Pelvic pain in men
NHS Borders clinical guidelines
What's new / Latest updates
No major changes since Version 9, 2014
Background
From time to time we see men who complain of 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. Often this follows very rapidly from an episode of sexual contact that the man regrets and/or about which he is anxious. Although it is possible that pain felt in a deeper, pelvic location could be due to prostatitis, this is an extremely rare diagnosis in our clinics. (The management of prostatitis is described below.) The biggest error that can be made is to prescribe an antibiotic “in case there is an infection such as prostatitis”, as this serves to convince the patient that there must be something wrong. Symptoms may improve transiently, but almost invariably recur when the course of treatment ends.
For more superficial pain/discomfort, there is a temptation to manage the pain/discomfort by undertaking an STI screen and then simply telling the patient that there is nothing wrong when the tests are all negative. However, many patients continue to experience discomfort despite this attempt at reassurance.
There are differing views as to the likely diagnosis in these cases. One theory that has proved fairly resilient is that the symptoms are due to bladder neck spasm, but accurate localisation of pain is difficult. Therefore, the site where pain/discomfort is felt may vary. The advantage of this as an explanation is that it is easily understood, there is no infection requiring treatment, and anxiety is reduced.
Prostatitis
The classification system for prostatitis is as follows:
| I. Acute Bacterial Prostatitis | Evidence of acute bacterial infection. |
| II. Chronic Bacterial Prostatitis | Evidence of recurrent bacterial infection. |
| III. Chronic Pelvic pain Syndrome | No demonstrable infection |
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| IV. Asymptomatic Inflammatory Prostatitis |
I. Acute bacterial prostatitis as a cause of pelvic pain is associated with other significant symptoms such as urgency, frequency, dysuria, painful ejaculation, abnormal urine flow, alteration in colour of the semen, back pain and/or fever.
Most common causes include: coliform organisms such as E coli, Klebsiella spp, Pseudomonas spp, Proteus spp.. Gonococcal prostatitis is rare. Chlamydial prostatitis does not occur
Signs:
Gentle PR = tender swollen irregular indurated prostate.
Diagnosis:
Obtain a mid-stream specimen of urine for culture and undertake a full STI screen if a risk is identified.
Treatment:
| 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 NSAIDs and quinolones.
Follow up:
- Review at 1 week to ensure improvement.
- Arrange renal tract ultrasound scan and cystoscopy to exclude obstruction as a predisposing cause of infection.
II. Chronic bacterial prostatitis causes relapsing urinary tract infections due to coliform micro-organisms and occurs most commonly in middle aged men. It is a rare presentation in our service.
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. |
Consider referral to Urology.
III. Chronic pelvic pain syndrome
Symptoms:
- Symptoms as above, but present for more than three months
Treatment:
- Reassure patient that there is NO infection, and that symptoms are probably related to bladder neck spasm. After discussion with consultant consider:
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Use of an α-blocker such as alfuzosin Use of a non-steroidal anti-inflammatory agent Urological referral as a last resort |