Up to 50% of men may experience pelvic pain or symptoms consistent with prostatitis in their lifetime, yet the condition is poorly understood and can be a challenge for physicians. In this first part in a new series, the authors look at classification and diagnosis of chronic prostatitis and chronic pelvic pain syndrome

Dr Jonathan Rees GP with special interest in Urology, Backwell & Nailsea Medical Group
Dr Alison Cooper Prostate Cancer UK On behalf of the Prostatitis Expert Reference Group, Prostate Cancer UK

CASE STUDY
NM, a 48 year old salesman presented to his GP with a one-year history of recurrent episodes of pain, felt in the perineum and at the tip of the penis during and for some time after passing urine. In addition, he experienced significant discomfort on ejaculation, and at times of more severe symptoms, increased urinary frequency and urgency. As a result of these symptoms, he was becoming increasingly low in mood – he also noticed that symptoms would often flare up during times of fatigue or stress.
Prostatitis is a common condition, with estimates of prevalence suggesting 35-50% of men experience symptoms consistent with the condition at some time in their life.1 Prostatitis is poorly understood, under- diagnosed and presents a diagnostic and therapeutic challenge for physicians.1 However, the condition has attracted relatively little attention from urologists (perhaps because it rarely requires surgical treatment) or the wider medical community when compared with other urological conditions, has often been presented as a ‘heartsink’ problem, and is under- represented in the medical literature. Prostatitis can have a huge detrimental impact on quality of life, 2 and is a cause of great frustration for patient and doctor due to the difficulty in understanding the condition and treating it successfully. However, if the symptoms are recognised and the diagnosis made, a symptom-based approach to treatment can be undertaken. 
 
Classification of prostatitis
The classification system used most commonly is that of the research centre National Institutes of Health (NIH) (see Table 1 ), splitting the condition into four main subtypes.3
 
Acute bacterial prostatitis (type I) is a rare condition, usually involving the spread of bacterial infection from the bladder, urethra or epididymis, and can also be a complication of transrectal prostate biopsy. 
 
Chronic bacterial prostatitis (CBP) (type II) with persistent or recurrent symptoms and proven infective aetiology is also uncommon. Together, type I and type II account for less than 5% of patients with prostatitis.
 
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (type III) which accounts for almost 95% of prostatitis diagnoses. A number of causal hypotheses have been postulated for this condition, both infective and non-infective, but there is, as yet, no widely accepted full explanation for the condition. Indeed, it is likely that a number of different aetiologies share the same symptomatic end-point. While some of the symptoms experienced by men with CP/CPPS do originate from the prostate, it is increasingly understood that many of the symptoms do not, and are generated by other structures within the pelvis, or by neuropathic mechanisms within the sensory nervous system (eg, central sensitisation). It is for this reason that the term Chronic Pelvic Pain Syndrome (CPPS) is used, to emphasise that the prostate may not be to blame and that a more holistic approach to managing patients with these symptoms is required.
Asymptomatic inflammatory prostatitis (type IV) is diagnosed either at prostate biopsy for suspected prostate cancer or on histological examination of prostatic tissue from trans-urethral resection of the prostate – it is of little significance in the context of this article, which will concentrate on the management of CP/CPPS (type III).
 
Presenting symptoms of CP/CPPS
 
There is wide heterogeneity in terms of clinical presentation, and symptoms can fluctuate over time – however, symptoms can be broadly categorised in four main domains: 4
 
Pain: men with CP/CPPS can experience pain or discomfort in the perineal, suprapubic, scrotal, testicular, penile, lower back, abdominal, inguinal or rectal regions. In addition, they may report dysuria, or pain during or after ejaculation. Findings from a retrospective analysis of clinical records (n=1,563) indicate that the most prevalent localisation for pain is the perineal region (63% of patients), followed by the testicular, pubic and penile areas. 5
 
Urinary symptoms: lower urinary tract symptoms (LUTS) are also a common clinical presentation, with cohort studies reporting at least one such symptom in 39–68% of patients.6,7 LUTS include voiding symptoms (for example, weak stream, straining and hesitancy) or storage symptoms (for example, urgency with or without urgency incontinence, increased urinary frequency, nocturia and dysuria). 
 
Sexual dysfunction: erectile dysfunction (ED), ejaculatory dysfunction (whether delayed, premature or painful) and loss of libido are all associated with CP/ CPPS. Total or partial ED is reported by 15–55% of CP/CPPS patients, 8–12 while the prevalence of overall, self-reported sexual dysfunction is higher at 46– 92%. 8,9,12,13 Correlation studies of sexual dysfunction symptoms with CP/CPPS symptom scores indicate that CP/CPPS patients with sexual dysfunction suggest that sexual symptoms can contribute substantially to the morbidity experienced by men with CP/CPPS. 
 
Psychological symptoms: depression, anxiety and panic disorder are significantly more common in men with chronic symptoms compared with controls. 14–17 Furthermore, a small (n=61) cohort study suggests CP/ CPPS patients can experience pain catastrophising – a negative cognitive-affective response to anticipated or actual pain. Those with a high tendency towards this may experience more severe pain and QoL issues, and are at risk of developing chronic pain. 18

Chronic prostatitis and chronic pelvic pain syndrome - Part 1 - Table 1 
CP = chronic prostatitis; CPPS = chronic pelvic pain syndrome; EPS = expressed prostatic secretions; NIH = National Institutes of Health; VB = voided bladder; VB3 = post-prostatic massage voided bladder urine aDuring CP/CPPS, it is possible for patients to switch between the two subcategories (IIIa and IIIb), but this has little effect on their subsequent clinical management.
 
Assessment and diagnosis in primary care
 
A full history is needed, with enquiry about the range of symptoms outlined above. There are a number of validated symptom scores that can be useful, both for initial evaluation and for assessing response to treatment: 4
  • NIH Chronic Prostatitis Symptom Index (NIH-CPSI) for general assessment of prostatitis symptoms
  • International Prostate Symptom Score (IPSS) for quantification of urinary symptoms
  • International Index of Erectile Function (IIEF-5) or Sexual Health Inventory for Men (SHIM) enable measurement of erectile function/sexual symptoms
  • Patient Health Questionnaire-9 (PHQ-9) and/or the Generalised Anxiety Disorder-7 (GAD-7) for assessment of psychological impact of the condition, and can be used if a patient indicates that anxiety or mood issues have been a problem.

Examination of the patient should include a digital rectal examination (DRE), firstly to exclude abnormalities suggesting the possibility of prostate cancer which can occasionally present with pelvic pain, to estimate prostate size in the presence of urinary symptoms and to assess for excessive tenderness of the prostate and sometimes for pelvic floor issues, particularly hypertonicity. Only three key investigations need to be considered in primary care (see Table 2 ): urinalysis and microscopy if appropriate (in order to exclude urinary tract infection (UTI)), exclusion of sexually transmitted infection (particularly chlamydia) and discussion with the patient about the pros and cons of Prostate Specific Antigen (PSA) testing.4

Chronic prostatitis and chronic pelvic pain syndrome - Part 1 - Table 2
This should be considered under the following circumstances: an abnormal prostate on DRE; patient concern in relation to prostate cancer; or when symptoms are suggestive of bladder outlet obstruction secondary to benign prostatic enlargement. While the PSA level can be falsely elevated during an infective or inflammatory flare of prostatitis, most men with pelvic pain and urinary symptoms are concerned about the possibility of prostate cancer. Therefore a baseline PSA test is often useful, if only hopefully for reassurance.
References

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