Chronic Pelvic Pain Syndrome Affects Men as Well

Affecting more than 10% of men at any given time, getting the right diagnosis can lead to a tailored treatment plan for relief.

Male Chronic Pelvic Pain Syndrome, also known as chronic nonbacterial prostatitis, refers to pain or discomfort in the pelvis or genitals lasting for at least 3 months that cannot be explained by a readily identifiable cause.1-3  Several conditions may be classified as Chronic Pelvic Pain Syndrome (CPPS), including:

  • Pelvic floor dysfunction: the inability to control the muscles that help you have a complete bowel movement; Levator ani syndrome is a type of non-relaxing pelvic floor dysfunction in which the muscles are too tight leading to frequent dull pain in the rectum
  • Coccydynia: inflammation of the tailbone; pain often worsens when sitting
  • Rectal pain
  • Perineal pain: in men, this is the area between the anus and the genitals
  • and the list goes on.

According to the National Center for Pelvic Pain Research, these distinctions “possess the same root cause.”2 Overall, CPPS is common, affecting up to 10% of all men at any given time. Its effect on quality of life is comparable to that of other serious health conditions such as diabetes or stroke.3 Even so, this syndrome is rarely discussed.2

Here, PPM delves into the symptoms, diagnosis, and treatment of CPPS.

Male with "problem" sign over pelvic areaChronic pelvic pain syndrome affects up to 10% of men at any given time. (Source: 123RF)

Symptoms

The main symptom of CPPS is pelvic or genital pain. The characteristics of this pain can vary from person to person. For some men, the pain may be dull and achy. For others, it may be sharp and intense. Some men suffer from pain constantly, and other men experience it intermittently.1

Many men with CPPS have accompanying symptoms as well.1 Examples include:

  • pain during urination
  • difficulty with urination
  • pain when ejaculating
  • constipation
  • diarrhea
  • bloating
  • fever or chills

Symptom flares, that is, worsening of symptoms for periods of time, may also occur.3

Diagnosis

Many diseases may lead to pelvic pain. Doctors must, therefore, rule out potential other conditions before CPPS can be officially diagnosed. If you visit a doctor for evaluation of pelvic pain, he or she is likely to ask you several questions about your symptoms and medical history, in addition to performing an initial physical exam.1-2

Several tests may be conducted, which may include but are not limited to the following:1

  • Lab tests such as bloodwork and/or a urinalysis
  • Imaging tests, including an ultrasound, X-ray, or computerized tomography (CT) of the pelvis and abdomen
  • Diagnostic laparoscopy, which is a minimally invasive surgical procedure that allows the doctor to see the pelvic organs
  • Lower endoscopy, which allows the doctor to visualize the rectum.

These tests can help your doctor diagnose your condition and, in some cases, determine its cause.3

Treatment

If your doctor is able to pinpoint an underlying cause for at least some of your symptoms, a treatment plan will focus on that cause. Often, however, the cause remains unknown, in which case, your clinician’s goal will be to reduce your symptoms and improve your quality of life.3-4

Regardless of the cause of your symptoms, your clinician should educate and counsel you about your diagnosis. Be sure to ask questions if certain aspects are unclear. A doctor may first recommend diet and lifestyle modifications, such as low-impact exercise (eg, walking or yoga) to help with your pain. Local heat therapy may also provide relief while learning coping strategies for stress and anxiety may help to alleviate suffering related to chronic pain.4

If the pain continues, some common examples of pain management interventions that may be used to address CPPS include:

  • Pain relievers: Options include over-the-counter medications, tricyclic antidepressants, gabapentinoids, and, if all else fails, opioids.
  • Trigger point injections: If your pain can be localized to a specific area, numbing medicine may be injected into spots in that region called trigger points. 
  • Physical Therapy: Physical therapists are experts in stretching exercises, massage, and other techniques that can improve pain. Seek out a physical therapist who specializes in pelvic pain.
  • Psychotherapy: Cognitive behavioral therapy is commonly implemented; practitioners teach patients strategies to cope with pain.
  • Surgery: If the underlying cause of your pelvic pain is correctable by surgery, only then does it become an option.4

A doctor may recommend additional interventions based on the specific symptoms you are experiencing.3-4

UPOINT Classification System

Daniel Shoskes, MD, a urologist and CPPS specialist based at the Cleveland Clinic, and his colleagues developed the UPOINT classification system for symptoms of Chronic Pelvic Pain Syndrome.4

In an interview with PPM, Dr. Shoskes stated, “We are dealing with a syndrome that has multiple clinical phenotypes and multiple potential etiologies… That’s where I had the idea that if we are going to move forward at all in the treatment and understanding of this disease, we need a framework to classify the men and in particular in a way that could drive therapy.”

Symptoms are assigned to one of the following domains:

  • Urinary
  • Psychosocial
  • Organ-Specific
  • Infection
  • Neurologic-systemic
  • Tenderness

Using this approach, doctors can individualize your treatment plan toward the domain under which your symptoms fall, rather than apply a generic treatment plan for CPPS.4

Wise-Anderson Protocol

David Wise, PhD, a licensed psychologist, and Rodney U. Anderson, MD, FACS, a urologist, both from the Department of Urology at the Stanford Medical Center, developed the Wise-Anderson Protocol between 1995 and 2003 as a method of treatment –and the approach is still widely used today.2

“Most of the symptoms of pelvic pain or discomfort, urinary frequency and urgency, and pain related to sitting or sexual activity in cases diagnosed as prostatitis…can be caused by chronically tightened muscles in and around the pelvis,” according to the National Center for Pelvic Pain Research website, headed by both experts.2

The Wise-Anderson Protocol focuses on relaxing the pelvis to stop spasms in pelvic floor muscles. It may be implemented in individuals with the following symptoms:

  • urinary problems
  • pain with sitting
  • pain when ejaculating
  • rectal, penile, or testicular pain
  • suprapubic (below the umbilical region), coccygeal (the tailbone area), perineal (between the legs, around the anal area), rectal, groin, and lower back pain
  • mood or social impairment related to the pelvic pain.2

Other Possibilities

“I want to really emphasize that just because a man has pain in the pelvic area, it doesn’t mean he has CPPS,” clarified Dr. Shoskes. “There are a lot of structures that live in this area and a lot of interventions that men can have. Someone who has had pelvic radiation for cancer in the rectum or the bladder may have pain. Men who have stones in the ureter can have pain. Men with sports injuries and orthopedic issues will have pain in the pelvis. So it is important that the correct diagnosis be made.”

He added, “I think it’s important anytime someone has a chronic pain syndrome to keep an open mind. There can be a tendency when someone has a condition like this that any new symptom in this region gets attributed to it. And certainly, I have found people with the appropriate diagnoses of this condition but then went on to develop prostate or bladder cancer that was not immediately detected because the symptoms were attributed to that.”

Updated on: 10/04/18
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