Changes

June 2024 — reviewed. A literature search was conducted in June 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

Update

Goals

To support primary healthcare professionals to:

• Be aware of when to suspect chronic prostatitis.
• Accurately assess pain, urinary symptoms, and quality of life.
• Provide advice, support, and treatment to men with suspected chronic prostatitis.
• Refer when appropriate to a urologist or specialist in chronic pain management.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

What is it?

• Chronic prostatitis is defined as at least 3 months of urogenital pain, which may be perineal, suprapubic, inguinal, rectal, testicular, or penile and is often associated with lower urinary tract symptoms (such as dysuria, frequency, hesitancy, and urgency), and sexual dysfunction (erectile dysfunction, painful ejaculation, or postcoital pelvic discomfort).
• Chronic prostatitis can be further classified as:
  • Chronic prostatitis/chronic pelvic pain syndrome/primary prostate pain syndrome (CP/CPPS/PPPS) (sometimes also referred to as abacterial prostatitis) — accounts for over 90% of men with chronic prostatitis (there is no proven bacterial infection).
  • Chronic bacterial prostatitis (CBP) — less than 10% of men with chronic prostatitis. 

[Zhang, 2020; BMJ Best Practice, 2023; EAU, 2024a]

What causes chronic prostatitis?

• Chronic prostatitis/chronic pelvic pain syndrome/primary prostate pain syndrome (CP/CPPS/PPPS)
  • The exact cause of chronic prostatitis is unknown but is thought to be multifactorial. Infection and chronic inflammation have been implicated as possible triggers and there is some evidence that the pain associated with CP/CPPS/PPPS may be a centralised neuropathic pain state [Rees, 2014; EAU, 2024a]
  • Factors associated with chronic prostatitis (either as an underlying cause or possible effect) include; previous pelvic infection, psychosocial factors, immune dysfunction, pelvic floor muscular dysfunction,  intra-prostatic urinary reflux and adrenocortical hormone imbalances [BMJ Best Practice, 2023].
• Chronic bacterial prostatitis (CBP)
  • CBP is thought to be caused by [Pendegast, 2024]:
    • An ascending urethral infection, or
    • Lymphogenous spread of rectal bacteria, or
    • Undertreated acute bacterial prostatitis, or
    • Recurrent urinary tract infection with prostatic reflux.
  • A wide range of pathogens are thought to be responsible for infection, including Escherichia coli (most common), Klebsiella species, Proteus mirabilis  — comprising 50-80% of infections, Enterococcus faecalis, and Pseudomonas aeruginosa [Lam, 2023; Pendegast, 2024]. 
  • Men who have HIV or who are immunocompromised are more susceptible to prostate infection with Mycoplasma tuberculosis, Candida species, Coccidioides immitis, Blastomyces dermatitidis, and Histoplasma capsulatum [Kanani, 2020; EAU, 2024b].
  • Rarely, CBP can occur secondary to a sexually transmitted infection such as chlamydia, gonorrhoea or trichomoniasis [Sherrard, 2022].

How common is it?

• Primary prostate pain is a common symptom worldwide.
  • In the United States it represents 1% of all primary care consultations and 8% of urology outpatient appointments [BMJ Best Practice, 2023]
  • It is the most common category of prostatitis, representing 90-95% of all cases with prostatitis symptoms [BMJ Best Practice, 2023; Healy, 2023].
  • It most often occurs in those aged 35-50 years with no difference in ethnic representation [Pendegast, 2024].
• Prostatitis-like symptoms have a lifetime prevalence of 8.2-14.2% in men worldwide [BMJ Best Practice, 2023]. 
• The risk of chronic prostatitis is thought to increase with age. 
  • Middle-aged men have a three-fold increased risk of having prostatitis, but older men more commonly have benign prostatic hypertrophy or prostate cancer [EAU, 2024a].

What is the prognosis?

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

• In a study of the lifetime risk of CPPS occurrence in Chinese middle-aged males and the prognosis of CPPS with and without treatment (n = 4135), 1091 men had been diagnosed with CPPS, 843 (77.3%) had received treatment for their associated symptoms, and 248 (22.7%) had not received treatment. 
  • Of those who had received treatment, 422 (50.1%) reported that their symptoms had been relieved, and 421 (49.9%) reported that their symptoms had either worsened or not changed.
  • Of those who had not received treatment, 142 (57.3%) reported spontaneous symptom resolution, while 106 (42.7%) reported that their symptoms were unchanged or worse [Zhang, 2019].  However, there are limitations with this study including the following:
    • The severity of symptoms could not be measured using the National Institutes of Health Chronic Prostatitis Symptom Index.
    • Information about CPPS symptoms experienced, and whether they were relieved, unchanged, or worse, was collected using a questionnaire, and was self-reported by the participants.
    • No objective measures were included.
    • Chart reviews and laboratory examinations (including expressed prostatic secretions) were not conducted.
• A 2019 Cochrane review of 99 studies involving 9119 men using 16 different types of treatment found that most studies were of low quality [Franco, 2019]. There was evidence that antibiotics, alpha blockers, anti-inflammatories, phytotherapy, intraprostatic botulinum toxin A injection, and traditional Chinese medicine provided short-term (up to 12 months) relief. All except alpha blockers had low risk of adverse effects.
• Patient reported outcomes are highly variable [Pendegast, 2024].
• Symptoms may wax and wane as seen in other chronic pain disorders, but some people may have symptoms for many years [BMJ Best Practice, 2023].

