Prostatitis- Male Pelvic Pain


This one is for the guys.  While 75-80% of the patients I treat are women,  I do treat quiet a few male patients.  The number one reason that men come to me for treatment is for chronic pelvic pain syndrome, often diagnosed as “chronic non-bacterial prostatitis”.  Now this diagnosis can be really confusing.  “Prostatitis”  means “inflammation  of the prostate gland”, but in many cases it has nothing to do with the prostate at all.  Symptoms  of “prostatitis” include pain in the area of the prostate (perineal, testicular, penile, lower abdominal) and difficulty with, or painful, urination.  The National Institutes of Health (in the USA) breakdown the diagnosis of prostatitis to 4 categories

  • Category I: Acute bacterial prostatitis
  • Category II: Chronic bacterial prostatitis
  • Category III: Chronic pelvic pain syndrome (CPPS)
    • A. Inflammatory
    • B. Noninflammatory
  • Category IV: Asymptomatic inflammatory prostatitis

The patients that I treat typically fall into the Category III, Chronic Pelvic Pain Syndrome which makes up to 90-95% of patients diagnosed with prostatitis.  This category may or may not have anything to do with the prostate.   NIH describes type III as:

Irritation with urination, without indication of urinary tract infection (for over 3 months duration). The prostate may be normal or enlarged, but not tender. Chronic pelvic pain may include, perineal, lower abdominal, penile, testicular, rectal and lower back, pain and may include ejaculatory pain.

90-95% of cases of “prostatitis” are non-bacterial (category III)  Yet, surprisingly, even with only 5-10% of cases actually showing an infection in the prostate, antibiotics are still the most common treatment prescribed for all patients with prostatitis in the US.  I can attest, that most of the patients that eventually come to see me have been  on  4, 5 …or more courses of antibiotics, with no success.   Although antibiotics are very necessary for the treatment of bacterial prostatitis , they are not effective for non-bacterial categories.

So why do doctors still prescribe antibiotics?

This may be from the notion that there may be a hidden, undetected infection that is the cause of the pain.  Or it may be from lack of knowledge about other possible treatment options.

So if it is not an infection, what is it?

There have been research studies trying to determine the “one” cause of chronic pelvic pain.  Is it neurological? Is it hormonal? Is musculo-skeletal?  Is it psychological?  While all of these have shown some relationship, none have provided us with the “smoking gun”.

The most effective model that I have seen so far for treating patients with prostatitis is the UPOINT model  (J.C .Nickel, et al).  Although there is plenty room for improvement, the UPOINT model is a good start and shows good improvement in dealing with this challenging condition.

The UPOINT model suggests that there may be multiple different factors that contribute to ongoing pelvic pain in men.  It suggests that treatment recommendations should be individualized to the patient, based on their clinical findings.  This should include a team approach including medication, physical therapy and psychology when indicated.


Pelvic physical therapy has been shown to be very effective treatment for pelvic floor muscle pain (Tenderness), with very little risk.   However, what is not shown on this (medication dominant) table is that physical therapy treatment can also have a positive impact on the urinary, psychosocial and neurologic components.

Now, don’t get me wrong, I am not a psychologist and I don’t pretend to be!   I do work closely with several counselors who provide amazing care.  However, we do know that simply providing education, a supportive environment, and reassurance, we can significantly reduce psychological distress, and may be appropriate for those with only mild clinical findings in the psychosocial category.

We also know that appropriate exercise, breathing, mindfulness and relaxation training can have a significant effect on the nervous system , which may be better tolerated than any of the medications recommended to address these same issues.  Concerning urinary symptoms, I have seen with many patients, that if they improve the function of their pelvic floor muscles, the urinary urgency, frequency, and incomplete emptying can resolve.


So, my wish list is this:


1) I would like to see more physicians using a modified  UPOINT model to guide care for men with prostatitis. ( please consider non-mediation options before medication options, when appropriate)

2) I would like to see more physicians assessing the pelvic floor for tenderness to help know when to refer to physical therapy.

2a) And for those physicians that don’t feel competent in assessing the pelvic floor muscles, I would like to see them connect with one of the amazing pelvic floor therapist all around the world that would happily work with them 🙂

3)  I would like for more men with prostatitis get appropriate early treatment, so that they don’t have to suffer for months or years with this distressing and debilitating condition.

If you share these wishes with me, please share this information!

Please contact me at with any questions