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Nursing Practice Keywords Chronic pelvic pain/ /Urinary/ 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 ● 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, 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. 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 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 , 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

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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 l Pain in the perineum lesions and are involved in urine reflux with chronic prostatitis and/or CPPS are l Pain in the lower abdomen into the prostate (Inamura et al, 2016); no longer considered a homogenous group l Pain in the , especially the tip, ● An infection that does not show in tests; affected by a single disease entity, so a and the ● Inflammation of the nerves around the newer tool, the UPOINT classification l Pain in the rectum and lower back prostate gland; (upointmd.com), is increasingly used l Pain or burning during l Problems with nerves that send pain (Nickel and Shoskes, 2009). It classifies l Premature ejaculation signals to the brain without physical signs and symptoms in six domains: l Erectile dysfunction cause; l Urinary; l Urinary problems such as feeling that l Stress and/or anxiety; l Psychosocial; the bladder is not emptying properly, l Problems with, or previous damage to, l Organ specific; urinary frequency or urgency, and the pelvic floor muscles. l Infection; pain when urinating l Neurologic/systemic; l Bowel problems Symptoms and comorbidities l Tenderness. l 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 l Blood in (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 , 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 l Acute bacterial prostatitis; mation of the prostate may lead to the and/or an early morning urine specimen l Chronic bacterial prostatitis (rare); development of prostate cancer. Studies and expressed prostatic secretions for cul- l Chronic non-bacterial prostatitis/CPPS; are under way to determine whether ture/microscopy (Rees et al, 2015). l 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, l 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). l 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 l Urinary frequency or urgency least three months (Krieger et al, 1999). Clinical diagnosis of CPPS and/or chronic l Pain or stinging during or after Although it is a benign condition, it can prostatitis relies on patient history and urinating severely reduce quality of life, as patients physical examination. Various investiga- l Feeling as though sitting on a golf often experience considerable physical and tions are conducted to detect signs and ball psychological morbidity (PCUK, 2015). exclude other pathologies. l Lack of libido Chronic prostatitis is related to CPPS due l Less common: erectile dysfunction, to the following possible causative factors: Symptom scoring pain or burning during ejaculation, l Urine entering the prostate gland Patients are normally assessed using the and (Kirby et al, 1982); the prostatic utricle Chronic Prostatitis Symptom Index of the

Nursing Times [online] May 2017 / Vol 113 Issue 5 35 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Review urethral swab and culture taken if ure- Box 3. Self-management measures and lifestyle changes thritis is suspected (Rees et al, 2015). Uroflometry, retrograde urethrography l Fluids – adequate fluid intake and avoidance of alcohol, fizzy drinks and caffeine and/or a bladder scan will help exclude uri- reduce the risk of bladder irritation, which can exacerbate urinary symptoms nary retention, while cystoscopy can be l Diet – some men find certain foods – for example, citrus fruits and spicy foods performed to exclude bladder outlet – can trigger symptoms, and should be advised to recognise and avoid them obstruction, bladder neck stenosis, l Posture – sitting for long periods can increase pain: patients should be advised to bladder cancer or (Rees avoid this and/or use a soft or inflatable cushion; they should also avoid activities et al, 2015). that put pressure on the perineum, such as cycling Magnetic resonance imaging and com- l Temperature – cold seems to aggravate symptoms, while often heat brings relief puterised tomography are useful to rule (Hedelin and Jonsson, 2007); warm