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Chronic Pelvic Pain and Prostatitis: Symptoms, Diagnosis and Treatment

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Chronic Pelvic Pain and Prostatitis: Symptoms, Diagnosis and Treatment Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Keywords Chronic pelvic pain/ Prostate/Urinary/Erectile dysfunction Review This article has been Male pelvic pain double-blind peer reviewed In this article... ● Causes and symptoms of chronic pelvic pain syndrome (CPPS) and prostatitis ● Investigations needed to diagnose CPPS and chronic prostatitis and exclude other conditions ● Drug and non-drug treatment approaches for CPPS and chronic prostatitis Chronic pelvic pain and prostatitis: symptoms, diagnosis and treatment Key points Author Teresa Lynch is specialist nurse, Prostate Cancer UK. Chronic pelvic 1pain syndrome Abstract Chronic pelvic pain syndrome and chronic prostatitis are long-term in men is continuous conditions in men. They are poorly understood, difficult to treat and cause a range of or recurrent symptoms including pain, urinary problems, reduced quality of life and sexual non-malignant pain dysfunction. This article gives an overview of these two related and overlapping perceived in conditions, explains how to assess patients and diagnose, and presents the various structures such as treatment approaches. Nurses have an important role in helping men manage the the muscles and physical, psychological and emotional effects of these conditions. nerves of the pelvis Prostatitis is Citation Lynch T (2017) Chronic pelvic pain and prostatitis: symptoms, diagnosis and 2thought to be treatment. Nursing Times [online]; 113: 5, 34-37. caused by infection or inflammation of the prostate gland hronic pelvic pain syndrome structures in the pelvis, abdomen and Both conditions (CPPS) and chronic prostatitis spine (Rees et al, 2015). The causes are not 3cause a wide are long-term conditions that completely understood; CPPS is not range of symptoms Care poorly understood, difficult thought to be caused by infection, but a related to pain, to treat and for which there is currently no number of other factors may be involved urinary function, cure. As well as causing a range of disrup- (Prostate Cancer UK, 2015). A range of quality of life and tive symptoms – including severe pain, genetic variations have been described sexual dysfunction erectile dysfunction and urinary and bowel that may explain chronic pelvic pain Affected men problems – that patients often find diffi- (Marszalek et al, 2009). 4can find these cult to cope with, they can have a delete- conditions difficult rious effect on an individual’s psycholog- Prostatitis to cope with and ical wellbeing. Prostatitis, which is a contributing factor may experience to CPPS, is a set of symptoms thought to be emotional or CPPS caused by infection or inflammation of the psychological issues This non-malignant pain is perceived in prostate gland. It is common but poorly Holistic care is structures such as the muscles and nerves understood (European Association of 5needed to help of the pelvis that has been continuous or Urology, 2014; Pavone-Macaluso, 2007), patients manage recurrent for at least six months – the min- and a significant burden in terms of phys- these long-term imum length of time for pelvic pain to be ical symptoms, emotional distress and conditions regarded as chronic. ‘Perceived’ indicates financial costs (Schaeffer, 2008; Calhoun et that the patient and clinician, to the best of al, 2004; McNaughton Collins et al, 2001). their ability from the history, examination Men with prostatitis have a very poor and investigations (where appropriate) have quality of life: it is comparable to that of localised the pain as being felt in the speci- people with conditions such as unstable fied anatomical pelvic area (Fall et al, 2010). angina, inflammatory bowel disease or CPPS can encompass several conditions congestive heart failure (bit.ly/MSHProsta- causing pain in the different anatomical titis). structures around the prostate, including The condition affects men of all ages various muscle types, nerves and bony but it is most prevalent in those aged Nursing Times [online] May 2017 / Vol 113 Issue 5 34 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice For more articles on sexual health, go to Review nursingtimes.net/sexualhealth Box 1. Symptoms of chronic cyst and dilated prostatic duct in the US National Institutes of Health (bit.ly/ pelvic pain syndrome peripheral zone of the prostate should NIHCPSI), which scores issues relating to be recognised as prostate benign pain, voiding and quality of life. Patients ● Pain in the perineum lesions and are involved in urine reflux with chronic prostatitis and/or CPPS are ● Pain in the lower abdomen into the prostate (Inamura et al, 2016); no longer considered a homogenous