Urology Textbook
Clinical Essentials
By Dirk Manski, MD

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Signs and Symptoms and Diagnostic Workup of Chronic Pelvic Pain Syndrome

Signs and Symptoms

The classification according to UPOINT(S) domains enables structured multimodal treatment; see Table UPOINT(S) domains.

Prostate pain syndrome:

Pain perceived in the prostate area, a painful digital rectal examination, pain radiating to the perineum, rectum, testes, penis, and lower abdomen, and often painful ejaculation.

Bladder pain syndrome:

Suprapubic pain that increases with bladder filling, pollakiuria, nocturia, and pain radiating to the perineum, rectum, testes, penis, and lower abdomen. Voiding partly relieves the pain.

Urethral pain syndrome:

Urethral pain during voiding, urinary urgency, pollakiuria, and often dyspareunia.

Testicular pain syndrome:

Pain perceived in the testis or epididymis, with tenderness. If symptoms are attributed to vasectomy, the condition is termed postvasectomy pain syndrome.

Pudendal pain syndrome:

Neuropathic pain in the territory supplied by the pudendal nerve, typically unilateral.

Sexual dysfunction:

Erectile dysfunction, reduced libido, premature or delayed ejaculation, and painful ejaculation.

Association with other diseases:

Fibromyalgia, irritable bowel syndrome, depression, anxiety disorders, substance use disorders, migraine, and bruxism.

Classification of clinical phenotypes and treatment options in CPPS according to the UPOINT(S) domains: disease severity increases with the number of affected domains. This classification enables structured multimodal treatment (Shoskes et al., 2009).
Domain Signs and symptoms Treatment options
U (Urinary) Obstructive and irritative voiding symptoms Alpha blockers, 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/systemic) Fibromyalgia, irritable bowel syndrome, chronic pain in other regions Anticonvulsants, antidepressants, analgesics
T (Tenderness) Muscle induration and trigger points Physical therapy, acupuncture, extracorporeal shock wave therapy
S (Sexuality) Erectile dysfunction, painful ejaculation PDE5 inhibitors, behavioral therapy

Diagnostic Workup

Routine examinations:

At initial presentation.

History:

Pain localization (see definitions)? Voiding symptoms? Sexual dysfunction? General symptoms?

NIH-CPSI questionnaire:

The internationally validated questionnaire (NIH-CPSI = National Institutes of Health Chronic Prostatitis Symptom Index) quantifies symptoms.

Physical examination:

Including digital rectal examination for differential diagnosis.

Uroflowmetry:

A screening test for voiding dysfunction.

Bladder ultrasonography:

Postvoid residual urine? Bladder stones? Prostate size?

Prostate-specific antigen (PSA):

To rule out significant prostatitis or cancer.

Microbiological testing:

According to the symptoms; see also bacterial prostatitis.

Extended investigations:

For treatment-refractory or recurrent symptoms. Perform invasive additional tests or extended imaging only for specific clinical questions, not to reassure or appease the patient or clinician. Prolonged exclusionary testing focused solely on organic disease can lead to somatic fixation and make it more difficult to address psychosocial factors later (DGPM, 2018).

Transrectal ultrasonography (TRUS):

To exclude differential diagnoses such as abscesses, prostatic cysts, and seminal vesicle disorders. Prostate biopsy is indicated only if the digital rectal examination is suspicious or PSA is elevated in the absence of bacterial infection.

Pelvic MRI:

To exclude differential diagnoses.

Repeated microbiological testing:

If indicated, including semen culture or urethral swab.

Urodynamic investigation:

For the differential diagnosis of unclear voiding symptoms. Bladder outlet obstruction caused by bladder neck obstruction, dysfunctional voiding, or detrusor overactivity may be associated with the symptoms or contribute causally.

Cystoscopy:

For voiding symptoms.

Rectoscopy:

For rectal symptoms.

Differential Diagnosis






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

References

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

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