baths, for example, can provide temporary out a prostate abscess (Venyo, 2011). A relief number of other tests can be useful; for l Bowel care – defaecation requires relaxation and coordination of the pelvic floor example, if prostate cancer is a concern, a muscles and anal sphincters, so CPPS can cause pain and difficulty, leading to blood test to measure PSA levels can be constipation (bit.ly/PPHLevatorAni); men experiencing pain or discomfort when undertaken. defecating should take measures to avoid constipation l Exercise – brisk walking, jogging, running, playing sports or yoga may increase Sexual and psychological factors wellbeing and reduce symptoms Taking a detailed sexual history is essen- l Stress relief – stress can exacerbate symptoms, so patients should try to avoid tial. Patients who disclose information stressful situations and learn to manage stress; anecdotal reports to Prostate about sexual abuse need to be managed Cancer UK indicate that relaxation techniques can be helpful sensitively and, with their consent, rele- vant agencies should be involved. Patients also should be assessed for the Antibiotics potentially have a moderate blood, can also ease pain and alleviate uri- psychological impact of their symptoms effect on pain, urinary symptoms and nary symptoms. using an appropriate tool such as the quality of life, and should be considered as Patient Health Questionnaire-9 to monitor an initial treatment option (Rees et al, 2015). Treating urinary symptoms depression severity or the seven-item Gen- Like antibiotics, alpha-blockers may A recent study in men with CPPS/chronic eralised Anxiety Disorder Assessment. If have a modest effect on urinary symptoms, prostatitis concluded that quality of life is they experience low mood and attribute it pain and quality of life. They should be con- more affected by pain than by urinary to pain, psychologically based pain man- sidered as an initial treatment option in symptoms (Wagenlehner et al, 2013). How- agement may be required. men with voiding issues, as they help relax ever, urinary symptoms still need investi- the muscles of the prostate and bladder gating, and should be managed in line Management neck. Side-effects include: with guidance on lower urinary tract Health professionals in primary care are in l Decreased or retrograde ejaculation; symptoms in men (NICE, 2010). an ideal position to identify chronic pros- l Nasal congestion; tatitis/CPPS, explain to patients the avail- l Dizziness; Treating erectile dysfunction able treatment options, and provide l Tiredness. Erectile dysfunction is a major concern in appropriate therapy and ongoing support. If no symptom relief is seen with alpha- men with prostatitis and should be man- It is essential to combine physical and blocker therapy within 4-6 weeks, an alter- aged according to the British Society for emotional and/or psychological interven- native alpha-blocker should be considered ’s (2013) guidelines. tions, and adopt a multiprofessional (bit.ly/PatientProstatitis). approach. Non-steroidal anti-inflammatory drugs Surgery There are no established treatments (NSAIDs), such as ibuprofen, are some- Evidence about the usefulness of surgery is that consistently relieve symptoms, but times prescribed. Although there is no very limited. Techniques include: treatment options are improving (Strauss strong evidence that they are effective, l Prostatectomy; and Dimitrakov, 2010). However, there some men find they alleviate symptoms l Transurethral resection of the prostate; have been few randomised controlled such as pain. Some NSAIDs are available l Transrectal high-intensity focused trials (RCTs) focusing on chronic prosta- over the counter, but men should always ultrasound; titis/CPPS, so more research is needed. discuss them with their GP because of l Transurethral needle ablation of the Chronic prostatitis and CPPS can be their potential side-effects (such as prostate; refractory, in which case they require treat- stomach irritation and stomach ulcers). l Transurethral microwave ment by specialist professionals. If the thermotherapy. drug treatment options outlined below are Other drug options for pain relief However, large RCTs are needed before ineffective, patients should be referred to Some drugs may ease discomfort or pain; firm conclusions can be made about their secondary care (Rees et al 2015). sometimes an over-the-counter medica- effectiveness (Rees et al, 2015). tion such as paracetamol may be effective. The ‘3As’ Low doses of (such as Complementary therapies Antibiotics, alpha-blockers and anti-inflam- amitriptyline) or anti-epileptic drugs Complementary therapies may also be matory drugs – the ‘3 As’ of drug treatment – (such as gabapentin or pregabalin) can be helpful. Acupuncture appears to be a safe, are all used to treat chronic prostatitis and used to treat long-term pain. Allopurinol, effective, durable treatment option when CPPS (Thakkinstian et al, 2012). which decreases uric acid levels in the it comes to reducing symptoms and

