What is the best course of treatment for a 28-year-old male with a family history of prostate cancer, experiencing urinary urgency, hesitancy, and chronic left testicular pain, despite a previous hernia repair?

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

This 28-year-old patient's constellation of symptoms—chronic testicular pain, perineal pressure ("sitting on a ball"), urinary urgency, and hesitancy—is most consistent with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and should be managed with alpha-blockers as first-line therapy, specifically tamsulosin 0.4 mg daily. 1

Clinical Reasoning

The patient's presentation is classic for CP/CPPS (formerly known as chronic nonbacterial prostatitis):

• Perineal pain/pressure between the scrotum and anus is pathognomonic for prostatic inflammation 2
• Chronic testicular pain persisting for 2+ years without identifiable structural cause (hernia repair did not resolve symptoms) 3
• Urinary symptoms (urgency and hesitancy) are common in CP/CPPS and overlap with lower urinary tract symptoms (LUTS) 2, 4
• Age 28 years makes benign prostatic hyperplasia (BPH) extremely unlikely, as BPH typically affects men >50 years 2

Prostate Cancer Screening Considerations

Do NOT pursue prostate cancer screening in this patient. Here's why:

• Age <40 years: Prostate cancer screening is not recommended for men under 40, even with family history 2
• Symptoms are NOT cancer-related: Urgency, hesitancy, and perineal pain are symptoms of prostatic inflammation, not malignancy 2, 4
• PSA testing would be misleading: Prostatitis causes spurious PSA elevation, making interpretation impossible 5, 6
• Life expectancy consideration: Even if cancer were present, the patient has >40 years of life expectancy, but his symptoms require immediate management 2

Recommended Treatment Algorithm

First-Line Therapy

Start tamsulosin 0.4 mg once daily, taken 30 minutes after the same meal each day 1:

• Alpha-1 blockers are first-line for LUTS and have rapid onset of action 2
• Tamsulosin specifically improves urgency, hesitancy, and weak stream 1
• If no response after 2-4 weeks, increase to 0.8 mg daily 1
• Expected improvement in symptoms within 1 week, with maximal benefit by 13 weeks 1

Adjunctive Measures

• Avoid bladder irritants: Caffeine, alcohol, spicy foods 2
• Pelvic floor physical therapy: Can address chronic pelvic pain component
• NSAIDs: For pain management during acute flares

When to Reassess

• If symptoms persist after 8-12 weeks on maximum-dose tamsulosin, consider:
  • Trial of antimicrobial therapy (fluoroquinolone for 4-6 weeks) to rule out occult bacterial prostatitis
  • Referral to pelvic pain specialist
  • Consider muscarinic receptor antagonist if urgency predominates 2

Common Pitfalls to Avoid

• Do not order PSA testing: Prostatitis will elevate PSA, leading to unnecessary biopsies and anxiety 5, 6
• Do not perform prostate biopsy: No indication based on age, symptoms, or examination 2
• Do not attribute symptoms to hernia repair: The hernia was coincidental; symptoms are prostatic in origin 3
• Do not use antibiotics empirically without trial of alpha-blocker first: Most CP/CPPS is nonbacterial 2
• Do not dismiss family history entirely: Document it for future screening starting at age 40-45, which is 10 years earlier than average-risk men 2

Future Prostate Cancer Screening Plan

Begin individualized early detection discussions at age 40 (not now) 2:

• Family history of prostate cancer warrants earlier screening consideration
• At that time, shared decision-making about PSA testing should occur 2
• Current symptoms should be resolved before any cancer screening to avoid confounding PSA results 5