What causes perineal pain in males?

From the Guidelines

Perineal pain in men should be evaluated promptly as it can stem from various causes requiring different treatments, with a focus on identifying and addressing the underlying cause to minimize morbidity, mortality, and improve quality of life. For immediate relief, over-the-counter pain medications like ibuprofen (400-600mg every 6-8 hours) or acetaminophen (500-1000mg every 6 hours) can help reduce discomfort 1. Warm sitz baths for 10-15 minutes several times daily often provide significant relief. If the pain is related to prostatitis, which is common, antibiotics such as ciprofloxacin (500mg twice daily for 2-4 weeks) or trimethoprim-sulfamethoxazole (one double-strength tablet twice daily for 2-4 weeks) may be prescribed 1.

Causes of Perineal Pain

• Infection: prostatitis, anorectal abscess, or Fournier’s gangrene
• Trauma: injury to the perineum or surrounding areas
• Prolonged sitting: putting pressure on the perineum
• Referred pain: from nearby organs such as the prostate or rectum

Diagnosis and Treatment

A thorough medical history and physical examination, including a digital rectal examination, are essential for diagnosing the underlying cause of perineal pain 1. Laboratory tests, such as complete blood count, serum creatinine, and inflammatory markers, may be necessary to assess the severity of the condition 1. Imaging studies, such as ultrasound or MRI, may also be used to evaluate the perineum and surrounding areas.

Management of Perineal Pain

• For chronic perineal pain, pelvic floor physical therapy can be beneficial, focusing on relaxation techniques and stretching exercises. Avoiding prolonged sitting, using cushioned seats, wearing loose-fitting underwear, and staying hydrated can prevent exacerbation. If pain persists beyond a week, worsens, or is accompanied by fever, urinary problems, or discharge, medical evaluation is essential as these could indicate infection, nerve compression, or other serious conditions requiring specific treatment 1.

Serious Conditions Requiring Prompt Attention

• Fournier’s gangrene: a rare and potentially life-threatening necrotizing infection involving the fascia and subcutaneous tissues of the external genitalia or perineum 1
• Anorectal abscess: a collection of pus in the tissue around the anus, which can cause severe pain and discomfort 1
• Prostatitis: inflammation of the prostate gland, which can cause pain, discomfort, and urinary problems 1

From the Research

Perineal Pain in Men

Perineal pain in men can be associated with various conditions, including prostatitis. The following points summarize the key aspects of perineal pain in men:

• Definition and Classification: Prostatitis is classified into four syndromes: acute bacterial prostatitis, chronic bacterial prostatitis (CBP), chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis 2.
• Causes and Risk Factors: Risk factors for chronic prostatitis include conditions that facilitate the introduction of bacteria into the urethra and prostate, as well as conditions that can lead to chronic neuropathic pain 2.
• Symptoms: CBP and CNP/CPPS both lead to pelvic pain and lower urinary tract symptoms 2. CNP/CPPS presents as prostatic pain lasting at least three months without consistent culture results 2.
• Treatment Options: Treatment options for CNP/CPPS include alpha blockers, pain medications, and a four- to six-week course of antibiotics 2, 3. Pelvic floor physical therapy, phytotherapy, and pain management techniques may also be effective 2, 3.
• Pharmacotherapy: Pharmacotherapeutic options for CP/CPPS include antimicrobials, alpha blockers, 5-alpha reductase inhibitors, and anti-inflammatories 3. The use of antibiotics, such as fluoroquinolones, may be effective in reducing symptoms 3, 4.
• Efficacy of Combination Therapy: A systematic review found that combination therapy of antibiotics and alpha-blockers is not substantially better than antibiotic monotherapy in the first 6 weeks of treatment for CP/CPPS patients 5. However, combination therapy may be more effective in the long term 5.

Management of Perineal Pain

The management of perineal pain in men requires a comprehensive approach, including:

• Diagnosis: Diagnosis of prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage 6.
• Treatment: The mainstay of therapy is an antimicrobial regimen, with chronic pelvic pain syndrome being a more challenging entity to treat 6.
• Non-Pharmacologic Modalities: Non-pharmacologic modalities, such as pelvic floor physical therapy, may be useful in managing perineal pain 3.