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improving quality of life in men with Marszalek M et al (2009) Chronic pelvic pain and Box 4. Further resources lower urinary tract symptoms in both sexes: refractory chronic prostatitis/CPPS (Chen analysis of 2749 participants of an urban health and Nickel, 2003). Further information and useful advice screening project. European Urology; 55: 2, Therapy with the bioflavonoid for patients can be found online: 499-507. l Prostate Cancer UK. Chronic Prostatitis McNaughton Collins M et al (2001) Quality of life is quercetin is well tolerated and provides impaired in men with chronic prostatitis: the significant symptomatic improvement in and Chronic Pelvic Pain Syndrome: Chronic Prostatitis Collaborative Research most men with chronic pelvic pain syn- A New Consensus Guideline. Network. Journal of General Internal Medicine; 16: drome (Shoskes et al, 1999). Bit.ly/PCUK_CPPSGuideline 10, 656-662. National Institute for Health and Care Excellence A simple remedy such as the herbal sup- l NHS Choices. Prostatitis. (2010) Lower Urinary Tract Symptoms in Men: plement serenoa repens (saw palmetto) has Bit.ly/NHSChoicesProstatitis Management. nice.org.uk/cg97 been reported to have a relaxing effect on l BMJ Group. Prostatitis. Nickel JC, Shoskes D (2009) Phenotypic approach to the management of chronic prostatitis/chronic urinary sphincter smooth muscles, a strong Bit.ly/BMJBestPracticeProstatitis pelvic pain syndrome. Current Urology Reports; 10: anti-inflammatory effect, and an antiprolif- l WebMD. Men’s Health Guide: 4: 307-312. erative effect (Wagenlehner et al, 2011). Prostatitis. Pavone-Macaluso M (2007) Chronic prostatitis Bit.ly/WebMDProstatitis syndrome: a common, but poorly understood Physical techniques such as specialist condition. Part I. EAU-EBU Update Series; 5: 1-15. physiotherapy and biofeedback can help l Rees J. Men’s health: chronic Prostate Cancer UK (2015) Prostatitis: A Guide to men to gain better control of their pelvic prostatitis. GP Online. Infection or Inflammation of the Prostate. Bit.ly/ floor muscles. There is no evidence, how- Bit.ly/GPOnlineProstatitis PCUKProstatitisGuide Rees J et al (2015) Diagnosis and treatment of ever, to support the use of repetitive pros- l National Center for Pelvic Pain chronic bacterial prostatitis and chronic prostatitis/ tate massage (Rees et al, 2015). Research. Levator Ani Syndrome. chronic pelvic pain syndrome: a consensus Bit.ly/PPHLevatorAniSyndrome guideline. BJU International; 116: 4, 509-525. Schaeffer AJ (2008) Epidemiology and evaluation Psychological therapies of chronic pelvic pain syndrome in men. Patients who have chronic conditions International Journal of Antimicrobial Agents; 31 often need to adjust their aspirations as and identifying useful complementary (Suppl 1): S108-S111. Shergill I et al (2010) Medical Therapy in Urology. well as adapting their lifestyles and work therapies will all help to give hope and help London: Springer. conditions. Many grieve their predica- patients to gain control of, and better cope Shoskes DA et al (1999) Quercetin in men with ment, others have protracted distress and with, their condition. NT category III chronic prostatitis: a preliminary develop psychiatric disorders – most com- prospective, double-blind, placebo-controlled trial. Urology; 54: 6, 960-963. monly depression or anxiety (Turner and References British Society for Sexual Medicine (2013) Sinclair A (2014) ‘Prostatitis’ is a Kelly, 2000). Counselling and cognitive Guidelines on the Management of Erectile Psychoneuromuscular Condition. Prostatitis behavioural therapy can be considered and Dysfunction. Bit.ly/BSSMErectileDysfunction2013 Network. Bit.ly/ProstatitisPsychoneuromuscular (2010) New treatments accessed via a GP, who can refer patients to Calhoun EA et al (2004) The economic impact of Strauss AC, Dimitrakov JD chronic prostatitis. Archives of Internal Medicine; for chronic prostatitis/chronic pelvic pain appropriate specialists. 