Clinical Notes : Urology

103. Chronic Non-Bacterial Prostatitis (Chronic Pelvic Pain Syndrome)


NIH consensus definition and classification of prostatitis (1)

Prevalence :

International studies show approximately

  • Bacterial prostatitis (acute and chronic) : 10%

  • Nonbacterial prostatitis (Chronic Pelvic Pain Syndrome)  : 90%


Etiology of Chronic Non-Bacterial Prostatitis (Chronic Pelvic Pain Syndrome) :

Chronic nonbacterial prostatitis (also known as chronic pelvic pain syndrome) is characterized by episodes of pain and discomfort that come and go unpredictably.

It may also involve inflammation and difficulties with urination.

It is most common of the four categories of prostatitis, accounting for about 90% of all cases.


CPPS presents with symptoms similar to Benign Prostatic Hypertrophy

Differentiating CPPS from BPH  (2)


The typical patient is a young to middle-aged man with variable symptoms of

chronic, irritative, and/or obstructive voiding accompanied by moderate to severe pain in the pelvis, lower back, perineum, and/or genitalia.

Erectile dysfunction is the symptom that initially brings many men to seek medical attention.


In the OOH setting, Chronic Bacterial Prostatitis can be diagnosed by :

  • Primarily, history and presentation

  • ​Digital rectal examination (DRE)

    • In Chronic non-bacterial Prostatitis (Chronic Pelvic Pain Syndrome),the prostate is moderately to severely tender, and slightly congested or boggy.

    • In Chronic Bacterial Prostatitis, the prostate may be normal in size and consistency or may seem slightly boggy.

    • In Acute Bacterial Prostatitis, the prostate is very tender, warm, swollen, and boggy.

  • Urine dipstick  to evaluate for signs of infection and hematuria. 


A urine sample should be collected for urine culture.​


Further testing to exclude differential diagnoses, is best left for the GP follow-up or Urology referral, and includes :​semen culture

  • PSA testing

  • imaging studies

The list of differential diagnoses to consider is extensive, warranting referral of all cases of CPPS to Urology for investigation :

  • Inflammatory bowel disease

  • Nonbacterial prostatitis

  • Acute bacterial prostatitis

  • Prostate cancer

  • Tuberculosis of the genitourinary system

  • Urethral cancer

  • Urethral diverticula

  • Urethritis

  • Tuberculous prostatitis

  • Sexually transmitted diseases

  • Congenital or acquired abnormalities of the urethra

  • Prostatic cyst

  • Prostatic abscess

  • Seminal vesiculitis

  • Myofascial pain syndrome

  • Reactive arthritis

  • Pelvic joint dysfunction

  • Coccydynia

  • Chronic urethritis

  • Interstitial cystitis

  • Carcinoma in situ of the urinary bladder


Chronic pelvic pain syndrome (CPPS) is a well-established condition that is notorious for the pain and disability it causes.

Treating CPPS challenges even the most compassionate physician. Patients are often understandably tense, wary, and defensive, and most of them will have already encountered frustration and rejection under the care of several unsympathetic physicians.

These patients often approach new physicians with an off-putting combination of unrealistic hopes for a cure and suspicion related to past diagnosis and treatment failures.

The patient and OOH physician must agree on a workable relationship at the outset of treatment.

In the OOH setting this includes :

  • acute management of pain and stress

  • reassurance that CPPS is 

    • a real physical condition, not an imagined one

    • not cancer or life-threatening

    • not a venereal disease, and not contagious

  • referral to GP for follow up and for referral on to Urolgist for investigation


1. Krieger JN, Nyberg L Jr, Nickel JC.

NIH consensus definition and classification of prostatitis. 

JAMA. 1999. 282:236-7. 


2. McNaughton Collins M, Stafford RS, Leary MP, Barry MJ.

Distinguishing chronic prostatitis and benign prostatic hyperplasia symptoms: results of a national survey of physician visits. Urology. 1999;53:921.


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