Chronic bacterial prostatitis (CBP)

• Bacterial eradication rates reported in clinical trials, following treatment with antibiotics are [Rees, 2014]:
  • Ciprofloxacin — up to 77%.
  • Levofloxacin — up to 75%.
  • Azithromycin — up to 80%.
  • Doxycycline — up to 77%.
  • Clarithromycin — up to 80%.
• These trials also reported significant symptom improvement after treatment, however, only two trials used the validated NIH-CPSI tool to measure clinical outcomes.
• More recent evidence suggests 6-month cure rates of 60-70% if fluoroquinolones are prescribed for 4 weeks or longer [Kanani, 2020].
• Bacterial eradication does not always guarantee freedom from symptoms and approximately 10% of patients will progress to have a chronic prostatic pain syndrome [Pendegast, 2024].

What are the complications?

• Chronic prostatitis is associated with [Rees, 2014]:
  • A greatly reduced quality of life — psychological distress and difficulties in coping with employment, activities of daily living and social relationships [BMJ Best Practice, 2023].
  • People prescribed opioids for chronic pain are at increased risk of developing medication overuse disorder [Dowell, 2022].
  • Depression, anxiety, and panic disorder — small case-control studies have found that these conditions are more common in men with chronic prostatitis [Rees, 2014].

When to suspect chronic prostatitis

• Suspect chronic prostatitis in men who present with pain or discomfort (for at least 3 months) in the: 
  • Perineum (the most commonly reported location for pain).
  • Inguinal, or suprapubic region.
  • Scrotum, testis, or penis (especially pain at the penile tip).
  • Lower back, abdomen, or rectum.
• Symptoms that may also be present include:
  • Lower urinary tract symptoms (LUTS): 
    • Voiding symptoms (for example, straining, hesitancy, and weak stream).
    • Storage symptoms (for example, urinary urgency, frequency, and nocturia).
    • Dysuria.
  • Sexual dysfunction symptoms:
    • Erectile dysfunction.
    • Pain or discomfort during or after ejaculation. 
    • Premature ejaculation.
    • Decreased libido.
  • Psychosocial symptoms: 
    • Anxiety or stress.
    • Depression.
    • Cognitive/behavioural consequences.
    • Decreased quality of life.
  • Other symptoms:
    • Haematospermia.
    • Neuropathic pain.
• If the man has LUTS, perineal or suprapubic pain and a feverish illness of sudden onset (with or without rigors, arthralgia, or myalgia), these may indicate the presence of acute bacterial prostatitis which requires urgent management. For more information, see the CKS topic on Prostatitis - acute.
  • Unlike men with acute bacterial prostatitis, men with chronic bacterial prostatitis (CBP) or chronic prostatitis/chronic pelvic pain syndrome/primary prostate pain syndrome (CP/CPPS/PPPS) are not systemically unwell.

How do I assess someone with chronic prostatitis?

• A diagnosis of chronic prostatitis is made based on the man's history and the exclusion of other conditions that may be causing symptoms.
• Take a detailed history and ask about: 
  • Recurrent or relapsing urinary tract infections — this may indicate the presence of chronic bacterial prostatitis.
  • A history of acute prostatitis — about 10% of men with acute bacterial prostatitis go on to develop chronic bacterial prostatitis, and a further 10% develop chronic pelvic pain syndrome. 
  • Sexual history. 
  • Medication history.
  • Onset, severity and duration of symptoms:
    • Urinary symptoms — straining, hesitancy, frequency, urgency. 
    • Pain symptoms — any association with urination or ejaculation, for example. 
    • Sexual dysfunction symptoms — decreased libido, erectile dysfunction, haematospermia. For more information, see the CKS topics on Erectile dysfunction and Haematospermia.
    • Psychosocial symptoms — anxiety, stress, depression. For more information, see the CKS topics on Depression and Generalized anxiety disorder.
  • Their concerns — about cancer, infertility, or symptom progression. 
  • Irritable bowel syndrome (IBS) — present in 22–31% of men with chronic prostatitis and can increase pain severity. 
    • For information on how to assess and manage IBS, see the CKS topic on Irritable bowel syndrome.
• Assess the severity and impact of symptoms using the National Institutes of Health Chronic Prostatitis Symptom Index, NIH-CPSI. 
  • This self-administered questionnaire asks nine questions that are scored in three domains: pain, urinary symptoms, and the impact on quality of life. 
• Assess the severity of lower urinary tract symptoms using the International Prostate Symptom Score (pdf) (IPSS), if appropriate
  • For more information, see the CKS topic on LUTS in men.
• Examine the:
  • Abdomen to exclude other causes of abdominal pain and demonstrate the site of tenderness — the bladder may be palpable if there is urinary retention.
  • Costovertebral angle. 
  • Suprapubic area. 
  • External genitalia — in men with scrotal pain, perform gentle palpation of each component of the scrotum to search for masses and painful spots. The penis and urethra may be palpated in a similar way. 
  • Perineum. 
  • Pelvic floor and prostate — perform a digital rectal examination (DRE). The prostate may be enlarged, tender, or normal.
    • Do not perform a prostatic massage to obtain prostatic secretions to test for infection in the prostate.
• Consider a general musculoskeletal and neurological examination. 

