Son’s chronic pelvic-pain syndrome is a mystery

Dear Dr. Roach: My 46-year-old son has suffered for nearly five years with what seems to be chronic pelvic-pain syndrome.

Being the mother, I am involved only to a limited extent, as my son, of course, is embarrassed to go into detail with me.

However, after he read an article delineating the symptoms of CPPS, he said: “Yes, that’s exactly it!” He has sought medical help, but after two colonoscopies and several prostate exams, he has been told only variations of “We can’t find anything” and “There’s nothing we can do for you.”

Articles I’ve read state that millions of men suffer from this worldwide, and it is the third most common reason men visit a urologist. Can you shed any light on this painful, mysterious condition and outline what steps he might take next? V.P.

I’ve written several times about chronic pelvic pain in women, but this is the first question I’ve received on chronic pelvic pain in men.

It is, indeed, far more common than many, including me, may have thought: 10 per cent overall, and about one man in eight (13 per cent) in your son’s age group, the most common group to have this symptom. As men get older, the condition decreases in frequency. The definition of CPPS is “chronic pelvic pain in at least three of the six preceding months, in absence of other identifying causes.”

As such, it’s unclear what is causing this condition, or even if the prostate is the source of the problem. There is some evidence to suggest that it is. Prostate inflammation often is found, but men can have symptoms with or without inflammation, and with or without evidence of bacterial infection. Most men have urinary symptoms as well, including increased urinary frequency and discomfort when voiding. Some men also have pain or discomfort during sexual activity. Symptoms are often ascribed to chronic prostate infection, but antibiotics may not be helpful in treatment, and unlike in most cases of chronic bacterial prostatitis, there is no tenderness of the prostate.

The severity of CPPS can be measured by a tool that is available online at upointmd.com/ NIHCPSIEnglish.pdf. The scores range from 0-43. The mean score for someone with CPPS is about 20. He can fill out this form and take it to his urologist.

No treatment has been shown to alleviate symptoms in all men. However, there are several treatments that are effective in some, and combinations of treatments may be effective in the majority of men.

Most experts will try a course of antibiotics, but if it isn’t effective, it should not be repeated. Medications such as tamsulosin (Flomax) are helpful in some, as is the prostate medicine dutasteride (Avodart). Cognitive-behavioural therapy is very helpful for some men. Other medications that sometimes are tried include steroids, anti-inflammatories and medications for chronic pain, such as gabapentin (Neurontin).

One study suggested that there is some benefit from acupuncture and myofascial trigger point release by a pelvic-floor physical therapist.

Less-common therapies with some evidence for benefit include botulinum toxin (Botox) injection, heat therapy and shockwaves to the bladder. Finding a specialist in chronic pelvic pain for men would be ideal. Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Email questions to ToYourGoodHealth @med.cornell.edu.