164: 11, 1231-1236. syndrome. Nature Reviews Urology; 7: 3, 127-135. Chen R, Nickel JC (2003) Acupuncture ameliorates Thakkinstian A et al (2012) Alpha-blockers, Self-management and lifestyle changes symptoms in men with chronic prostatitis/chronic antibiotics and anti-inflammatories have a role in pelvic pain syndrome. Urology; 61: 6, 1156-1159. the management of chronic prostatitis/chronic A range of self-management measures can Clemens JQ et al (2005) Incidence and clinical pelvic pain syndrome. BJU International; 110: 7, alleviate symptoms (Box 3). It can be useful characteristics of National Institutes of Health type 1014-1022. for patients to keep a diary of symptoms, III prostatitis in the community. Journal of Urology; Turner JA et al (2002) Primary care and urology 174: 6, 2319-2322. patients with the male pelvic pain syndrome: food and fluid intake, exercise undertaken Daniels NA et al (2007) Association between past symptoms and quality of life. Journal of Urology; and the amount of stress experienced; this urinary tract infections and current symptoms 167: 4, 1768-1773. will them help identify and avoid triggers suggestive of chronic prostatitis/chronic pelvic Turner J, Kelly B (2000) Emotional dimensions of pain syndrome. Journal of the National Medical chronic disease. Western Journal of Medicine; 172: (PCUK, 2015). Some find online forums and Association; 99: 5, 509-516. 2, 124-128. peer support groups helpful, such as those European Association of Urology (2014) Guidelines Venyo A (2011) Prostatic abscess: case report and provided by the British Prostatitis Support on Chronic Pelvic Pain. Bit.ly/CPPGuideline review of literature. WebmedCentral Urology; 2: 11, Association (bps-assoc.org.uk) Fall M et al (2010) EAU guidelines on chronic WMC002433. pelvic pain. European Urology; 57: 1, 35-48. Wagenlehner FM et al (2013) National Institutes of Hedelin H, Jonsson K (2007) Chronic prostatitis/ Health Chronic Prostatitis Symptom Index Holistic support chronic pelvic pain syndrome: symptoms are (NIH-CPSI) symptom evaluation in multinational Recognising and managing the emotional aggravated by cold and become less distressing cohorts of patients with chronic prostatitis/chronic with age and time. Scandinavian Journal of pelvic pain syndrome. European Urology; 63: 5, and psychological dimensions of long- Urology and Nephrology; 41: 6, 516-520. 953-959. term conditions can be challenging both Inamura K et al (2016) Abnormal 18F-FDG uptakes Wagenlehner FME et al (2011) Pollen extract for for patients and health professionals. in the prostate due to two different conditions of chronic prostatitis: chronic pelvic pain syndrome. urine reflux: a mimicker of prostate cancer. Urologic Clinics of North America; 38: 3, 285-292. Whether in primary or secondary care, Springerplus; 5: 46. Walsh PC, Worthington JF (2012) Dr Patrick health professionals need to develop an Kirby RS et al (1982) Intra-prostatic urinary reflux: Walsh’s Guide to Surviving Prostate Cancer. New understanding of what men with chronic an aetiological factor in abacterial prostatitis. York, NY: Grand Central Publishing. British Journal of Urology; 54: 6, 729-731. prostatitis or CPPS experience, so they can Wood N (2013) Survivor Narratives of Men with Krieger JN et al (2008) Epidemiology of Chronic Prostatitis/Chronic Pelvic Pain Syndrome offer appropriate physical, psychological prostatitis. International Journal of Antimicrobial (CP/CPPS). Bit.ly/UHProstateNarratives and emotional support. Education and Agents; 31: (Suppl 1), S85-S90. Krieger JN et al (1999) NIH consensus definition support will help patients to understand and classification of prostatitis. Journal of the For more on this topic go online... their condition and manage the often dis- American Medical Association; 282: 3, 236-237. l Broaching sexual health issues with ruptive symptoms. Showing empathy, Kwon JK, Chang IH (2013) Pain, catastrophizing, and depression in chronic prostatitis/chronic pelvic patients supporting patients with treatment, pain syndrome. International Neurology Journal; 17: Bit.ly/NTBroachingSexualHealth encouraging them with lifestyle changes 2, 48-58.

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