Dr. med. Dirk Manski

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Symptoms and Diagnosis of Chronic Prostatitis and CPPS

Review literature: (Nickel et al, 2003) (Schaeffer et al, 2002). EAU guidelines (Fall et al, 2010).

Signs and Symptoms of Chronic Prostatitis and CPPS

The internationally validated questionnaire (NIH-CPSI: chronic prostatitis symptom index) from the NIH Chronic Prostatitis Collaborative Research Network reflects well the broad clinical spectrum of symptoms:

Pain or discomfort:

Pain localization:

1. In the last week, have you experienced any pain or discomfort in the following areas? (1 point for each localization):

Painful urination or ejaculation:

2. In the last week, have you experienced:

Pain frequency:

3. How often have you had pain or discomfort in any of these areas over the last week:

Pain intensity:

4. Which number best describes your average pain or discomfort on the days you had it, over the last week? (Numeric pain rating scale from 0–10 points)

Micturition (urination):

Residual urine:

5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week?


6. How often have you had to urinate again less than two hours after you finished urinating, over the last week?

Quality of life (Impact of symptoms):

7. How much have your symptoms kept you from doing the things you would usually do, over the last week?

8. How often did you think about your symptoms, over the last week?

9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?

Interpretation von the NIH-CPSI

The scores of the pain questions (1–4), micturition questions (5–6) and quality of life questions (7–9) are calculated and documented separately.

Diagnostic Work-Up of Chronic Prostatitis and CPPS

Basic Work-Up

Medical and urological history:

Urination? Sexual disorders? General symptoms? Urological operations?

NIH-CPSI questionnaire:

Questionnaire (NIH-CPSI) for the assessment of symptom severity (see above).

Physical Examination

Physical examination with rectal exam. The prostate examination should take place after the initial urine collection.


The uroflow test serves as a screening test for voiding dysfunctions.

Sonography of the bladder:

Residual urine? Bladder stones? Prostate size?

Prostate-specific antigen (PSA):

A PSA-Test should be done to rule out prostate cancer, if indicated from age and comorbidities.

Lower urinary tract culture tests:

In order to identify a chronic bacterial prostatitis, four separate specimens (4-glass test) are collected and examined microbiologically with urine sediment microscopy and culture. Bacterial prostatitis is diagnosed if there is a 10-fold increase in bacteria between VB1/2 and EPS/VB3:

  1. The first 10 ml of urine (urethral specimen, VB1)
  2. Midstream urine (bladder specimen, VB2)
  3. Expressed prostate secret (EPS)
  4. The first 10 ml of urine after prostatic massage (prostate specimen VB3)

Due to the high costs and effort, a two-glass test has become standard, recent studies have confirmed the equivalence:

  1. Midstream urine (bladder specimen)
  2. The first 10 ml of urine after prostatic massage (prostate specimen)

Advanced Work-Up

Transrectal ultrasound (TRUS):

There are no specific signs of chronic prostatitis in transrectal ultrasound imaging. Variably associated with chronic prostatitis are inhomogeneities of the prostate echo, prostate calcifications, dilatation of the venous plexus, prostatic stones and dilatation of the seminal vesicles. Furthermore, TRUS is important for differential diagnosis (abscess, cysts and seminal vesicle diseases). A prostate biopsy is only indicated, if a suspicious digital rectal examination or an elevated PSA is present.

Repeated and extended lower urinary tract culture tests:

A 2-Glass test is repeated, possibly including a sperm culture or urethral swab culture.

Urodynamic investigation:

Urodynamics are helpful for differential diagnosis of voiding dysfunction. Chronic prostatitis or chronic pelvic pain syndrome are often associated with voiding symptoms. Possible findings are: bladder neck obstruction, detrusor-sphincter dyssynergia, urethral obstruction, overactive bladder.


Cystoscopy is indicated for the differential diagnosis of voiding dysfunction.

Experimental Diagnostics:

The following parameters and markers were investigated, but could not establish themselves in clinical practice: antibodies against gram-negative bacteria, IgA and IgG in the prostatic, various cytokines (interleukins, TNF-alpha) and the zinc concentration in the seminal plasma.

Differential Diagnosis of Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


Fall, M.; Baranowski, A. P.; Elneil, S.; Engeler, D.; Hughes, J.; Messelink, E. J.; Oberpenning, F.; de C Williams, A. C. u.a.
EAU guidelines on chronic pelvic pain.
Eur Urol, 2010, 57, 35-48

Nickel 2003 NICKEL, J. C.:
Recommendations for the evaluation of patients with prostatitis.
In: World J Urol
21 (2003), Nr. 2, S. 75–81

Schaeffer u.a. 2002 SCHAEFFER, A. J. ; DATTA, N. S. ; FOWLER, Jr. ; KRIEGER, J. N. ; LITWIN, M. S. ; NADLER, R. B. ; NICKEL, J. C. ; PONTARI, M. A. ; SHOSKES, D. A. ; ZEITLIN, S. I. ; HART, C.:
Overview summary statement. Diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
In: Urology
60 (2002), Nr. 6 Suppl, S. 1–4

  Deutsche Version: Symptome und Diagnose der chronischen Prostatitis