Which investigations should I arrange?

• Dipstick the urine to check for blood, glucose, protein, leucocytes, and nitrite, and collect a mid-stream specimen of urine (MSU) to send for culture and sensitivity to confirm or exclude the presence of a urinary tract infection. For more information, see the CKS topic on Urinary tract infection (lower) - men. 
  • A positive urine culture indicates the presence of chronic bacterial prostatitis; however, unless an acute UTI is present, an MSU may be normal in men with chronic bacterial prostatitis. Therefore, it is also advisable to check previous MSU reports.
• Perform a sexually transmitted infection (STI) screen (first pass urine for gonorrhoea/chlamydia NAAT [Nucleic Acid Amplification Test]), and consider sending a urethral swab for trichomoniasis, particularly in sexually active men younger than 35 years and men with multiple sexual partners or recent partner change.
  • For more information, see the CKS topics on Gonorrhoea, Chlamydia - uncomplicated genital, and Trichomoniasis.
• Consider a prostate-specific antigen (PSA) blood test to rule out prostate cancer only after discussing the indications for the test, the interpretation and implications of the result, and considering with the man whether an abnormal result would affect further management choices.
  • Provide sufficient time for the man to decide whether to have the test.
  • For more information, see the Investigations section in the CKS topic on LUTS in men, and the section on PSA testing in the CKS topic on Prostate cancer.  
• Assess renal function by measuring serum creatinine and estimated glomerular filtration rate (eGFR) if clinically indicated, for example, if the man has:
  • Recurrent urinary tract infection.
  • Chronic urinary retention.
  • A history of renal stones.
    • For more information, see the CKS topics on Chronic kidney disease and Acute kidney injury.

What else might it be?

• Conditions which present with similar features to chronic prostatitis include:
  • Acute prostatitis — suspect if the man presents with sudden onset of fever, irritative urinary symptoms (dysuria, frequency, urgency), perineal or suprapubic pain, pain on ejaculation, or pain during defecation. For more information, see the CKS topic on Prostatitis - acute.
  • Benign prostatic hyperplasia (BPH) — for more information, see the CKS topic on LUTS in men. 
  • Cancer of the prostate, bladder, or colon — for more information, see the CKS topics on Prostate cancer, Urological cancers - recognition and referral, and Gastrointestinal tract (lower) cancers - recognition and referral. 
  • Epididymitis — suspect when there is scrotal pain, and the epididymis is oedematous and tender.
  • Irritable bowel syndrome. 
  • Neurogenic bladder. 
  • Obstructive calculus in the urinary tract or a foreign body.
  • Pelvic floor dysfunction, pelvic injury or trauma. 
  • Prostatic abscess — suspect if the prostate is fluctuant on gentle palpation or fever persists, particularly in men who are immunocompromised, have diabetes mellitus, or have had recent instrumentation of the urinary tract.
  • Pudendal neuralgia — pain is usually localized to the perineum, rectum, and area immediately medial and anterior to the ischial tuberosities. Pain is usually worse on sitting and relieved when standing.
  • Pyelonephritis — suspect when there is loin pain and/or fever. For more information, see the CKS topic on Pyelonephritis - acute.
  • Urethral stricture — suspect if there is reduced urine flow, straining, spraying urine or a double stream, or dysuria.
  • Urethritis — suspect when there is dysuria, frequency, or urethral discharge, if the man is sexually active or at risk of a sexually transmitted infection, or if symptoms persist despite treatment for a presumed UTI. For more information, see the CKS topic on Urethritis - male.
  • Urinary tract infection — suspect if there is dysuria, frequency, urgency, nocturia, and suprapubic discomfort. For more information, see the CKS topic on Urinary tract infection (lower) - men. 

Scenario: Managing chronic prostatitis

From age 16 years onwards (Male).

Paracetamol and NSAIDs

For prescribing information on paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.

Alpha-blockers

For prescribing information on alpha-blockers see the prescribing information section on Alpha-blockers in the CKS topic on LUTS in men.

Trimethoprim

Azithromycin

Search strategy

Scope of search

A literature search was conducted for guidelines and ystematic reviews on primary care management of chronic prostatitis.

Search dates

August 2019 - June 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 28th August 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases.

S5    S1 OR S2 OR S3 OR S4 
S4    AB prostate pain syndrome OR TI prostate pain syndrome 
S3    AB (chronic pelvic pain syndrome) OR TI (chronic pelvic pain syndrome) 
S2    AB prostatitis OR TI prostatitis 
S1    (MH "Prostatitis") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.