Pelvic Pain in Men is NOT prostatitis

August 10, 2016

The NIH/NIDDK branded Prostatitis Classification System, endorsed in 1996, has negatively impacted the care of men with chronic pelvic pain syndrome and misdirected attention and resources to research more holistic approaches. Designating the most common type (90-95% of prostatitis diagnoses) as Category 3, beneath the broad umbrella of Prostatitis is like placing headaches under a ridiculous classification system for encephalitis. Like headaches, pelvic pain in men has a broad differential diagnosis, often not even urological. And to further to my point, doctors don't empirically treat all headaches with antibiotics, which sadly remains standard practice for doctors treating men with urological complaints associated with discomfort.

Pelvic Pain in Men is NOT Prostatitis

Since the 1960's there have been studies showing the inadequacy of antibiotics for treating prostatitis [symptoms]. It is still amazing that thousands of men are still diagnosed and treated for an infection, even when the vast majority of these men have:

  1. no risk factors for an infection of the urinary tract or prostate gland,
  2. no fever and
  3. no abnormality of their urinalysis!

A national survey conducted in the 1990's demonstrated that most doctors do not perform specialized localization cultures to prove or disprove prostate infection. This would be excusable in light of the very well accepted and widely published data showing that localization cultures have only a 5-7% yield. However, the same survey revealed that most doctors will still choose antibiotics as treatment of choice for these patients. Unfortunately, this antibiotic over use and co-dependency still exists. And it is even more disappointing as we are facing a general world crisis of antibiotic resistance in all medical specialties.

The causes and treatments for pelvic pain in men, still erroneously referred to as prostatitis, can be discovered by means of a thorough history exploring risk factors, orthopedic, colorectal, neurological, and psychosocial contributors, as well as urological concerns. A comprehensive physical examination would culminate in methodical evaluation of areas or organ systems elucidated from the history. These might include spinal mechanical examination, peripheral nerve testing by careful palpation and dermatomal mapping, muscle texture and Myofascial trigger points, Core muscle evaluation and both external and internal evaluation of the pelvis, anorectal anatomy, genitals, nerves and muscles.

I firmly believe that a thoughtful and compassionate approach to patients with pelvic/genital pain syndromes provides phase one of therapy. It is not surprising to hear patients express how much better they feel after their initial evaluations. Validation, authority and reassurance are a foundation to long term management, and help to immediately assuage despair and catastrophic thinking, which are often associated with the condition and have been proven to be exacerbating factors.

As I explained to my partner, when we met 10 years ago, this condition calls upon physicians to be genuine healers and not just technicians. Most of our patients can't be diagnosed nor "fixed" by means of a high tech test or surgery, much less an antibiotic, prostate-centric drug or urological procedure. Typically, a non-urological approach is required.

As stated in the NIH prostatitis consensus statement in 1996, Category 3 Chronic Prostatitis/Chronic Pelvic Pain Syndrome has never been proven to be caused by infection nor to be caused by a malady of the prostate gland. And yet, instead of a thoughtful interview and methodical physical examination, many patients are still subjected to unnecessary x-rays, invasive diagnostic procedures and lengthy courses of antibiotics.

Avoiding the empiric use of antibiotics and promoting thorough evaluation and re-evaluation of patients will help convince physicians and their patients about the broader, and often non-prostatic, causes of prostatitis symptoms. This in turn will lead to more appropriate individualized treatment strategies.