Chronic pelvic pain syndrome (CPPS) in men: symptoms, causes and treatment

Chronic pelvic pain syndrome is a long-term pain condition in people with a prostate. The pain is felt in the pelvic region, and the NHS Borders guideline describes it appearing at the tip of the penis, inside the shaft of the penis, in one or both testicles, in the region of the prostate gland or across the lower abdomen. It is often accompanied by urinary symptoms such as pain when peeing, needing to pee more often or urgently, and by sexual difficulties.

Doctors classify prostatitis into three broad groups: acute bacterial prostatitis, chronic bacterial prostatitis and chronic pelvic pain syndrome. In the first two a bacterial infection is proven. In CPPS no infection is found. The guideline states that this third group is much more commonly seen than bacterial prostatitis, even though it is sometimes grouped with prostate disorders and may not be related to the prostate at all.

This guide is about the male form of CPPS. Pelvic pain in women has different causes and is covered separately in the library, for example on the chronic pelvic pain page.

Symptoms vary from person to person and can fluctuate. The NHS lists the symptoms of prostatitis in general as pain when peeing that may feel like stinging or burning, difficulty peeing or straining, needing to pee more often than usual, pain in the penis, scrotum, testicles or bottom, pain when you ejaculate and, with infection, a high temperature.

The NHS Borders guideline notes that people may also have other regional pain syndromes, and that on examination there may be a tender prostate or muscle spasm in the pelvic floor.

• Aching or burning pain in the pelvis, perineum (between the scrotum and anus), testicles, penis or lower abdomen.

• Pain or discomfort when peeing, or a frequent or urgent need to pass urine.

• Pain during or after ejaculation, or other sexual difficulties.

• Symptoms that are worse with stress or anxiety, which the guideline describes as contributing factors.

The honest answer is that the cause is not fully understood. The NHS says that prostatitis is usually caused by an infection such as a urinary tract infection, but that it is not always known what causes long-term (chronic) prostatitis, and that it is thought an infection or inflammation may cause it, possibly a combination of these things.

The NHS Borders guideline emphasises two practical points. First, CPPS is usually related to tension in the pelvic floor, the group of muscles that supports the bladder and bowel. Second, stress and anxiety are often a contributing factor, and anxiety can make the condition worse. In some people the problem begins after a worry about a sexually transmitted infection, and repeated testing in the absence of risk is described as unhelpful.

None of this means the pain is imaginary. Pelvic floor muscle tension is a physical process, which is why the guideline’s plan aims at the muscles and at stress as well as at any urinary symptoms.

A GP will usually ask about your symptoms and how long they have lasted, examine your tummy and genitals, and may examine the prostate through the back passage (a rectal examination). A urine test checks for infection, and the NHS Borders guideline lists blood tests and a sexual health screen where there is a relevant risk.

CPPS is a diagnosis made when infection and other causes have been looked for and not found. For chronic bacterial prostatitis the guideline says the diagnosis is made by finding the same organism on each occasion of a urinary infection. Where bacterial infection is suspected and has not been investigated, it recommends referral to urology. The NHS says that if you have had symptoms for 3 months or longer you may be referred to a urologist.

It is also worth knowing that an apparent improvement after an earlier course of antibiotics does not prove a bacterial infection, according to the NHS Borders guideline, which is one reason repeated courses are discouraged.

Treatment is usually a combination. The NHS says chronic prostatitis may be treated with antibiotics and other medicines to help with symptoms, cognitive behavioural therapy (CBT) or counselling, physiotherapy, and alternative therapies such as acupuncture if available in your area. The NHS Borders guideline for CPPS describes a plan of reassurance that there is no infection, an explanation of the diagnosis and acknowledgement of its impact.

• The NHS suggests drinking plenty of fluids and using paracetamol or ibuprofen for pain.

• If you have been given antibiotics, the NHS advises finishing the whole course even if you feel better.

• Check with a pharmacist or GP that ibuprofen is safe for you, as it is not suitable for everyone.

Most chronic pelvic pain is not an emergency, but acute prostatitis can be. The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you are unable to pee, or if you have been taking antibiotics for prostatitis for 48 hours and your symptoms have not got better or have got worse.

The NHS says to go to A&E or call 999 if you suddenly feel confused, have slurred speech or are not making sense, have blue, grey, pale or blotchy skin, lips or tongue, have a rash that does not fade when you roll a glass over it, or have severe difficulty breathing. These may mean a serious infection or sepsis.

The sources used here do not give a precise recovery time for CPPS, and it is better not to promise one. What the NHS Borders guideline describes is a condition that is complex, that tends to prompt repeated visits and testing, and that responds best to a steady plan that stops the cycle of testing and antibiotic courses and focuses on pelvic floor, stress and pain management.

The guideline recognises that sexual dysfunction and anxiety are frequent companions of the pain, so talking with a partner or a trusted person about the effect on sex and mood is worthwhile, and psychological support is part of the plan.

On the NHS, assessment starts with the GP, with referral to urology, sexual health services or pelvic floor physiotherapy depending on local arrangements. Waiting times and the availability of specialist pelvic pain physiotherapy vary between areas.

Some people choose a private urologist or physiotherapist for quicker access. Whichever route you use, it is reasonable to ask what the working diagnosis is, whether infection has actually been shown, and what the plan is if the first treatment does not help.