Dr. med. Dirk Manski

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Symptoms and Diagnosis of Chronic Pelvic Pain Syndrome

Signs and Symptoms of Chronic Pelvic Pain Syndrome

The classification into UPOINT(S) domains enables a structured multimodal therapy, see table UPOINT(S) domains.

Prostate pain syndrome:

Pain perception in the prostate area with a painful rectal examination, painful ejaculation, and pain radiation to the perineum, rectum, testis, penis, and lower abdomen.

Bladder pain syndrome:

Suprapubic pain and painful bladder filling; pain may radiate to the perineum, rectum, testis, penis, and lower abdomen. Micturition may partly relieve the pain; pollakiuria and nocturia are common.

Urethral pain syndrome:

Urethral pain during micturition, urge symptoms, pollakiuria, and dyspareunia.

Testicular pain syndrome:

Pain perception in the testicle or epididymis. Chronic testicular or genital pain after vasectomy is classified as post-vasectomy pain syndrome.

Pudendus pain syndrome:

unilateral neuropathic pain in the area supplied by the pudendal nerve.

Sexual dysfunction:

erectile dysfunction, decreased libido, premature or delayed ejaculation, painful ejaculation.

Association with other diseases:

fibromyalgia, irritable bowel syndrome, depression, anxiety disorders, addictions, migraine, teeth grinding.

Classification of clinical phenotypes and therapeutic options in CPPS according to UPOINT(S) domains: The severity of the disease increases with the number of domains affected. The classification according to UPOINT(S) allows for a structured multimodal therapy (Shoskes et al., 2009).
Domain Symptoms Treatment options
U (Urinary) Obstructive and irritative micturition symptoms Alpha blocker, 5α-reductase inhibitors, anticholinergics.
P (Psychosocial) Depression, anxiety, helplessness Psychotherapy, antidepressants.
O (Organ specific) See section signs and symptoms See section Treatment.
I (Infection) Dysuria, leukocyturia, urethral discharge Antibiotics if there is evidence of significant infection.
N (Neurologic or systemic) Fibromyalgia, irritable bowel syndrome, chronic pain in other regions Anticonvulsants, antidepressants, analgesics.
T (Tenderness) Muscle spasm, tenderness, trigger points Physical therapy, acupuncture.
S (Sexuality) Erectile dysfunction, painful ejaculation PDE5 inhibitors, behavioral therapy.

Diagnostic Workup of Chronic Prostatitis and CPPS

Routine examinations

Routine examinations are done at first at the initial manifestation.

Medical and urological history:

Urination? Sexual disorders? General symptoms? Urological operations?

NIH-CPSI questionnaire:

The internationally validated questionnaire is used to quantify symptoms.

Physical Examination

Physical examination with prostate examination for differential diagnosis.


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 is done to rule out significant prostatitis or prostate cancer.

Microbiological diagnosis of chronic prostatitis:

In order to identify 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)

Extended Investigations

Extended investigations are done in the case of refractory or recurrent complaints. Invasive additional examinations or repeat imaging should only be performed in case of concrete concerns and not to reassure or appease the patient or the therapist. Protracted, purely organic exclusion diagnostics can lead to somatic fixation of the patient, making it challenging to address psychosocial factors later (DGPM, 2018).

Transrectal ultrasound (TRUS):

TRUS is essential 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 without bacterial infection is present.

Pelvic MRI:

MRI: for differential diagnosis.

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. Possible findings are: bladder neck obstruction, detrusor-sphincter dyssynergia, urethral obstruction, and overactive bladder.


Cystoscopy is indicated for the differential diagnosis of voiding dysfunction.


Rectoscopy is indicated for the differential diagnosis of rectal complaints.

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


EAU guidelines: Chronic pelvic pain

Krieger u.a. 1999 KRIEGER, J. N. ; NYBERG, Jr. ; NICKEL, J. C.: NIH consensus definition and classification of prostatitis.
In: Jama
282 (1999), Nr. 3, S. 236–7

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