Symptoms and Diagnosis
Chronic Pelvic Pain Syndrome isn’t caused by infection — it is best understood as persistent pelvic muscle tension, like a “tension headache” in the pelvis. This tension affects the organs it supports, leading to pain, urinary issues, and sexual symptoms.
Common Symptoms Include:
- Pelvic or groin pain (in the perineum, testicles, penis, or bladder region)
- Urinary problems such as urgency, frequency, nighttime urination, and burning
- Sexual symptoms including painful ejaculation, premature ejaculation, or erectile dysfunction
Symptoms often flare with stress, sexual activity, or lifestyle changes, vary in severity, and can significantly affect quality of life.
How CP/CPPS Is Diagnosed
CP/CPPS is a diagnosis of exclusion, meaning other causes must be ruled out.
Evaluation typically includes:
- A medical and sexual history
- Physical and pelvic examination
- Urinalysis and targeted testing
- Non-invasive bladder function tests
- Erectile function assessment when indicated
At Maze, we avoid unnecessary invasive testing and focus on identifying tension-driven causes so treatment can be targeted and effective.
What causes CP/CPPS?
The cause of CP/CCPS is unknown, but it is most useful to think of it as tension held in the pelvis, causing pain and spasm, leading to the symptoms described above. Again, it is most useful to conceptualize it as “a tension headache in the pelvis.” It is very unlikely to be caused by actual infection of the prostate and in many cases does not involve the prostate at all.
What are the Symptoms of CP/CPPS?
The three main symptoms of CP/CPPS are:
- Pain
- Urinary Symptoms
- Sexual Issues
Most men will have flare-ups of their symptoms, which can last from seconds to months. Sometimes the pain is very minor, and sometimes quite significant. The pain can vary in location as well.
Fortunately, it does tend to “burn itself out”; both the frequency of symptoms and their intensity often decrease over time. Flare-ups seem to be caused by stress, sexual activity, and changes in lifestyle habits. Like any chronic pain syndrome, it often causes decreased quality of life and depression.
Pain
As suggested by its name, the primary symptom of CP/CPPS is pain, which may be felt in any of the following locations.
Perineum: The most common location (63%) is the perineum, the area between the pubic bone and tail bone (coccyx).
Testes: 58% of men will have testicular pain.
Bladder/Suprapubic Area: 42% of men will have pain above the pubic bone, which is where the bladder is located.
Penis: 32% of men will have pain in the penis. It is the most common cause of pain in the penis after Peyronie’s disease. However, with Peyronie’s disease the pain is often accompanied by scar tissue (which can be felt), curvature, and/or a history of trauma. Also, the pain from Peyronie’s disease is usually worse with an erection. Thus, for a urology specialist, the diagnosis of Peyronie’s disease is an easy one to make. Other penile pain is CP/CPPS until proven otherwise!
What does the pain feel like?
The pain is usually dull but can be sharp for some. It is rarely “colicky” like a kidney stone. It can vary in duration, lasting minutes, hours, or days. Many men with CP/CPPS have chronic pain or discomfort in other parts of their body, like migraine headaches, irritable bowel syndrome, interstitial cystitis, chronic fatigue syndrome, and fibromyalgia.
Urinary Symptoms
In addition to pain, many men have urinary symptoms. The most frequent symptoms are:
- Frequency (needing to go to the bathroom too often)
- Urgency (needing to urinate right away when the urge hits)
- Nocturia (being woken up several times nightly to urinate)
- Dysuria (pain with urination)
- Painful bladder filling
These urinary symptoms are often what causes men to receive the wrong diagnoses of either having chronic prostatitis or an asymptomatic enlarged prostate.
Sexual Symptoms
Many men will develop sexual symptoms from CP/CPPS. These include:
Pain with Ejaculation
Painful ejaculation occurs in 58% of men with CP/CPPS, and of course, dramatically decreases sexual satisfaction. Some men find the pain worsens with frequent ejaculation while others find that the longer the interval between ejaculations, the more discomfort they have. This pain may occur every time a man ejaculates or intermittently. Ejaculation is an intense series of physical and neurological events, but should be pleasurable, not painful!
Premature Ejaculation (PE)
An estimated 30% have lifelong PE, making it the most common sexual issue affecting men generally. However, many men with reasonable control over ejaculation can begin experiencing control problems with CP/CPPS. 64% of men with CP/CPPS complain of PE, many of whom did not have it before. Learn More
Erectile Dysfunction (ED)
15% – 40% of men with CP/CPPS will either develop or have worsening of their erectile dysfunction. In fact, we often diagnose CP/CPPS in men who present to us with ED. Learn More
How is CP/CPPS Diagnosed?
CP/CPPS is considered a “diagnosis of exclusion.” In other words, to have it, a man must have the symptoms consistent with diagnosis, and other specific causes need to be ruled out. All men should have a thorough history taken, as well as a physical examination, and urinalysis. Based on the findings of the physical examination and the urinalysis, other testing may be indicated.
In some cases, other symptoms or physical findings may be discovered which will require a different evaluation than outlined here. These include blood in the urine, lower extremity tingling or pain, lymph nodes in the groin, hernias, or abdominal masses.
Urological Physical Examination
All men will need a urological examination, which will include a scrotal examination looking for tenderness or masses. (If any masses are seen, an ultrasound would be indicated, which is a simple procedure, causing no discomfort.)
Most men should have a digital rectal examination (unless acute prostatitis is suspected).
Urinalysis and Urine Culture
All men with a possible diagnosis of CP/CPPS should have a urinalysis. If the urinalysis shows evidence of infection (which would include white blood cells, bacteria, or other specific finding) a urine culture should be performed, ideally on the same specimen. The urine is sent to a lab to see if a significant number of bacteria can be grown out of it. If so, the specific bacteria growing are identified. Simultaneously, an evaluation of which antibiotics would best treat these bacteria is performed.
Clearly, an infection must be treated with antibiotics, and an evaluation must be done to look for underlying causes of the infection.
If the urinalysis shows red blood cells (indicative of bleeding somewhere) a more intense urologic workup may be indicated to rule out other issues, including cancer and kidney stones.
Urethral Discharge Culture
Occasionally, men with CP/CPPS will complain of a urethral discharge or drip. If so, the discharge should be examined under the microscope and cultured for bacteria, chlamydia, and gonorrhea.
Testing for Urination Issues
If a man has significant urination issues, a basic, non-invasive evaluation is often indicated.
Men with symptoms consistent with not emptying their bladder completely, or with flow issues, will receive two simple non-invasive tests done at the same time.
Uroflow
While a man urinates into a funnel, the rate at which he empties his bladder and the total volume is measured.
Post Void Residual
After the man finishes urinating, a small ultrasound probe is placed on the skin over his bladder, and the amount of urine left in the bladder is measured.
If the above tests are abnormal, then further urologic testing and treatment are warranted. This may include a cystoscopy (looking in the bladder with a scope) or urodynamics (measuring pressure as the bladder fills and empties). However, we believe that these more invasive tests are done far too often and too early in the diagnosis and treatment of CP/CPPS.
Evaluation of Erectile Dysfunction
If a man has ED, then a full ED evaluation is performed. This will include a full sexual history, targeted physical exam, testing of penile sensation, assessment of nighttime erections, and measurement of blood flow in and out of the penis.
Often, CP/CPPS is only one of the contributing causes of ED.