P-070 - An Integrated Approach to Pain Management in Chronic Prostatitis: A Case Study

Abstract Title: An Integrated Approach to Pain Management in Chronic Prostatitis: A Case Study


Background: Chronic Prostatitis (CP) also known as Chronic Pelvic Pain Syndrome (CPPS) is a clinical syndrome with complex pathophysiology leading to pain in the pelvic region with a variety of symptoms¹ affecting 2-6% of men². There are four types of prostatitis that can be distinguished between using lab results, imaging, and symptoms¹. The pathophysiology of CP is not completely understood but involves the hypogastric nerve, pelvic nerve, and pudendal nerve³. Proposed etiologies include autoimmunity, neurogenic pain, inflammation, or psychological factors¹. The complex nature of CP requires a multimodal approach to treatment that is individualized to maximize improvement.

Purpose/Objectives: A systematic approach such as UPOINT helps clinicians standardize and more easily implement this approach to cases of CP/CPPS⁴. UPOINT stands for urinary, psychosocial, organ, infection, neurologic, and tenderness⁴. This approach also addresses the various potential etiologies that may be present in this clinical syndrome. This single case report is to evaluate how a multimodal approach to CP can result in improved pain and function. It also looks at how a systematic approach such as UPOINT can be implemented and used to help clinicians.


Methods: A 31-year-old male presented to the clinic with pain in the scrotal and penile area for the past 2 months. Past medical history revealed an emergency room visit for 8/10 sharp lower left quadrant and a burning penile pain that was treated empirically as pyelonephritis. Cystoscopy and CT showed know abnormalities with his urinary tract. In addition to pain, patient was now complaining of increased urinary frequency. In two clinic visits that followed, any infectious etiologies were ruled out and PHQ-4 was used to evaluate for possible psychosocial origins. Treatment in the clinic was a combination of Pregabalin, Tamsulosin, acupuncture and OMM. These interventions were continued in subsequent clinic visits. Specifically, a variety of OMM techniques treated somatic dysfunction found in the lumbar spine, sacrum, pelvis and pelvic diaphragm. Additionally, the patient was referred for evaluation by Physical Medicine and Rehabilitation (PM&R) and Pelvic Floor Physical Therapy (PFPT). PM&R recommended pudendal nerve blocks which the patient decided to undergo. PFPT preformed dry needling and kinesiotaping.

Results: The patient experienced a decrease in pain following each clinic visit. His pain went from an 8/10 at the ED to a 4/10 after his second clinic visit accompanied by resolution of increased urinary frequency. Four months following his third clinic visit, after attending PFPT, and undergoing bilateral pudendal nerve blocks the patient was relatively pain free. He was no longer being seen by PM&R, had weaned off of all of his prescription medications, and was only seeing PFPT once every three weeks. On occasion he experienced a dull pain that was a 2/10 but was easily managed with over-the-counter pain medication.

UPOINT easily categorizes the treatments and problems evaluated in this patient. Urinary symptoms were treated using tamsulosin. Possible psychosocial problems were evaluated through screening with PHQ4. Organs of the urinary tract were evaluated using cystoscopy and CT. Infection was investigated through urine cultures. Neurologic pain and tenderness were addressed using pregabalin, OMM, Acupuncture, PFPT, and pudendal nerve blocks.

Conclusions/Implications for future research and/or clinical care: Overall, the complex nature of CP requires a multimodal approach. Studies have shown using OMM, Acupuncture, and PFPT have improved CP/CPPS patients’ pain and quality of life, and this was evident in this case^5-7. These manual interventions allow for the targeting and normalization of the sympathetic, parasympathetic and somatic innervation of the prostate while also addressing the muscular and biomechanical structures in the region. This integrated approach to treatment provided individualized care that targeted multiple aspects of CP, maximized pain relief, and improved function for the patient. In the future continued research with larger clinical studies evaluating the use of OMM, acupuncture, PFPT, and other manual therapies in the treatment of CP/CPPS would be beneficial. Additionally, increased awareness and education to clinicians about systematic approaches to treating CP/CPPS, such as UPOINT, need to occur to allow for more standardized, comprehensive treatment while still encouraging individualized care.

References: 1. Vaidyanathan R, Mishra VC. Chronic prostatitis: Current concepts. Indian J Urol. 2008;24(1):22-27. doi:10.4103/0970-1591.38598

2. Doiron RC, Nickel JC. Management of chronic prostatitis/chronic pelvic pain syndrome. CUAJ. 2018;12(6S3):S161-3. doi:10.5489/cuaj.5325

3. Luisetto M. Receptor Pharmacology and Other Relevant Factors in Lower Urinary Tract Pathology under a Functional and Toxicological Approach: Instrument to Better Manage Antimicrobials Therapy. APCT. 2018;3(5). doi:10.23880/APCT-16000146

4. Bryk DJ, Shoskes DA. Using the UPOINT system to manage men with chronic pelvic pain syndrome. Arab J Urol. 2021;19(3):387-393. Published 2021 Jul 23. doi:10.1080/2090598X.2021.1955546

5. Rabal Conesa C, Cao Avellaneda E, López Cubillana P, et al. Manual Therapy Intervention in Men With Chronic Pelvic Pain Syndrome or Chronic Prostatitis: An Exploratory Prospective Case-Series. Cureus. Published online April 25, 2022. doi:10.7759/cureus.24481

6. Franco JV, Turk T, Jung JH, et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Urology Group, ed. Cochrane Database of Systematic Reviews. 2018;2018(5). doi:10.1002/14651858.CD012551.pub3

7. Marks SK, Rodriguez NA, Shah A, Garcia AN, Ritter L, Pierce AN. Clinical Review of Neuromusculoskeletal Complementary and Alternative Approaches for the Treatment of Chronic Pelvic Pain Syndrome. Cureus. Published online July 20, 2022. doi:10.7759/cureus.27077