Sexual Health and Genital Medicine in Clinical Practice

Chapter 14. Prostatitis, Chronic Pelvic Pain Syndrome, and Hematospermia

Men with "prostatitis" often find their way to either urology or GU medicine.

Acute bacterial (Type I) prostatitis commonly presents with fever, chills, frequency, dysuria or strangury, and rectal pain. Examination reveals a tender, swollen prostate gland.

Chronic bacterial (Type II) prostatitis (CBP) may be more difficult to diagnose clinically. Symptoms may include perineal or suprapubic discomfort or pain sometimes radiating to the testes and penis. This may be associated with dysuria, frequency, and postejaculatory pain. CBP may also present as recurrent urinary tract infection. Rectal examination does not usually reveal prostatic tenderness. True CBP is thought to account for approximately 5% of cases of symptomatic prostatitis.

Chronic pelvic pain syndrome (CPPS) (Type III) accounts for the remaining 95% of cases and is subdivided into inflammatory (Type IIIa) (formerly known as "chronic abacterial prostatitis") and non-inflammatory (Type IlIb) (formerly known as "prostato- dynia"). Type IIIa and IIIb are equally prevalent and may even be the same condition. Men with CPPS are usually young to middle-aged and present with perineal or genital pain lasting for several weeks or months. Pain is central to the diagnosis and is usually variable in intensity and typically widely distributed in the genital, perineal, and pelvic areas. There may be associated urinary symptoms such as frequency, variable urine flow, and urgency and sexual disturbance in the form of ejaculatory discomfort.

Other causes of "prostatitis-like" symptoms are as follows:

• Bladder neck dyssynergia (muscular incoordination) may present with frequency, urgency, and postmicturition dribbling. Diagnosis is usually by urinary flow studies.

 Pelvic floor tension myalgia presents with frequency, urgency, and perineal discomfort and there is pain on palpating the levator ani.

 Pudendal neuralgia may present with perineal and genital pain.

 Benign sacral meningeal cysts have been reported as a cause of genital pain and are best visualized by magnetic resonance imaging (MRI) scanning of the lumbosacral spine. However, it is probably prudent to consider seeking a neurological or urological opinion before embarking on costly investigations.


Diagnosing chronic prostatitis can be difficult in general practice. "Localization studies" are no longer felt to be necessary as a similar percentage of normal controls have been found to have positive cultures of expressed prostatic secretions as CPPS patients.

Mid-stream urine culture should be performed as this may be positive in some patients with type II prostatitis.

Transrectal ultrasound should be necessary only if a prostatic abscess is suspected or as part of a research study.


An urgent urological opinion should be sought for patients with presumed acute prostatitis. The condition is usually caused by the common urinary pathogens (e.g. E. coli, Proteus spp., Streptococcus faecalis, Klebsiella spp., Pseudomonas spp.) and is best treated with trimethoprim or a 4-quinolone such as ciprofloxacin or ofloxacin. Intravenous therapy is usually required initially and treatment should continue with oral antibiotics for up to 6 weeks.

Chronic bacterial prostatitis requires an antibiotic that can pass readily into the prostate. A 6-8-week course of ciprofloxacin (500 mg bd) or ofloxacin 400 mg daily should be considered. Trimethoprim is less effective in this condition.

Patients with CPPS often prove difficult to manage. The following have been reported as potentially useful.

• A 6-week course of antibiotics is often tried although their role in the management of CPPS is not well defined. Ofloxacin or ciprofloxacin are reasonable choices. Doxycycline (100 mg bd) has the possible advantage of an anti-inflammatory as well as an antibacterial action and may be tried if quinolones are ineffective.

 Non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes given at the same time as antibiotics, either orally or, possibly preferably, as suppositories.

 Low to medium dose amitriptyline (e.g. 25-75 mg), as used for chronic pain control, may prove helpful and antidepressants (e.g. fluoxetine) if a co-existent depressive element is suspected.

 Some patients with CPPS have a spastic dysfunction of the bladder neck and prostatic urethra and may benefit from an alpha-blocker (e.g. tamsulosin, terazosin).

 Finasteride (5 mg daily) is worth trying if there is evidence of co-existent prostatic enlargement.

 The bioflavanoid, quercetin (500 mg bd for one month) may prove helpful if pain is the predominant feature rather than urinary symptoms.

 Pollen extract (cernilton) is reported to have anti-inflammatory and anti-adrenergic properties and has been used successfully in some cases of CPPS. Treatment may need to be continued for some months.

 Microwave hyperthermia to the prostate has also been used with variable success.

 Psychological factors should be tactfully sought and addressed and the use of acupuncture, hypnosis or relaxation, and visualization techniques considered. Most importantly, time should be taken to explain that the condition is not precancerous, will not affect fertility, and cannot be passed on or acquired through sexual intercourse.

 The natural history of CPPS is often fluctuating and symptoms may resolve over time.

 Referral to a chronic pain clinic should be considered in patients with persisting symptoms.


Blood in the ejaculate is a worrying condition that often raises concerns about cancer or sexually transmitted infection. It is important to distinguish a blood stained ejaculate from fresh bleeding per urethra (e.g. secondary to intrameatal or distal urethral warts) and traumatic lesions (e.g. a torn frenulum). A careful genital and prostatic examination are therefore required and the appropriate tests taken to check for urethritis, including chlamydial and gonococcal infection, although in the majority of cases these prove negative. The blood pressure should be measured and urinalysis performed to exclude hematuria.

Men over 40 years of age with no other urinary or genital symptoms require reassurance. The condition may recur but will eventually cease. Men over 45 years of age are at greater risk of having underlying pathology and should undergo further investigation, including prostate specific antigen (PSA) testing after appropriate counseling.

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