Case of the Month #38: Chronic pelvic pain by Dr Kerry Bosworth

Published: 02/05/2024

Discussion

Chronic abdominopelvic pain is common and often debilitating1. Chronic pelvic pain syndromes can be classified using the taxonomy described the EAU Guidelines on Chronic Pelvic Pain2.

Chronic prostatitis is defined as at least 3 months of urogenital pain which is often associated with lower urinary tract symptoms and sexual dysfunction3. In 90% of cases, there is no proven bacterial infection. There is a lifetime prevalence of 2-8% in men with incidence increasing with age.

Differential diagnoses for chronic prostatitis include:

  • Urinary tract infection
  • Epididymo-orchitis
  • Epididymitis
  • Benign prostatic hypertrophy
  • Cancer of the prostate, bladder or colon
  • Urethral stricture
  • Obstructive calculus or foreign body in urinary tract
  • Secondary to sexually transmitted infection
  • Secondary to immunocompromise

Initial management by the GP should follow the NICE CG97 guidelines4. A single course of antibiotics can be considered if symptoms have been present for less than 6 months. A repeated course of antibiotic therapy should only be offered if a bacterial cause is confirmed or there is a partial response to the first course. Trial of an alpha-blocker may be beneficial. Referral to a urologist is indicated if symptoms are severe or there is diagnostic uncertainty. 

The Prostate Cancer UK consensus guidelines on chronic prostatitis and chronic pelvic pain syndrome5 have a treatment algorithm for persisting symptoms with assessment of pain, psychosocial, urinary and sexual symptoms.

Consideration of neuropathic agents may already have occurred before the patient is reviewed in pain clinic. If not, treatment should follow the NICE CG173 guidelines6. Short courses of NSAIDs may be helpful for pain flares. Opioids should be avoided.

Peripheral nerve blocks, including pudendal, ilio-inguinal, ilio-hypogastric and genitofemoral blocks, may be helpful to inhibit ascending input. Visceral pain can be targeted at the ganglion of impar and superior hypogastric plexus7.

Neuromodulation with spinal cord or sacral nerve root stimulation may be considered. 

Pelvic floor exercises and acupuncture can also be helpful as part of a multidisciplinary approach.