group ● Pain in the penis, especially the tip, ● An infection that does not show in tests; affected by a single disease entity, so a and the testicles ● Inflammation of the nerves around the newer tool, the UPOINT classification ● Pain in the rectum and lower back prostate gland; (upointmd.com), is increasingly used ● Pain or burning during ejaculation ● Problems with nerves that send pain (Nickel and Shoskes, 2009). It classifies ● Premature ejaculation signals to the brain without physical signs and symptoms in six domains: ● Erectile dysfunction cause; ● Urinary; ● Urinary problems such as feeling that ● Stress and/or anxiety; ● Psychosocial; the bladder is not emptying properly, ● Problems with, or previous damage to, ● Organ specific; urinary frequency or urgency, and the pelvic floor muscles. ● Infection; pain when urinating ● Neurologic/systemic; ● Bowel problems Symptoms and comorbidities ● Tenderness. ● Mild discomfort or pain when The hallmark of chronic prostatitis and A reliable tool to assess urinary symp- urinating CPPS is persistent and disabling pain toms is the International Prostate Symptom ● Blood in semen (haematospermia) (Kwon and Chang, 2013), but both condi- Score (urospec.com/uro/Forms/ipss.pdf ). tions can cause a wide range of symptoms relating to pain, urinary function, quality Physical examinations 36-50 years. Its presentation in some older of life and sexual dysfunction (Boxes 1 and If CPPS and/or chronic prostatitis is sus- men may be due to normal prostate 2). Each man is affected differently and pected, examination of the abdomen and enlargement; it is known that increased symptoms can be constant or intermit- external genitalia (Rees et al, 2015; National detrusor pressure is needed to empty the tent. Institute for Health and Care Excellence, bladder in obstructive voiding, which can Many mechanisms involved in CPPS are 2010) and a digital rectal examination (Rees predispose men to a reflux of urine into the based in the central nervous system (EAU, et al, 2015) should be performed. This last prostate gland (Kirby et al, 1982). 2014), which is why it is sometimes called may reveal a tender prostate on palpation; A systematic review found an 8.2% pelvic myoneuropathy. Affected men are it will also allow the health professional to prevalence of prostatitis symptoms (range more likely to develop allergies, fibromy- assess the pelvic floor muscles’ tenderness 2.2-9.7%) in a population of over 10,600 algia, chronic fatigue syndrome, irritable and ability to relax and contract. men (Krieger et al, 2008) while, between bowel syndrome and anxiety disorders April 2016 and March 2017, the specialist such as panic attacks and obsessive-com- Tests to rule out other pathologies nurse team at Prostate Cancer UK received pulsive disorder (Sinclair, 2014). Urodynamic studies can demonstrate 289 contacts from men seeking help about Inflammation in the prostate can cause decreased urinary flow rates, incomplete prostatitis. a rise in blood levels of prostate-specific relaxation of the bladder neck and pros- The condition can be acute or chronic, antigen (PSA), which can cause anxiety – as tatic urethra, and/or an abnormally high bacterial or non-bacterial, and symptoms a raised PSA level is a potential marker of urethral closure pressure at rest (Shergill can occur with or without signs of infec- prostate cancer. However, there is debate as et al, 2010). To detect infection, common tion. It is categorised as: to whether continued or recurrent inflam- investigations include a urine dipstick test ● Acute bacterial prostatitis; mation of the prostate may lead to the and/or an early morning urine specimen ● Chronic bacterial prostatitis (rare); development of prostate cancer. Studies and expressed prostatic secretions for cul- ● Chronic non-bacterial prostatitis/CPPS; are under way to determine whether ture/microscopy (Rees et al, 2015). ● Asymptomatic inflammatory reducing inflammation can prevent pros- Screening for sexually transmitted prostatitis (Krieger et al, 1999). tate cancer (Walsh and Worthington, 2012). infections should be considered, and a Persistent and recurrent pelvic pain can Chronic prostatitis significantly reduce quality of life (Turner Box 2. Prostatitis symptoms Chronic non-bacterial prostatitis is the et al, 2002), causing disturbed sleep, most common type experienced (Daniels et fatigue, withdrawal, social isolation, ● Discomfort, pain or aching in the al, 2007; Clemens et al, 2005) and is defined shame, anger and depression, and, in some testicles, perineum or tip of the penis as urological pain or discomfort in the cases, suicidal feelings (Wood, 2013). ● Discomfort, pain or aching in the pelvic region associated with urinary symp- lower abdomen, groin or back toms and/or sexual dysfunction lasting at Assessment and investigations
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