The prostate is a small gland, around the size of a walnut, that’s only found in men. It lies just underneath the bladder and surrounds the top part of the urethra. It makes fluid that protects and feeds sperm, which is around 1/3 of the fluid ejaculated at orgasm. If the prostate gland becomes inflamed, this is called Prostatitis.
A short term infection is called Acute Prostatis. This usually gets better after a few days, or possibly weeks, of antibiotics.
A longer term infection is called Chronic Prostatitis. This is much less common – maybe 10% of prostatitis cases.
Over the years, pelvic pain in men has consistently been blamed on Chronic Prostatitis. While Prostatitis can cause pelvic pain, and may have been present at some stage, we now know that Chronic Prostatitis is present in only a small number of men with long term pelvic pain.
How is Prostatitis diagnosed?
Men with prostatitis due to infection will have bacteria found in their urine or prostatic secretions – so tests for infection should be positive. If these tests are negative, and he was not using antibiotics at the time of testing, then prostatitis is much less likely. It is important to check for prostatitis, but to recognise that there are other causes of pelvic pain in men too.
If it isn’t Prostatitis, what else could be causing the pain?
For reasons that are not well understood, some men start with pain in one organ then develop pain from overly tight pelvic muscles and sensitised nerves. This results in the situation now called Chronic Pelvic Pain Syndrome (CPPS). This condition is poorly understood and often not recognised because it doesn’t show on scans or at an operation. Unfortunately, many men are treated with antibiotics for ‘Chronic Prostatitis’ for a long time when no infection is present.
There are many conditions that can initiate CPPS, and may different symptoms. Typically, the pain is present on most days for at least 3 months. Affected men might complain of any of the following symptoms:
- Pelvic pain – in the perineum, testicles, tip of penis, abdomen (pubic / bladder area)
– Constant burning pain in the penis
– Tenderness – pain on touch, sitting, walking or wearing tight underwear
– Arthralgia/ myalgia (joint/ muscle pain including back pain) - Bladder troubles
– Dysuria (painful urination)
– Frequency or urgency passing urine (possible Painful Bladder Syndrome) - Bowel troubles
– Irritable Bowel Syndrome (constipation, diarrhoea, bowel pain)
– Food intolerances - Sexual difficulties
– Low libido (reduced sex drive)
– Post-ejaculatory pain (pain after ejaculating)
– Pain on erection or erectile difficulties
“38 year old male: I had pelvic pain for four years! My private regions were so sensitive to touch that when the doctor examined my rectum it was like murder! At first I started having urinary frequency where I had to go to the toilet every 30 minutes. Then it started hurting every time I passed bowel motions. It was difficult to have sex because when I had an erection or ejacualated. Even sitting down or walking with hard shoes was unbearable and I had to wear loose fitting underwear. After seeing multiple doctors and urologists and having a dozen investigations come back normal, everyone said there was nothing wrong with me.”
How does Chronic Pelvic Pain Syndrome develop?
There’s a lot still to learn about CPPS. In some men, stressors or anxiety result in excessive pelvic muscle tension (causing pain) and excessive pain signalling via the pelvic nerves (increased pain sensitivity).
Pelvic Floor muscles work best when they can tighten and relax normally. They control bladder and bowel motions by tightening to stop urine or stool passing, and then relax to allow us to urinate or defecate (open your bowels) when appropriate. When these muscles are constantly tensed, shortened and tight, they start hurting and can go into spasm. Trying to pass urine or a bowel action past painful tight pelvic muscles that can’t relax normally is extremely painful.
Anyone who has had pain of some kind on most days for more than 3-6 months will develop changes in the spinal cord that result in pain sensitivity. With these changes come other symptoms such as anxiety, low mood, nausea, dizziness, fatigue and poor sleep.
How is CPPS managed?
Just as in pain in women, there are three aspects to pelvic pain management:
- Manage the original cause of the pain, if this can be determined. This is usually a problem with one of the pelvic organs, although sometimes no cause is obvious.
- Reduce pelvic muscle tension and spasm. View the other pages on this site for stretches, information, access to a pelvic muscle audio download and correct exercise.
- Treat the pain sensitisation. This can improve with increased understanding of the condition, reducing fear, determining the pain aggravators, getting good sleep, relaxation, exercise, and the use of neuropathic medications such as amitriptyline, duloxetine or pregabalin/gabapentin. It is important to avoid opiate medications such as oxycodone as opioids will make the pain worse if taken regularly
Resources available from our website https://www.pelvicpain.org.au/online-shop/ include the Mens Pelvic Muscle Relaxation Audio prepared for men just like you by Dr Patricia Neumann; The Explain the Pain Handbook Protectometer Workbook to help you determine your pain aggravators; and Peter Dornan’s book A Musculoskeletal Approach for Treatment for causes of pelvic pain.
Are my pain troubles the same ones that many older men complain of?
Generally, no. As men age, the prostate enlarges. This narrows the urethra making it harder to pass urine. They feel the need to pass urine more frequently, and the urine stream is slower. It does not mean that the prostate is inflamed (prostatitis) or that they have CPPS. Men with pelvic pain may have a slow urine stream too, but this is generally because the pelvic floor muscles are tight or in spasm. When the pelvic muscles learn to relax, the urine stream improves.
