Chronic Noninfectious Prostatitis

Aka: Chronic Noninfectious Prostatitis, Prostatodynia, Nonbacterial Prostatitis, Chronic Pelvic Pain in Men, Chronic Prostatitis Related Pain

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II. Epidemiology

  1. Young or middle aged patients (under age 50 years)

III. Pathophysiology

  1. Prostate inflammation without pathogenic organism
  2. Chronic Pelvic Pain syndrome and diagnosis of exclusion
  3. Causes are not yet fully identified
    1. Pelvic Floor inflammation
    2. Perineal neuromuscular dysfunction
    3. Bladder neck spasm may increase Urethral pressure
      1. Intraprostatic urine reflux
      2. Chemical Prostatitis

IV. Symptoms

  1. Symptoms typically start suddenly
  2. Chronic Pain and discomfort in Pelvis
    1. Low pack pain
    2. Perineal pain
    3. Lower Abdominal Pain
    4. Scrotal Pain
    5. Pain in penis
    6. Pain in inner thighs
  3. Irritative urinary symptoms (Mild to Moderate)
    1. Urine hesitancy
    2. Urine interruption (voiding in pulses)
    3. Decreased urine stream and caliber
    4. Postvoid dribbling
  4. Sexual Dysfunction
    1. Ejaculatory pain
    2. Premature Ejaculation
    3. Erectile Dysfunction
  5. Associated symptoms
    1. Mood Disorder (e.g. emotional stress, Anxiety Disorder, Major Depression)

V. Signs

  1. General physical exam
  2. Digital Rectal Exam
    1. Prostate minimally tender or normal on exam

VI. Labs

  1. Urinalysis and Urine Culture
    1. Hematuria is NOT due to Chronic Noninfectious Prostatitis
  2. Urine Cytology
  3. Post-void residual
  4. Expressed Prostatic Secretion
    1. Leukocytosis
      1. White Blood Cells with excessive fat droplets
      2. Macrophages with excessive fat droplets
    2. Urine Culture negative
      1. Segmented Urine Cultures normal in 75% of cases

VII. Diagnostics: Advanced testing to consider

  1. Prostate Specific Antigen
    1. PSA elevation is NOT due to Chronic Noninfectious Prostatitis
  2. Semen Analysis and culture
  3. Transrectal Ultrasonography-guided biopsy
  4. CT Abdomen and Pelvis
  5. Urine flow (urodynamics)

VIII. Differential Diagnosis

  1. See Prostatitis
  2. Chronic Bacterial Prostatitis
  3. Benign Prostatic Hyperplasia
  4. Voiding dysfunction
  5. Bladder Cancer
  6. Prostate Cancer
  7. Mullerian duct remnants
  8. Neuropathy
  9. Ejaculatory duct obstruction
  10. Cystitis
    1. Interstitial Cystitis
    2. Radiation cystitis
    3. Eosinophilic cystitis
    4. Chronic proliferative cystitis

IX. Diagnosis: Chronic Prostatitis or Chronic Pelvic Pain Syndrome

  1. Pelvic Pain for at least 3 of the preceding 6 months
  2. Other causes are excluded (e.g. Bacterial Prostatitis, renal stones, Orchitis, Abdominal Hernia)
  3. Possible associated findings (not required)
    1. Urinary symptoms
    2. Sexual Dysfunction (e.g. Ejaculatory pain, Premature Ejaculation, Erectile Dysfunction)

X. Evaluation

  1. NIH Chronic Prostatitis Symptom Index
    1. https://repository.niddk.nih.gov/media/studies/mapp_ep/Forms/MAPP_MGUPI_v1.0.20090819.pdf

XI. Management

  1. See Chronic Prostatitis for urology Consultation
  2. Step 1: Consider causes above
  3. Step 2: Consider infectious cause
    1. Treat as Chronic Bacterial Prostatitis
    2. Antibiotics do not improve Chronic Noninfectious Prostatitis
  4. Step 3: Symptomatic Management
    1. See Prostatitis Management for general measures
    2. Obstructive Uropathy symptoms
      1. Alpha Adrenergic Antagonists (Prazosin, Doxazosin, Tamsulosin, Terazosin
        1. Reduces pain in Chronic Prostatitis
        2. Cheah (2003) J Urol 169:592-6 [PubMed]
    3. Pain symptoms predominate: Antiinflammatory agents
      1. Pentosan (Elmiron) 900 mg daily for 16 weeks
        1. Risk of Retinal damage (Pigmentary Maculopathy) with prolonged use (typically with years of use)
      2. Finasteride (Proscar) 5 mg daily for 6 weeks
      3. Quercetin (bioflavinoid supplement) 500 mg twice daily for 30 days
    4. Irritation symptoms: Anticholinergic Agents
      1. Oxybutynin (Ditropan)
    5. Neuropathic pain agents
      1. Gabapentin (Neurontin)
      2. Pregabalin (Lyrica)
      3. Tricyclic Antidepressants (e.g. Amitriptyline, Nortriptyline)
  5. Step 4: Non-pharmacologic management
    1. Biofeedback
    2. Physical therapy
    3. Sacral neuromodulation

XII. References

  1. Habermacher (2006) Annu Rev Med 57:195-206 [PubMed]
  2. Holt (2016) Am Fam Physician 93(4):290-6 [PubMed]
  3. Lam (2024) Am Fam Physician 110(1): 45-51 [PubMed]
  4. Pontari (2008) Urol Clin North Am 35(1): 81-9 [PubMed]
  5. Pontari (2007) J Urol 177(6): 2050-7 [PubMed]
  6. Sharp (2010) Am Fam Physician 82(4): 397-406 [PubMed]
  7. Schaeffer (2006) N Engl J Med 355(16): 1690-8 [PubMed]

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