Male Pelvic Pain: Beyond Urology and Chronic Prostatitis

Dr. Potts, the author of this excellent review article, specializes in male chronic pelvic pain (CPP).  CPP in men continues to be misdiagnosed as prostatitis.   Although these men also report lower urinary tract symptoms (LUTS), that does not necessarily mean they are related to prostate pathology. 

Physical examination on men with CPP can reveal pelvic floor muscle dysfunction, myofascial pain syndrome, dysfunctional somatic syndrome, central sensitization syndrome or psychosocial distress.  The article reviews research-based evidence that has studied LUTS and prostatitis.  The nomogram UPOINT (U=urinary, P=psychological, O=organ prostate, I=infection, N=neurologic, T=tenderness in muscle) should be used when assessing the patient with CPP. 

Dysorgasmia and post ejaculation pain are frequently associated with CPP syndrome but not necessarily with prostatitis.  In many cases, pain is originating from pelvic floor dysfunction and from myofascial trigger points.  The article provides a table of definitions of myofascial physical therapy and lists the different treatments performed in myofascial physical therapy.  There is also a nice review of central sensitivity syndrome. 

Central sensitivity syndrome has both visceral and somatic manifestation.  Desensitization is caused by chemical and anatomical changes leading to hyperexcitability in the dorsal horn cells from persistent afferent C-fiber bombardment by painful stimuli.  The presence of sensitization expands the pain field and creates a neuroanatomical basis for pain persistency reoccurrence in the presence of minimal or no discernable pathology.  This process will eventually cause a local upregulation central windup that creates a neuroanatomical basis for pain persistence in the presence of minimal disease stimuli.  As seen in clinical practice, chronic stress may have a role in initiating and exacerbating pain syndromes including chronic prostatitis and CPP syndrome. 

Dr. Potts also provides a simple flow chart that illustrates the multiple facets to be considered in evaluation in men with CPP, beginning with exclusion of very uncommon prostatic infections.  The clinician should first rule out an infectious process and if the pelvic pain persists, awareness of referral patterns caused by myofascial trigger points is an important part of the evaluation.  Variability of trigger points exists between patients.  I highly recommend this article as it is a thorough and current review of CPP in men, written by an expert in the field.  A review of available treatments is provided.  This can be an instructional article for clinicians who may encounter these men.

Potts JM. Male Pelvic Pain: Beyond Urology and Chronic Prostatitis. Curr Rheumatol Rev. 2016;12(1):27-39.

Written By:
Diane K. Newman, DNP
Adjunct Professor of Urology in Surgery, Research Investigator Senior, Co-Director, Penn Center for Continence and Pelvic Health
University of Pennsylvania, Division of Urology 
3400 Spruce Street, 3rd Floor Perelman Bldg, Philadelphia, PA. 19104