The information below is based on the European Association of Urology Guideline for Chronic Pelvic Pain (2019).

Self-care advice:

• Consider paracetamol or if preferred and suitable, ibuprofen for pain or fever
• Drink adequate fluids to avoid dehydration
• If defecation is painful — a stool softener such as lactulose or docusate may be helpful

Chronic Pelvic Pain Syndrome (CPPS) is characterized by at least 3 months of pain in the perineum or pelvic floor, often associated with lower urinary tract symptoms, and sexual dysfunction (erectile dysfunction, painful ejaculation, or postcoital pelvic discomfort).

CPPS is the occurrence of chronic pelvic pain when there is no proven infection or other obvious local pathology that may account for the pain.

For over 90% of men with chronic pelvic pain syndrome there is no proven bacterial infection.

A diagnosis is made based on the man's history, physical examination, and the exclusion of other conditions. Before considering antibiotic treatment for CPPS, exclude (or treat) the following other conditions that may be causing symptoms, such as:

• Prostatitis (acute)
• Urinary tract infections (UTI)
• Benign prostatic hyperplasia (BPH) / Lower urinary tract symptoms (LUTS)
• Epididymitis / Urethritis
• Sexual dysfunction
• Cancer of the prostate, bladder or colon
• Urethral stricture
• Obstructive calculus or a foreign body in the urinary tract

Consider a referral to specialist if there is diagnostic uncertainty, or if symptoms are severe.

If all other causes have been excluded, consider antibiotic treatment (see below).

Considerations when prescribing antibiotics:

When considering antibiotics (see specifics below), take account of severity of symptoms, risk of complications or having treatment failure (particularly after medical procedures such as prostate biopsy), previous urine culture and susceptibility results, and previous antibiotic use which may have led to resistant bacteria.

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• Alternative diagnoses
• Any symptoms or signs suggesting a more serious illness or condition, such as acute urinary retention, prostatic abscess, or sepsis
• Previous antibiotic use, which may lead to resistant organisms
• Consider CRGs if referral required:
  • Prostatitis Suspected - West Devon, South Devon
  • Chronic Pelvic Pain Syndrome - West Devon, South Devon

Where oral antibiotics are indicated

Patients can be advised to continue self-care options during antibiotic treatment

Consider referral to specialist if symptoms are not resolved after a course of antibiotics (see local referral guideline)

Trimethoprim

• 200mg twice daily for 4 to 6 weeks

OR

Azithromycin

• 500mg once daily, three times a week, for 3 weeks
• Caution in people with a prolonged QT interval or who have risk factors for QT interval prolongation or those taking other drugs that prolong the QT interval

Doxycycline

• 100mg twice daily for 4 to 6 weeks

See sections: 5.1.3 Tetracyclines, 5.1.5 Macrolides, and 5.1.8 Sulfonamides and trimethoprim