Dr. med. Dirk Manski

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Symptoms and Diagnosis of Chronic Pelvic Pain Syndrome

Signs and Symptoms of Chronic Pelvic Pain Syndrome

Prostate pain syndrome:

pain perception in the prostate area with 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, pollakiuria, nocturia, radiation of pain to perineum, rectum, testis, penis and lower abdomen. Micturition may partly relief the pain.

Urethral pain syndrome:

urethral pain during mictiurition, urge symptoms, pollakiuria, and dyspareunia.

Testicular pain syndrome:

pain perception in the testicle or epididymis. A post-vasectomy pain syndrome is complaints associated with a vasectomy.

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.

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)

Extended Investigations

In the case of refractory or recurrent complaints. Invasive additional examinations or extended 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, which makes it difficult to address psychosocial factors at a later stage (DGPM, 2018).

Transrectal ultrasound (TRUS):

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 without bacterial infection is present.

Pelvic 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, overactive bladder.


Cystoscopy is indicated for the differential diagnosis of voiding dysfunction.


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


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