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
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.
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.
- 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
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