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STI Online First, published on June 6, 2014 as 10.1136/sextrans-2013-051432

Education

How to manage the chronic pelvic pain syndrome in men presenting to sexual health services Megan Crofts,1 Kate Mead,2 Raj Persad,3 Paddy Horner1,4

▸ MCQs of the article and additional material are published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ sextrans-2013-051432). 1

Bristol Sexual Health Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK 2 Bristol University Medical School, Bristol, UK 3 Department of Urology, North Bristol NHS Trust, Bristol, UK 4 School of Social and Community Medicine, University of Bristol, Bristol, UK Correspondence to Dr Patrick Horner, School of Social and Community Medicine, University of Bristol, 39 Whatley Rd, Bristol, UK; [email protected] Received 5 November 2013 Revised 24 April 2014 Accepted 10 May 2014

To cite: Crofts M, Mead K, Persad R, et al. Sex Transm Infect Published Online First: [please include Day Month Year] doi:10.1136/sextrans2013-051432

BACKGROUND Chronic pelvic pain syndrome (CPPS) in men is an important and common condition in genitourinary medicine (GUM) and other sexual health services. It has a lifetime prevalence of 2%–14%.1–4 The terms CPPS and chronic prostatitis are often used interchangeably to describe a syndrome which causes perineal and genital pain that can be unrelenting and physically, as well as emotionally, exhausting.1–5 The median age of patients affected is 43 years and the syndrome is usually of sudden onset,2 4 though classically CPPS is only diagnosed when symptoms have been present for at least 3 months.1 5 Due to the nature of CPPS pain, including dysuria, penile tip, perineal, testicular and ejaculatory pain, as well as other commonly associated symptoms such as urinary frequency, patients often present to GUM departments, usually at onset of the acute phase; however no data are available as to the frequency of presentation.1 5 Managing men with CPPS is challenging as the aetiology is poorly understood, diagnosis is one of exclusion and management strategies are suboptimal.1 4 5 A number of hypotheses have been proposed as to the causes of CPPS, both infective and non-infective. It is well recognised that men with acute non-gonococcal urethritis (NGU) may go on to develop chronic urethritis.6 Although published data are limited, men with CPPS may have urethritis, and indeed symptom profiles overlap.1 6 7 W1 W2 Both Mycoplasma genitalium and Ureaplasma urealyticum are associated with chronic NGU although in the majority no infection is detected.6 W3 Chronic bacterial prostatitis is identified in up to 10% and is associated with recurrent urinary tract infections.4 5 Evidence supports a non-infective aetiology in the majority of cases. An infectious or inflammatory initiator may result in neurological dysfunction leading to increased pelvic tone.1–5 W4 There is some evidence to indicate that increased pelvic floor muscle tone may contribute by increasing intraurethral resistance to urinary flow.5 W4 This, in turn, may lead to reflux into the prostate causing symptoms.5 W4 W5 There is further evidence that symptoms may be caused by chronically tense myofascial tissue around the pelvic floor.2 4 5 8 W5–W7 Underlying anxiety or depression about the cause of symptoms may exacerbate this phenomenon; however, it remains uncertain whether these are premorbid conditions or a result of developing symptoms.1–3 5Although this has not been formally assessed, it is our experience in Bristol that men with obsessive personality traits who tend to get locked into circular trains of

Crofts M, et al. Sex Article Transm Infect 2014;0:1–4. Copyright author (ordoi:10.1136/sextrans-2013-051432 their employer) 2014. Produced

thought are over-represented in patients with CPPS. There is no reliable single therapy for effectively treating men with CPPS.1–5Although evidence for antibiotic therapy was thought to be unconvincing, a recent systematic review and meta-analysis suggests that antimicrobials may indeed be effective.9 The exact mechanism of action is unclear as antimicrobials may have other properties such as an antiinflammatory action.5 W8 W9 Thus, this should not be used to support an infection with an unknown microorganism as a possible cause. The findings also indicate that α-blockers, such as tamsulosin or alfuzosin, are effective with the greatest improvement being observed when a combination of an α-blocker and antibiotic are used.9 Evidence suggests prolonged treatment for more than 6 weeks (likely more than 12 weeks) with an α-blocker is required before a beneficial effect may be observed.4 10 There are a number of other therapeutic interventions which have various levels of evidence supporting their use such as non-steroidal anti-inflammatory drugs, finasteride, phytotherapy, myofascial trigger point release and paradoxical relaxation training, acupuncture and exercise.1 5 8 10 W7 W10 W11 Low dose tricyclic antidepressants have been demonstrated to be useful in neuropathic pain although there is no evidence from a randomised controlled trial demonstrating efficacy in men with CPPS.4 10 Nickel et al10 have proposed that the traditional pharmacotherapeutic approach to managing patients would be enhanced by addition of a biopsychosocial approach tailored to an individual’s presenting symptoms. Westesson and Shoskes demonstrated that multimodal therapy based on clinical presentation (UPOINT phenotype) resulted in significant benefit.8 W12 Patient outcome can be quantified using the American National Institutes of Health Chronic Prostatitis Symptom Index score (NIH CPSI).5 W13 Scores can range from 0 to 43, with scores closer to 0 reflecting a more favourable status. We detail below how to set up and run a clinic for men with CPPS using the novel biopsychosocial approach which we have developed, evaluated and demonstrated to be effective resulting in a significant decrease in mean NIH CPSI from 22.6 to 14.4 ( p=