What is the recommended treatment plan for a male patient with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) presenting with burning suprapubic pain, a sensation of incomplete bladder emptying, and a negative urine dipstick?

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

For a male patient with CP/CPPS presenting with burning suprapubic pain and incomplete bladder emptying, begin with pelvic floor physical therapy combined with behavioral modifications, then escalate systematically through oral medications (alpha-blockers, neuromodulators), and consider this condition may overlap with interstitial cystitis/bladder pain syndrome requiring IC/BPS-specific therapies. 1

Critical Diagnostic Consideration

CP/CPPS and IC/BPS have nearly identical clinical presentations in men—both cause suprapubic pain, incomplete bladder emptying, and urinary frequency. 1 The AUA guidelines explicitly state that IC/BPS should be strongly considered in men whose pain is perceived to be related to the bladder, and many men meet criteria for both conditions simultaneously. 1 When symptoms overlap, the treatment approach should include both CP/CPPS therapies and IC/BPS therapies. 1

First-Line: Behavioral and Physical Therapy

• Initiate pelvic floor physical therapy with manual therapy techniques applied to the pelvic floor musculature. 2, 3 This includes myofascial trigger point release and internal pelvic floor manipulation performed by a specially trained physical therapist. 3, 4

• Perform pelvic floor muscle relaxation exercises only—not strengthening exercises—as muscle tension contributes to symptoms. 2

• Eliminate bladder irritants from the diet: coffee, citrus products, spicy foods, and alcohol. 5, 2 Implement a systematic elimination diet to identify personal trigger foods. 5, 2

• Restrict fluid intake in evening hours to reduce nighttime symptoms while maintaining adequate daytime hydration to dilute urinary irritants. 5

• Apply local heat or cold over the suprapubic region or perineum for symptomatic pain relief. 2

• Implement stress management techniques including meditation and progressive muscle relaxation. 2, 3

Second-Line: Oral Medications

No single medication works for all patients, and the evidence does not establish clear superiority of one agent over another. 6, 7 A phenotype-directed approach using the UPOINT classification system achieves symptom improvement in 75-84% of patients. 6

Alpha-Blockers

• Consider alpha-adrenergic antagonists for patients with voiding symptoms or suspected pelvic floor tension. 6, 7, 8

Neuromodulators

• Amitriptyline 10 mg daily, titrating up to 100 mg as tolerated, is effective for pain management with Grade B evidence, though adverse effects are common. 5, 2

• Hydroxyzine is an alternative second-line oral medication with Grade B/C evidence and minor adverse events. 2

Anti-inflammatory Agents

• Nonsteroidal anti-inflammatory drugs may provide benefit, though evidence is limited. 4, 8

Antibiotics

• Antimicrobial therapy has not been uniformly effective, and asymptomatic men have equal or greater numbers of bacteria in prostatic fluid compared to symptomatic men, raising doubts about infection as a primary cause. 4, 8

IC/BPS-Specific Therapies for Overlapping Symptoms

Given the clinical overlap with IC/BPS (suprapubic pain, incomplete emptying), consider IC/BPS therapies when CP/CPPS treatments fail. 1

Oral Medications

• Cimetidine specifically improves nocturia and bladder-related symptoms with Grade B evidence and no reported adverse events. 5

• Pentosan polysulfate sodium (Elmiron) 100 mg three times daily is FDA-approved for IC/BPS, but mandatory ophthalmologic monitoring is required due to risk of macular damage. 2

Intravesical Therapies

• Heparin intravesical therapy repairs the damaged glycosaminoglycan layer and provides clinically significant symptom improvement. 5, 2

• Lidocaine intravesical therapy provides rapid onset temporary relief of bladder pain. 2

Multimodal Pain Management

• Initiate multimodal pain management approaches throughout all treatment phases, strongly preferring non-opioid alternatives due to the chronic nature of CP/CPPS. 5, 2

• Pain management alone does not constitute sufficient treatment—underlying bladder and pelvic floor symptoms must be addressed. 2

Advanced Interventions for Refractory Cases

• Sacral neuromodulation may be considered if other treatments have not provided adequate symptom control. 2, 8

• Minimally invasive procedures such as microwave thermotherapy or transurethral needle ablation are available options. 8

Critical Implementation Points

Document baseline symptoms using validated tools such as the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure treatment effects. 2, 3, 8

Set realistic expectations: no treatment reliably benefits most or all patients, and multiple therapeutic options may need to be tried before adequate symptom control is achieved. 1, 2

Use a phenotype-directed multimodal approach rather than sequential monotherapy trials, as the heterogeneous nature of CP/CPPS demands addressing multiple contributing factors simultaneously. 6, 7

Consider cystoscopy if symptoms persist despite treatment, particularly to identify Hunner lesions which would indicate IC/BPS and respond to fulguration or triamcinolone injection. 1, 2