Evaluation for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
Your symptoms—post-ejaculatory burning, dysuria, scrotal pain, and worsening urinary urgency after ejaculation—strongly suggest chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) rather than simple overactive bladder, and you need urological evaluation with specific focus on prostate inflammation and pelvic floor dysfunction before continuing Myrbetriq alone. 1
Why This Isn't Just OAB
Your symptom pattern reveals critical red flags that distinguish this from typical overactive bladder:
Post-ejaculatory pain syndrome: The burning with urination and increased urgency specifically after ejaculation, combined with scrotal pain, is pathognomonic for prostatic/pelvic floor involvement, not bladder dysfunction alone 1
Intermittent flaring pattern: The "comes and goes" nature over 5 years with occasional scrotal pain suggests chronic inflammatory or pelvic floor muscle dysfunction rather than progressive bladder pathology 1
Incomplete response to beta-3 agonist: While Myrbetriq 50mg effectively treats pure OAB in men, your persistent symptoms despite treatment indicate an alternative or additional diagnosis 2, 3
Immediate Diagnostic Steps Required
Before any treatment modification, you need:
Post-void residual measurement: Essential to exclude urinary retention or incomplete emptying from prostatic obstruction, which would contraindicate continuing antimuscarinic therapy if added later (PVR >250-300 mL requires extreme caution) 1, 4
Urinalysis and urine culture: Must exclude occult urinary tract infection or prostatitis, as infection mimics and exacerbates both OAB and CP/CPPS symptoms 1
Digital rectal examination: Assess for prostatic tenderness, nodularity, or asymmetry that would indicate prostatitis or other prostatic pathology 1
Prostate-specific symptom assessment: Use NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify pain, urinary symptoms, and quality of life impact specific to prostatitis 1
Treatment Algorithm Based on Findings
If CP/CPPS is Confirmed (Most Likely):
Pelvic floor physical therapy: First-line treatment for CP/CPPS with pelvic floor muscle dysfunction, addressing the myofascial trigger points causing post-ejaculatory pain and urinary symptoms 1
Alpha-blocker therapy: Add tamsulosin or alfuzosin to your current Myrbetriq, as alpha-blockers specifically address prostatic/bladder neck dysfunction contributing to both voiding and storage symptoms in men with CP/CPPS 5, 3
Anti-inflammatory therapy: NSAIDs during symptomatic flares can reduce prostatic inflammation driving your cyclical symptoms 1
Continue Myrbetriq 50mg: The beta-3 agonist remains appropriate for the OAB component of your symptoms and is safe in combination with alpha-blockers 5, 3
If Pure OAB with Inadequate Control:
Optimize behavioral therapies first: Before medication escalation, implement timed voiding (every 2-3 hours), caffeine/alcohol elimination, and fluid management (25% reduction in total intake, especially evening restriction) 6, 1
Consider dose escalation: Myrbetriq can be increased to 100mg daily if 50mg provides insufficient symptom control after 8-12 weeks, though this is less likely your primary issue given the post-ejaculatory pattern 2, 7
Add antimuscarinic therapy: Combination of Myrbetriq 50mg plus low-dose solifenacin 5mg provides superior efficacy to monotherapy, but requires confirmed PVR <250 mL first 8, 1
Critical Pitfalls to Avoid
Do not add antimuscarinic medications without measuring PVR: If you have occult urinary retention from prostatic obstruction, antimuscarinics will worsen retention and potentially cause acute urinary retention requiring catheterization 6, 1
Do not dismiss the post-ejaculatory pattern: This specific symptom timing is the diagnostic key—pure OAB does not worsen specifically after ejaculation, while CP/CPPS characteristically does 1
Do not continue current therapy unchanged: Five years of intermittent symptoms without complete resolution indicates your current approach is inadequate and requires diagnostic refinement 1
Specialist Referral Threshold
You should be evaluated by a urologist now because: 6, 1
- You have failed to achieve adequate symptom control with first-line behavioral therapy and second-line pharmacotherapy over 5 years
- Your symptom pattern (post-ejaculatory pain, scrotal pain, dysuria) suggests pathology beyond simple OAB requiring specialized evaluation
- Third-line therapies (sacral neuromodulation, peripheral tibial nerve stimulation, intradetrusor botulinum toxin) may be appropriate if combined medical management fails, but require comprehensive urological assessment first