Prostatitis (male pelvic pain)

Many men experience pain in the pelvis at some point in their life. Common symptoms may include difficult, painful, or frequent urination; pain in the area of the bladder, groin, anus, and abdomen; inability to obtain an erection or pain during ejaculation; and fever and chills.  The onset can be gradual (for chronic cases) or sudden (for acute cases).

In many cases this pain is referred to as “prostatitis”, that is to say inflammation of the prostate.  The prostate is a walnut-sized gland in males that sits in front of the rectum and below the bladder.  The urethra runs through the prostate.  The role of the prostate is to produce much of the fluid that makes up semen, the male ejaculate.

Prostatitis is the most common urologic diagnosis in men younger than 50. While the prostate may indeed be a source of pelvic pain, it is likely that in many cases that pain in the male pelvis does not stem entirely (or in some cases at all) from issues with the prostate itself. A more accurate terminology has been promoted by the National Institute of Health; in this classification scheme for Chronic Pelvic Pain Syndrome (CPPS), men may be diagnosed with:

  • Chronic Pelvic Pain Syndrome I: formerly known as Acute Bacterial Prostatitis, defined as acute sudden pelvic pain, typically associated with fevers and other signs of infection as well as bacteria identified in urine or prostate secretions
  • Chronic Pelvic Pain Syndrome II: formerly known as Chronic Bacterial Prostatitis, defined as recurrent or chronic pelvic pain, associated with  bacteria identified in urine or prostate secretions, usually in the absence of fevers or other signs of infection
  • Chronic Pelvic Pain Syndrome III: formerly known as Non-Bacterial Prostatitis or Prostatodynia, defined as recurrent or chronic pelvic pain that is not associated with bacteria identified in urine or prostate secretions.  CPPS III may be subdivided into type A, when inflammatory cells are found in urine or prostate secretions and type B, when inflammatory cells are NOT found in urine or prostate secretions
  • Chronic Pelvic Pain Syndrome IV: presence of inflammatory cells in urine or prostate secretions in the absence of any symptoms.

CPPS III is by far the most common entity encountered in clinical practice. 

The causes of chronic pelvic pain are varied; possibilities include urinary tract or sexually transmitted infections.  Risk factors include diabetes, immunosuppression, prostate enlargement, congenital urinary tract abnormality, urinary issues, tightness or problems of the pelvic floor musculature, and having recent urethral instrumentation (e.g. having a catheter put in).  In many cases there are no clear risk factors

A detailed history and physical exam of the genitals are essential.  Examination should include a digital rectal exam, where the doctor inserts a gloved, lubricated finger into the rectum to examine the prostate and determine if it is tender or swollen. Urine samples are typically taken and analyzed for presence of infection or inflammation.  In some cases additional urine, blood, or radiology tests may be indicated; some men may also be advised to have cystoscopy, in which a fiberoptic camera is inserted into the urethra to examine the prostate from the inside.

Treatment is geared towards eliminating and treatable causes. In the setting of bacterial infection, an extended course of oral antibiotics (selected based on test results or based on which drugs commonly work) is often used. For severe and acute infections, intravenous antibiotics and hospitalization may be required.  

In many cases no specific infection is identified; while a single course of antibiotics may be sensible in these cases in order to treat occult (hidden) infections, it is not generally a good idea to give recurrent cycles of antibiotics unless bacteria are identified on future tests. 

If pain is thought to be related to issues of pelvic floor muscle dysfunction, consultation with a pelvic floor physical therapist may be of benefit.  Additional options in these cases may include muscle relaxants and other medications designed to decrease muscle tension.

Additional or adjunctive treatment strategies include over-the-counter nonsteroidal anti-inflammatory medicines, brisk fluid intake, avoidance of bladder irritants, maintaining regularity in terms of bowel movements, and soaking in hot baths.

Pain always has a strong psychological component. Strategies to manage pain are key in getting the best outcomes.  In many cases chronic pelvic pain will resolve over time; management is geared primarily to minimizing symptoms and expediting recovery.