Chronic Pelvic Pain Syndrome and How it Can Present in Men? (CPPS in men) 

Pelvic pain in men might be more common than you think. It’s estimated that 8-12% of men will suffer with CPPS it at some point, so why is this not spoken of?

There are many misconceptions when it comes to pelvic pain, the most common I’ve heard is it only affects women who are either pregnant, or postpartum, this however, is false. Pelvic pain can happen to anyone with a pelvis, both women and men can suffer it. The medical community has made a lot of advances when it comes to dismissing this misconception, and now if a patient comes with pelvic pain, regardless of their sex, we know how to treat it.

The cause of pelvic pain in men can vary, it was most commonly known to be caused by prostatitis or inflammation of the prostate due to infection, as this diagnosis was the most common urologic diagnosis in men under 50, and this diagnosis can cause pelvic pain. Nowadays, we know that the cause of pelvic pain can and more often is not related to prostatitis, such as neuromuscular impairments, which means something is happening to their muscles, nerves or the tissue itself.

The National Institutes of Health classified Chronic Pelvic Pain Syndrome (CPPS) in men as follows:

• Chronic Pelvic Pain Syndrome I: formerly known as Acute Bacterial Prostatitis, defined as acute sudden pelvic pain, typically associated with fevers and other signs of infection as well as bacteria identified in urine or prostate secretions
• Chronic Pelvic Pain Syndrome II: formerly known as Chronic Bacterial Prostatitis, defined as recurrent or chronic pelvic pain, associated with  bacteria identified in urine or prostate secretions, usually in the absence of fevers or other signs of infection
• Chronic Pelvic Pain Syndrome III: formerly known as Non-Bacterial Prostatitis or Prostatodynia, defined as recurrent or chronic pelvic pain that is not associated with bacteria identified in urine or prostate secretions. CPPS III may be subdivided into type A, when inflammatory cells are found in urine or prostate secretions and type B, when inflammatory cells are NOT found in urine or prostate secretions
• Chronic Pelvic Pain Syndrome IV: presence of inflammatory cells in urine or prostate secretions in the absence of any symptoms

In clinical practice, CPPS III is the most common, and in my experience men have been over prescribed antibiotic therapy, even when there is no infection in place. In my clinical practice I have seen that the best prescription for CPPS III type B, specifically, is pelvic floor physical therapy, as we can directly treat the inflamed area. 

Symptoms of CPPS in men include:

They can present alone or in combination with each other.

• Pelvic pain: which can be burning, shooting, aching, and/or itching sensation in the lower abdomen, groin, buttocks, and/or inner thighs.
• Genital pain: this can present as pain in the scrotum, testicles, or general penile pain.
• Perineal and/or anal/rectal pain.
• Urinary dysfunction: this usually presents as urinary frequency, urgency, hesitancy, incomplete emptying, pain, and/or dribbling of the urine.
• Any bowel dysfunction, it can present with bloating, pain with bowel movements, constipation, incomplete emptying, gastrointestinal distress, if you are experiencing any of these symptoms, make sure to mention them to your primary care doctor as well as your physical therapist.
• Sexual dysfunction: it can present as erectile dysfunction, or pain before, during or after ejaculation.
• Pain with sitting, specially in the perineum or the “sit bones”.
• Pain with exercise, like squatting or heavy lifting. This can be present in daily life when these movements or lifting present.

These symptoms can be very disruptive to daily life, which is why it’s imperative that the patient see a pelvic floor physical therapist. I have seen many patients presenting with these symptoms, and the changes we are able to accomplish with physical therapy is outstanding, it’s all about reclaiming their life, their movements.

What can cause CPPS in men?

There are many causes of CPPS in men, so let’s name the most common ones:

• Excessive sitting: this can come from cycling, horseback riding, or with men in a sedentary lifestyle, doing jobs that require long periods of time sitting.
• Surgical trauma: surgeries such as inguinal hernia repairs, vasectomy, benign prostatic hyperplasia or BPH interventions.
• Orthopedic injuries or trauma: trauma to places such as the spine, knee, ankle, or other orthopedic pathologies, these can be a cause towards CPPS, even if it seems unlikely!
• Biomechanical or structural dysfunction: hip dysfunction, leg length discrepancy, sacroiliac dysfunction.
• It can present due to excessive exercise, or change to your exercise routine.
• Excessive and aggressive sexual activity and/or aggressive lengthening of the penis, also known as jelqing.
• Chronic constipation or straining with bowel movements.
• Chronic infections, this can be bacterial prostatitis, or sexually transmitted infections.

If you are still experiencing the before mentioned symptoms but can’t find a clear cause in this list, ask your pelvic pain physical therapist about it.

The best way to manage this condition is to consult with your urologist first, in order to rule out any pathology present within the prostate that must be treated medically before making the call to a pelvic floor physical therapist. If your urologist doesn’t medically find a cause for your symptoms, you should schedule an appointment for an evaluation with a licensed pelvic floor physical therapist.

A good way to manage your condition in your daily life, if you experience discomfort sitting and your job requires a lot of computer time or promotes a very sedentary lifestyle, you can get a standing desk, these are amazing and they can help manage your pain. If you, however, cannot get a standing desk, another good way to help your discomfort with sitting, a pressure relieving cushion is the way to go, these can minimize the compression of the pelvic floor structures, which will in turn help you relief the pain and continue with your daily life.

However, if you are experiencing increased discomfort with exercise, talk to your physical therapist, so they can walk you through modifications, and other types of exercises to add to your exercise program that will be helpful with your pain.

One of the things I like to suggest to my patients regardless of their diagnosis is the inclusion of mindfulness meditation, it’s an amazing practice that can help them with their pain management, the results are absolutely outstanding, if you want to read more about it, I have a blog post all about it, you can read it here.

CPPS in men can be incredibly challenging, both mentally and physically. I have seen many patients come in with this appointment being their last resort to help them manage their symptoms. There is hope, we will always find a solution to your particular case, as a successful treatment is achieved through a combination of therapies, which is why having a team of providers is the best option to help your symptoms. 

A team can include a urologist, a pain management specialist, mental health specialist, and most importantly, a pelvic floor physical therapist. The combination of these therapies will lead to managing and reducing the symptoms.

If you wish to set up an appointment with me, head over to this link!