Chronic Pelvic Pain Syndrome - Male
Male chronic pelvic pain syndrome (CPPS), commonly known chronic prostatitis (CP), is a common urological disorder that affects men of any age. CPPS is a type of prostatitis also known as Category III prostatitis (or chronic prostatitis), and it accounts for 90% of cases of prostatitis. CPPS is non-bacterial manifestation of the disease, and the usage of CPPS represents the acknowledgement that pain is the primary symptom of nonbacterial prostatitis. The etiology of male CPPS is not fully understood and thus treatment options are variable.   Chronic pelvic pain syndrome affect younger men (median age of 43), and presents with perineal and genital pain that can be unrelenting. Prevalence of CPPS in the United States is estimated between 2-16% while prevalence in Asia is estimated between 2.7-8.7%. 
Clinically Relevant Anatomy
A good understanding of the genitourinary system and pelvic floor musculature is crucial clinically.
The primary and most commonly reported symptom in CPPS is pain. Traditional presentation of CPPS is a patient who has pelvic, perineal, or genital pain associated with voiding and/or sexual dysfunction, characterized by a relapsing, remitting course. Patients with CPPS, however, can have very variable presentations with many different signs and symptoms associated with the syndrome that often overlap with other urological disorders.  
There are four cardinal symptom categories of CPPS:
- perineal/pelvic pain
- voiding symptoms
- sexual dysfunction
- systemic conditions
The onset of pain is usually sudden with a duration that must be present for at least three of the last six months. The intensity of pain can be quite severe and is most often located at the perineal and genital region but can manifest to other regions such as lower abdomen, penis, scrotum, rectum, and lower back. Urinary symptoms, both obstructive and irritable, are common. Ejaculatory pain is also a common symptom. Systemic symptoms include myalgia, arthralgia, and unexplained fatigue. CPPS symptoms commonly wax and wane with inconsistent remissions and exacerbations. 
The following are conditions that can mimic CPPS: 
- Granulomatous prostatitis
- Various abscesses and cysts
- Prostatic infections
- Fistulae from adjacent organs
- Prostatic urethral stricture
- Seminal vesiculitis/obstruction
- Bladder/prostatic calculi
- Ureteral lithiasis
- Tumours of the prostate
- Urinary tract infection
- Interstitial cystitis
- Overactive bladder
- Radiation cystitis
- Bladder cancer
- Urethral diverticulum
- Bacterial urethritis
- Diabetes mellitus
- Pudendal nerve entrapment
A physical pelvic examination will provide a good scan of the genitourinary system such as the penis, scrotum, perineum, prostate, and inguinal areas. A physical examination can be used to exclude other disorders such as inguinal herniation, nerve entrapment, or musculoskeletal inflammation. Suprapubic tenderness may be presented in some men with CPPS. The most important part of the examination is the digital rectal examination (DRE) which is used to assess the size, consistency, symmetry, and tenderness of the prostate. Most patients with CPPS will present with a normal DRE. Internal pelvic musculature should be palpated to examine muscle trigger points that can cause muscle spasm or pain. Often, patient report that symptoms can be reproduced by palpation of these trigger points.  Laboratory studies are useful in characterizing the type of prostatitis and to use to rule out other pathologies such as urinary tract infection and chronic bacterial prostatitis. Voiding studies are useful in those that complain of voiding symptoms. Imaging of the pelvis such as ultrasound, CT scan, and MRI is often not warranted but may be useful in ruling out conditions such as various abscesses and cysts, cancers, and prostatic calculi.
Physiotherapy management is indicated if through the digital rectal examination there was identified pelvic floor musculature tenderness. Physiotherapy provides a broad variety of techniques that are safe and effective for CPPS. The following are different modalities or techniques that are available under pelvic floor rehabilitation: 
- Biofeedback: helpful modality to help the patient avoid unnecessary increased resting muscle tone. Patients in weekly and biweekly physical therapy up to six to eight treatment sessions found significant improvement as shown by a decrease in the NIH-CPSI, and improved resting tone.
- Myofascial trigger point release: neuromuscular therapy aimed to reduce the tone of connective tissue, and restoring mobility of the muscle fascia. Patients treated for at least 1 month, about half of the patients had improvements associated with 25% or greater decrease in symptom scores.
- Acupuncture: insertion of needles at specific points of the body and manipulating the. CPPS patients randomized into acupuncture versus sham acupuncture groups. After 10 weeks those in the acupuncture group improved twice as much in their NIH-CPSI symptom scores vs the sham acupuncture. CPPS patients treated with weekly session of acupuncture for 6 weeks showed more than 50% decrease in their NIH-CPSI score from baseline.
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