —
  • fever and chills;
  • low back pain;
  • perineal pain;
  • generalized malaise; and
  • varying degrees of bladder outlet obstruction. 
Angry cartoon bladder showing prostatitis symptoms
angry cartoon bladder indicating symptoms of prostatitis

2.  Chronic Bacterial Prostatitis  (CBP)

“Chronic Bacterial Prostatitis can develop from acute bacterial prostatitis.”

J. Jurtis Nickel, M.D., FRCSC, Prostatitis Syndromes, “A Continuing enigma for the family physician,” Canadian Family Physician, Vol. 37: April 1991

Symptoms are variable and include:

  • dysuria (painful urination);
  • frequency (abnormally frequent urination);
  • nocturia (urination more than two times during the night);
  • ejaculatory pain (dyspareunia); and
  • discomfort in any area of the perineum or external genitalia.  

“This syndrome is difficult to treat.  Surgery is the treatment of last resort as impotence and incontinence are both possible results.”  

J. Jurtis Nickel, M.D., FRCSC, Prostatitis Syndromes, “A Continuing enigma for the family physician,” Canadian Family Physician, Vol. 37: April 1991
Businessman gesturing need to pee - standing outside bathroom, prostatitis, dyspareunia
Cartoon businessman gesturing that he needs to pee. Prostatitis and dyspareunia.

3.  Chronic Non-Bacterial Prostatitis (CNP) is also called CPPS and CP/CPPS

Non-Bacterial Prostatitis has clinical symptoms and physical findings similar to those of chronic bacterial prostatitis; however, the patient does not have a history of recurrent UTIs.

“Historically, conditions causing pelvic pain such as chronic prostatitis, bladder pain syndrome, interstitial cystitis, among others, were considered distinct and separate conditions.  Recent reviews of the literature emphasize the shared features between these conditions which is captured by the term urologic chronic pelvic pain syndrome.”

Adil, E., Anorectal and Pelvic Pain, Mayo Clin Proc. 2016, Oct; 91 (10):1471-1486

Here is a link to the Mayo Clinic to check out recent information about prostatitis: https://www.mayoclinic.org/disease-conditions/prostatitis/symptoms-causes/syc-20355766

The amount of overlap between these conditions is higher than once thought. It is recommended that people with one condition be evaluated for symptoms of the other disorders.

Happy cartoon bladder relieved of symptoms
Happy cartoon bladder feeling “relieved” of symptoms

Chronic Pelvic Pain Syndrome (CPPS) is similar to Chronic Bacterial Prostatitis (CBP) 

The symptoms of chronic bacterial prostatitis found in patients with Chronic Pelvic Pain Syndrome (CPPS) are:

  • dysuria (painful urination);
  • frequency (abnormally frequent urination);
  • nocturia (urination more than two times during the night);
  • ejaculatory pain (dyspareunia); and
  • discomfort in any area of the perineum or external genitalia.
Graph of pelvic pain symptoms associated with prostatitis.
Problems associated with prostatitis: Hesitant Urination, urinary urgency, burning sensation (dysuria), frequent urination (nocturne), pain in the groin, infertility, painful ejaculation or dyspareunia,  pelvic trauma (Horse Riding or Cycling) or prolonged sitting.

“Treatments that occasionally help include hot sitz baths, and avoidance of alcohol and foods that aggravate the problem.”   

J. Jurtis Nickel, M.D., FRCSC, Prostatitis Syndromes, “A Continuing enigma for the family physician,” Canadian Family Physician, Vol. 37: April 1991

Chronic Prostatitis / Chronic Pelvic Pain Syndrome

If prostatitis lasts more than three months then the condition is termed chronic prostatitis.  Chronic prostatitis can be difficult to diagnose and treat because of a lack of consensus on cause, definition of the problem, and management.

“More than ninety percent of people with symptomatic prostatitis are believed to have chronic prostatitis/chronic pelvic pain syndrome, which is a debilitating condition that impairs quality of life to a similar degree as a heart attack or Chron’s disease.”

Wenninger, K., Sickness Impact of Chronic Nonbacterial Prostatitis and its Correlates. J. Urol. 1996; 155:965

The cause of chronic prostatitis is unknown.  No established treatment exists. Evidence suggests that antibiotics  are not effective.  However, the literature shows that almost seventy percent of people diagnosed with chronic prostatitis are prescribed antibiotics.

Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CPPS) is poorly understood

Chronic prostatitis is a poorly understood condition. This is because of a number of factors such as:  

  • the organ is deeply placed in the body,
  • the prostate is poorly accessible to clinical examination,
  • the cause is frequently unclear,
  • the criteria for the diagnosis of some forms of prostatitis are not agreed upon by experts,
  • many cases of chronic prostatitis have unclear clinical features,
  • investigation is difficult, and
  • therapy may be time consuming and unsatisfactory.

