In a 32-year-old man with intermittent dysuria, bladder and testicular pain during urination, and normal complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis, what is the most likely diagnosis?

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Most Likely Diagnosis: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

This 32-year-old man with intermittent dysuria, bladder and testicular pain during urination, and completely normal laboratory studies most likely has Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), possibly with overlapping Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) features. 1

Why CP/CPPS is the Leading Diagnosis

The clinical presentation fits CP/CPPS precisely:

  • Pain pattern: Bladder and testicular pain with urination is characteristic of CP/CPPS, which causes pain in the perineum, lower abdomen/suprapubic area, testes, or penis 1
  • Normal urinalysis: CP/CPPS is specifically defined by the absence of identifiable infection—normal UA and negative cultures are expected 1
  • Intermittent nature: The intermittent pattern throughout the day is typical, as CP/CPPS presents with chronic symptoms and intermittent flares 1
  • Age: At 32, he fits the typical demographic for CP/CPPS

Critical Distinction: This is NOT an Infection

CP/CPPS is not due to ongoing infection. 1 The normal urinalysis effectively rules out:

  • Acute bacterial cystitis
  • Urinary tract infection
  • Acute bacterial prostatitis (which would show positive cultures and typically responds to antibiotics) 1

The 2025 AUA guidelines emphasize that CP/CPPS is a diagnosis of exclusion after ruling out confusable disorders like UTI, urogenital cancer, urethral stricture, neurologic disease, or bladder outlet obstruction 1.

Consider IC/BPS Overlap

Up to 75% of men with chronic pelvic pain report painful bladder filling or painful urge to urinate, indicating significant overlap between CP/CPPS and IC/BPS 1. Since this patient has bladder pain with urination, he may meet criteria for both diagnoses. The 2025 AUA guidelines note this overlap is under-appreciated in men 1.

Pelvic Floor Myalgia as Contributing Factor

Pelvic floor myalgia commonly co-exists with CP/CPPS and may be a significant contributor to his symptoms 1. Men with CP/CPPS have more difficulty relaxing their pelvic floor muscles than asymptomatic controls 1.

Essential Next Steps in Evaluation

Immediate Actions:

  1. Obtain urine culture (mid-stream): Even with normal UA, culture is recommended to definitively exclude bacterial infection 1

  2. Perform digital rectal examination with pelvic floor muscle palpation: Assess for tenderness in the posterior levator ani (1 and 11 o'clock), anterior levator ani (5 and 7 o'clock), and obturator internus muscles (3 and 9 o'clock) 1

  3. Assess psychosocial factors: Screen for anxiety, depression, major life stress, and impact on quality of life—these commonly accompany CP/CPPS 1

  4. Screen for neurological, musculoskeletal, and orthopedic abnormalities of the pelvis, hip, and lower spine 1

Consider if Diagnosis Remains Unclear:

  • Prostate massage with two-glass or four-glass localization test: Only if there's diagnostic uncertainty distinguishing chronic bacterial prostatitis from CP/CPPS (e.g., if patient reports recurrent "UTI" episodes without documented cultures) 1

  • STI testing: If sexual exposure, urethral discharge, or prior STI history—test for gonorrhea, chlamydia, trichomonas, and Mycoplasma genitalium 1

  • Post-void residual volume: Using bladder scanner to assess for retention 1

Advanced Testing (Only When Diagnosis Unclear):

  • Cystoscopy: If IC/BPS symptoms predominate (painful bladder filling) to evaluate for Hunner lesions 1
  • Urodynamics: If significant voiding symptoms, decreased flow, or elevated PVR 1
  • Imaging: Not routinely indicated unless evaluating for specific complications 1

Common Pitfalls to Avoid

  1. Do NOT empirically treat with antibiotics: CP/CPPS is not infectious, and antibiotics will not help 1. This wastes time and contributes to resistance.

  2. Do NOT wait for 3-month symptom duration: While research definitions require 3 months of symptoms, the 2025 AUA guidelines explicitly state that strict research criteria should be avoided in clinical practice to prevent misdiagnosis and treatment delays 1

  3. Do NOT dismiss bilateral testicular involvement: While unilateral scrotal pain suggests Chronic Scrotal Content Pain (CSCP), bilateral testicular pain with other pelvic sites of pain is consistent with CP/CPPS 1

  4. Do NOT order routine semen culture or next-generation sequencing for atypical organisms: These have no role in CP/CPPS diagnosis 1

Why Other Diagnoses Are Less Likely

  • Chronic bacterial prostatitis: Would typically show recurrent UTIs with the same organism and symptom-free intervals between infections 1
  • Chronic Scrotal Content Pain (CSCP): Presents with unilateral scrotal pain without other pelvic pain sites or urinary symptoms 1
  • Acute epididymitis/orchitis: Would show abnormal CBC, inflammatory markers, and typically unilateral findings
  • Urethral stricture: Would present with obstructive voiding symptoms and decreased flow

The combination of intermittent dysuria, bladder and testicular pain, and completely normal laboratory studies in a young man is pathognomonic for CP/CPPS until proven otherwise. 1

References

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