What is the appropriate diagnosis and treatment for a patient with left scrotal pain, intermittent pelvic pain, daytime urinary frequency, urgency, and nighttime incontinence?

Diagnosis and Management of Chronic Pelvic Pain Syndrome with Urinary Symptoms

This patient most likely has Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC) or Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), and should be treated with a multimodal approach targeting bladder-related pain while ruling out infection and other identifiable causes. 1, 2

Primary Diagnostic Considerations

Most Likely Diagnosis: PBS/IC or CP/CPPS

The constellation of left scrotal pain, intermittent pelvic pain, daytime urinary frequency, urgency, and nighttime incontinence strongly suggests PBS/IC or CP/CPPS in this male patient. 1, 2

In men, PBS/IC should be strongly considered when pain, pressure, or discomfort is perceived to be related to the bladder and associated with urinary frequency, nocturia, or an urgent desire to void. 1, 2 The scrotal and pelvic pain distribution is characteristic of CP/CPPS, which shares overlapping features with PBS/IC. 1

Key Distinguishing Features

Pain is the hallmark symptom that differentiates PBS/IC from overactive bladder (OAB). 1, 2 This patient's presentation includes:

• Pelvic and scrotal pain (characteristic of PBS/IC/CP/CPPS, not typical of pure OAB) 1, 2
• Urinary frequency and urgency (present in both conditions but qualitatively different) 1
• Nighttime incontinence (suggests urgency-related voiding to relieve pain rather than to avoid incontinence) 1, 2

PBS/IC patients typically void to avoid or relieve pain, whereas OAB patients void to avoid incontinence. 1, 2 The presence of pain makes PBS/IC/CP/CPPS the primary diagnosis. 1

Essential Diagnostic Workup

Mandatory Initial Testing

Perform urinalysis and urine culture immediately to exclude urinary tract infection, as PBS/IC is defined by the absence of infection or other identifiable causes. 1, 2, 3 This is critical because antibiotics should not be used when no infection is present, which can lead to antibiotic resistance. 2

Post-Void Residual Measurement

Measure post-void residual (PVR) to rule out overflow incontinence, particularly given the nighttime incontinence. 4 An elevated PVR (>250-300 mL) would suggest overflow incontinence and completely change the treatment approach. 4 This is a critical pitfall to avoid—misdiagnosing overflow incontinence as OAB or PBS/IC can lead to inappropriate antimuscarinic therapy that worsens retention. 4

Physical Examination Specifics

Perform a focused examination including:

• Abdominal examination to assess for bladder distention or masses 4
• Genital examination to evaluate for scrotal pathology, testicular tenderness, or epididymitis 1
• Digital rectal examination to assess prostate size, tenderness, and rule out obstruction 1, 4

Voiding Diary

Obtain a voiding diary to document frequency patterns, voided volumes, and timing of symptoms. 1, 3 This reliably measures urinary frequency and can distinguish between small-volume voids (typical of PBS/IC/OAB) versus large-volume voids (suggesting nocturnal polyuria). 1, 3

Differential Diagnosis Algorithm

Rule Out These Conditions First:

1. Urinary tract infection (urinalysis/culture) 2, 3
2. Overflow incontinence (PVR measurement) 4
3. Nocturnal polyuria (voiding diary showing normal/large volume nocturnal voids) 1, 3
4. Bladder outlet obstruction (history of obstructive symptoms, enlarged prostate on exam) 1

If Above Are Excluded:

The diagnosis is PBS/IC, CP/CPPS, or both conditions coexisting. 1, 2 Some men meet criteria for both conditions, and the clinical characteristics are similar. 1

Treatment Approach

Initial Management Strategy

Begin treatment after a relatively short symptomatic period (6 weeks) to minimize delays, as definitions requiring longer durations can lead to misdiagnosis and treatment delays. 2

First-Line Therapies for PBS/IC/CP/CPPS:

Behavioral modifications:

• Identify and avoid dietary triggers (foods/drinks that worsen pain) 1, 2
• Bladder training techniques 5
• Pelvic floor physical therapy 5, 6

Pharmacological options:

• Analgesics for pain management 6
• Alpha-receptor blockers (particularly useful in men with CP/CPPS features) 6
• Antimuscarinic therapy (e.g., oxybutynin) may be considered for urgency/frequency symptoms, but ONLY if PVR is normal (<250 mL) 4, 7

Critical Pitfall to Avoid

Do NOT prescribe antimuscarinic medications if PVR is elevated (>250-300 mL), as this will worsen urinary retention. 4 This is why measuring PVR before initiating therapy is essential.

When to Consider Cystoscopy

Perform cystoscopy if Hunner lesions are suspected, as this is the only reliable way to diagnose their presence and may guide specific treatment. 2 However, cystoscopy is not required for initial diagnosis in most cases. 1, 2

Treatment for Coexisting Conditions

If the patient meets criteria for both PBS/IC and CP/CPPS (which is common), the treatment approach should include established PBS/IC therapies as well as therapies more specific to CP/CPPS. 1 Empiric PBS/IC strategies have led to clinical symptomatic improvement in some CP/CPPS patients. 1

Common Diagnostic Pitfalls

• Using research definitions requiring 6+ months of symptoms delays treatment initiation 2
• Failing to distinguish pain-predominant conditions (PBS/IC) from urgency-predominant conditions (OAB) 1, 2
• Not measuring PVR before prescribing antimuscarinics 4
• Treating with antibiotics when no infection is present 2
• Assuming all urgency/frequency is OAB without assessing for pain 1, 8