A thorough and in-depth evaluation is vital for success in the management of chronic pelvic pain.

Paper with words "Pelvic Pain" covered with pills
Chronic Prostatitis / Chronic Pelvic Pain Syndrome.

CP/CPPS can be divided into two groups

Symptoms of men with chronic prostatitis /chronic pelvic pain syndrome appear to cluster into groups.

  • One group has primary pelvic pain or pain localized to one area in the pelvis. 
  • Another group of people has symptoms throughout the body.

Conditions associated with Chronic Prostatitis

Other conditions can be associated with chronic prostatitis, such as:

  • irritable bowel syndrome,
  • fibromyalgia, and
  • chronic fatigue syndrome.
3D man on the toilet
3d Man on the toilet seat, prostatitis, IBS

Depression with Chronic Prostatitis

Depression frequently occurs with Chronic Prostatitis / Chronic Pelvic Pain Syndrome which is also sometimes called urologic chronic pelvic pain syndrome.   Behavior therapy and mindfulness training are therapy options.  Many factors affect chronic prostatitis including biological, social, and psychological factors.

Recommendations for People with Chronic Prostatitis / Chronic Pelvic Pain Syndrome

There are some recommendations that may help people with chronic prostatitis/chronic pelvic pain syndrome:

  • Avoid food that makes symptoms worse;
  • Avoid activity that makes symptoms worse, such as bike riding;
  • Antibiotics may be used for four weeks and not further unless a true urinary tract infection is documented;
  • Use anti-inflammatory medication such as Tylenol, aspirin, and ibuprofen;
  • Physical therapy may be helpful;
  • There is not enough evidence to warrant recommending surgery;
  • Avoid rest as a treatment;
  • Use exercise as part of a treatment plan. 

Cholesterol’s role in benign prostate disease

The prostate makes and stores large amounts of cholesterol. The prostate accumulates cholesterol deposits with age.  The prostate may be quite sensitive to changes in cholesterol in the body.

There is evidence that cholesterol plays a role in benign prostate disease. Cholesterol is the precursor for the synthesis of hormones such as testosterone. 

Pathologic effects of high cholesterol levels are seen in atherosclerosis lesions of blood vessels in people with high levels of cholesterol. The accumulation of cholesterol rich deposits cause inflammatory changes. Inflammatory changes are associated with many types of commonly occurring cancers in people.

There are reports that indicate cholesterol lowering drugs reduce the risk of aggressive prostate cancer.

There are also reports of people taking cholesterol lowering drugs that experience prostate pain that find their pain improved or cured when they stop taking this medication. These reports are from individuals and not supported by the medical literature at this time.

4.  Asymptomatic Inflammatory Prostatitis  (AIP) (formerly Prostatodynia)

The patient with Asymptomatic Inflammatory Prostatitis (formerly Prostatodynia) does not have inflammation and will not benefit from a trial of antibiotics.  

It is important to clinically eliminate all extra-prostatic causes for the symptoms, such as interstitial cystitis, carcinoma of the bladder, and other conditions that could cause pelvic pain.   

“Usually this chronic disorder remains undefined despite repeated investigations and treatment.”  

J. Jurtis Nickel, M.D., FRCSC, Prostatitis Syndromes, “A Continuing enigma for the family physician,” Canadian Family Physician, Vol. 37: April 1991

Non-Bacterial Prostatitis Ignored

“The academic research community has almost completely ignored the common, but enigmatic conditions of non-bacterial prostatitis and prostatodynia. Once bacterial infection of the prostate was ruled out and/or the patient did not respond to antimicrobial therapy, the practicing physician did not know how to proceed in terms of management.”

Nickel, J., Treatment of Chronic Prostatitis / Chronic Pelvic Pain Syndrome. Int J Antimicro Agents. 2008 Feb; 31 (Supplement 1):112-116.

Chronic Pelvic Pain is defined differently by ACOG and EAU

The American College of Obstetricians and Gynecologists (ACOG) defines Chronic Pelvic Pain (CPP) differently than the European Association of Urology (EAU).  ACOG’s definition includes only women.  

The European Association of Urologists (EAU) revised their guidelines beginning in 2009 to include women and men in their definition of chronic pelvic pain.  Chronic pelvic pain (CPP) is a bladder pain syndrome that occurs in women and men.  Urological pain syndromes in men include Chronic Prostatitis/ Chronic Pelvic Pain Syndrome (CPPS).

References:  

  1.  Meares, E.M., Prostatitis and related disorders.  In:  Walsh PC, Gittes, RF, Perlmutter, AP, Stamey, TA, Eds., Campbell’s Urology.  Philadelphia Penn, WB, Saunders Co., 1986:868-85.
  2. J.  Jurtis Nickel, M.D., FRCSC, Prostatitis Syndromes, “A Continuing enigma for the family physician,” Canadian Family Physician, Vol. 37:  April 1991

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