Pelvic pain in men

NHS Borders clinical guidelines
NHS Borders

Male pelvic pain may present in various forms to our clinics. The most common cause that we are likely to see is Chronic Pelvic Pain Syndrome. This is a common condition that may also be called chronic prostatitis (however prostate inflammation is unlikely to be the cause.)

It may present with pain/discomfort either 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. This may have followed an episode of sexual contact that the man regrets and/or about which he is anxious.

Very rarely this pain could be related to a bacterial prostate infection and management is detailed below. However more commonly in our clinics this is Chronic Pelvic Pain or anxiety induced symptoms and if there is no evidence of bacterial infection, prescribing antibiotics empirically will only exacerbate the problem long term.

Prostatitis

The classification system for prostatitis is as follows:

Acute Bacterial Prostatitis Evidence of acute bacterial infection.
Chronic Bacterial Prostatitis Evidence of recurrent bacterial infection.
Chronic Pelvic pain Syndrome No infection

I. Acute bacterial prostatitis - Rare

  • Entry of micro-organisms into prostate gland via urethra
  • May be concurrent epidymis/urine infection
  • Symptomatic
    • Fever, malaise
    • Dysuria, increased frequency, urgency
    • Dribbling, hesitancy, retention
    • Painful ejaculation

Signs

  • Perform Gentle PR exam
    • Tender, swollen, irregular, prostate

 Management

  • FBC and CRP
  • MSU
  • STI screen if risk

Causes

  • Ecoli most common cause
  • Other Enterobactales
  • Proteus
  • Rarely STI

Treatment: To be discussed with GUM Senior prior to prescribing

Ciprofloxacin 500mg twice daily by mouth four weeks
Or
Trimethoprim 400mg twice daily by mouth four weeks
Plus
Analgesia as required*

*Note caution in prescribing quinolones. MHRA warning. And extreme caution if using with NSAIDS/Steroids

Follow up:

  • Review at 1 week to ensure improvement. Can be a phone call
  • Arrange renal tract ultrasound scan and cystoscopy to exclude obstruction as a predisposing cause of infection.

II. Chronic bacterial prostatitis 

  • Recurrent symptoms with microbiological evidence of prostate infection
  • Risk if prior urethra instrumentation/ Diabetes/ smoking/ Inadequate treatment of acute infection
  • Similar causes as acute – E.coli remains most common cause

 Signs

  • May have normal prostate exam
  • Prostate hypertrophy, tenderness, oedema.

The diagnosis is made by finding the same pathogen on each occasion of a urinary tract infection.

Treatment: 

Base treatment on the sensitivity of the infecting micro-organism.

Usually a fluoroquinolone for 6 weeks but need a clear discussion of risks with patient
Again to be discussed with GUM Senior prior to prescription.

If not previously investigated refer to urology

III. Chronic pelvic pain syndrome

Definition

Chronic pelvic pain for at least 3 of past 6 months  in Absence of other identifiable causes. Often will have associated symptoms including dysuria, frequency/urgency and sexual dysfunction.

  • Much more commonly seen in our service than bacterial prostatitis
  • Although grouped with prostatic disorders may not be related to prostate
  • Usually related to pelvic floor tension
  • Stress and anxiety often contributing factor
  • May have other regional pain syndromes
  • Signs May have tender prostate
  • Muscle spasm on examination

Management  

Often patients are complex and ask GUM Senior for assistance if required rather than repeated testing if previous negative results.  

  • Reassure patient that there is NO infection – in our patient group often the precipitant is anxiety around an STI repeated testing in absence of risk is unhelpful
  • Explain the diagnosis of CPPS – a complex regional pain syndrome and acknowledge the impact their symptoms may be having
  • Can recommend physiotherapy exercises to try at home and/or engage with male pelvic floor physio PIL(hyperlink)
  • Anxiety will excarbate condition and engaging with psychological support may be helpful.
  • A short course of analgesia – NSAIDS
  • A short course of an alpha blocker can be considered, particularly if urinary symptoms

Editorial Information

Last reviewed: 31/10/2024

Next review date: 31/10/2026

Author(s): Wielding S.

Version: 11

Reviewer name(s): Wielding S.

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