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Chronic Prostatitis / Chronic Pelvic Pain Syndrome CP/CPPS

Created: 14/2/2007
Updated: 8/3/2007


Chronic Prostatitis / Chronic Pelvic Pain Syndrome CP/CPPS

Definition: Infection or inflammation of the prostate

Prevalence approx 5%
Approx 30% of men have symptoms of CP/CPPS in their lifetime


Proposed in 1995 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) (also accepted internationally by the Prostatitis Collaborative Network)

  • NIH I; acute bacterial prostatitis.
  • NIH II; chronic bacterial prostatitis.
  • NIH III; CP/CPPS. (8x more common than NIH II)
  • III A; inflammatory III B; non-inflammatory.
  • NIH IV; asymptomatic inflammatory


  • Acute prostatitis (NIH I) - acute bacterial infection of the prostate
  • Chronic bacterial prostatitis (NIH II) can develop from acute prostatitis (NIH I) and is characterized by a chronic bacterial infection of the gland
    • NB Only found in 4-5% of patients with prostatitis
  • CP/CPPS is classified into inflammatory (NIH IIIA) and non-inflammatory (NIH IIIB) CPPS
  • IIIA: leukocytes found in
    • expressed prostatic secretion
    • urine after prostatic massage
    • in semen
  • NIH IIIB no leukocytes are detectable
  • NIH IV patients are asymptomatic-diagnosis may be coincidental, e.g. by detecting leukocytes in prostatic secretion or in the urine after prostatic massage as part of another examination or seen histologically after prostatic biopsy



  • Escherichia coli 80%
  • Pseudomonas aeruginosa, Klebsiella, Serratia and Proteus 10–15% of NIH II cases
  • Staphylococci and streptococci 5–10%

Risk factors

  • UTI
  • acute epididymitis
  • indwelling urethral catheters
  • Endoscopic surgery
  • Prostatic stones


Only 5–10% of patients show an infectious cause (success of antimicrobial therapy is limited in cases of CP/CPPS)


1 Infectious

  • Infectious pathogenesis as a cause remains unclear
  • No organism identified by conventional methods of microbiology for NIH II or CP/CPPS
  • Other methods (eg PCR) have identified other bacteria, but significance unclear

2 Intraprostatic reflux

Hypothesis for the induction of chronic inflammation

  • Mechanical/functional obstruction to urine flow and intraprostatic reflux of urine, micro-organisms, antigens, leukocytes, spermatozoa, urate metabolites, creatinine metabolites leads to an immunological reaction and chronic inflammation

3 Immune factors

  • Unclear but may involve Immune reactions against intraprostatic protein or even spermatozoa

4 Psychosomatic factors

  • Depression
  • Stress
  • Hypochondriac reactions can play a role

Signs and Symptoms


  • Pyrexia, rigors , nausea and vomiting, malaise, Sepsis
  • Perineal, suprapubic pain
  • LUTs
  • Tender prostate on DRE

NIH II NB Only found in 4-5% of patients with prostatitis

  • Characterized by symptoms of CP/CPPS (maybe indistinguishable) plus recurrent UTIs
  • Prostate feels normal, but sometimes swollen or firm
  • Chronic bacterial prostatitis may develop from acute bacterial prostatitis, but in many men there is no history of the latter


  • Pain symptoms- perineal, anal, suprapubic, ext genitalia
  • LUTs
  • sexual dysfunction-ED (approx 50%), painful ejaculation
  • General symptoms-myalgia, malaise, lethargy, headache


A Four-glass test/segmental urine culture

With bacterial prostatitis – 10 times more colony-forming units of bacteria than in the first-voided urine

If an organism is cultured or identified, bacterial prostatitis is diagnosed

If no organism identified CP/CPPS is diagnosed and classified according to presence of leucocytes

VB1 1st 10mls urine – Positive indicates urethritis or prostatitis

VB2 MSU – Positive indictates cystitis

VB3 1st 10 mls after prostatic massage – positive indicates prostatitis

EPS Expressed prostatic secretions – positive indicates prostatitis

B NIH Chronic Prostatitis Symptom Index (NIH CPSI)

3 subscores pertaining to pain (location, frequency and severity), LUTs and quality of life

Treatment (CP/CPPS)

  • Alpha blocker
    • NB Total reduction in NIH CPSI scores if used for < 3 months – relieve LUTs but no effect on pain
  • Antibiotics no effect
  • Triple therapy : Alpha-blocker, NSAIDS, Muscle relaxant
  • NB No difference in effectivess between monotherapy and triple therapy
  • 5 ARI’s
  • Alternative meds - flavoxate

Current evidence from RCTs for the treatment of CP/CPPS shows that there is no effective treatment for chronic pelvic pain syndrome

  • Pelvic floor electromagentic therapy - Some pain improvement (21 patients)
  • Aerobic exercise
  • Tricyclics, diazepam
  • Psychological support
  • Biofeedback


Dimitrakov JD, Kaplan SA, Kroenke K, Jackson JL, Freeman MR.
Management of chronic prostatitis/chronic pelvic pain syndrome: an evidence-based approach.
Urology. 2006 May;67(5):881-8. Review.

Yang G, Wei Q, Li H, Yang Y, Zhang S, Dong Q.
The effect of alpha-adrenergic antagonists in chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis of randomized controlled trials.
J Androl. 2006 Nov-Dec;27(6):847-52.

Tugcu V, Tasci AI, Fazlioglu A, Gurbuz G, Ozbek E, Sahin S, Kurtulus F, Cek M.
A Placebo-Controlled Comparison of the Efficiency of Triple- and Monotherapy in Category III B Chronic Pelvic Pain Syndrome (CPPS).
Eur Urol. 2006 Oct 17

Rowe E, Smith C, Laverick L, Elkabir J, Witherow RO, Patel A. Related Articles, Links
A prospective, randomized, placebo controlled, double-blind study of pelvic electromagnetic therapy for the treatment of chronic pelvic pain syndrome with 1 year of followup.
J Urol. 2005 Jun;173(6):2044-7

Giubilei G, Mondaini N, Minervini A, Saieva C, Lapini A, Serni S, Bartoletti R, Carini M.
Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments--could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study.
J Urol. 2007 Jan;177(1):159-65

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