Chronic Pelvic Pain Syndrome: Why It Is So Often Missed

Many men live for months, sometimes years, with a dull ache between the legs, burning when they pass urine, or pain after ejaculation. They see several doctors, take course after course of antibiotics, and are often told the tests are normal. Very few are told the name of what they actually have: chronic pelvic pain syndrome, or CPPS.

CPPS, also called chronic prostatitis, is one of the most common reasons men under 50 see a urologist. Prostatitis like symptoms affect roughly 2 to 10 percent of men. In his 2025 article in BJU International, Dr Datesh Daneshwar described CPPS as the most common urological disease that medicine chose to forget. This article explains why it is so often missed, and what good care looks like.

What does CPPS feel like?

• Pain or pressure in the area between the scrotum and the anus (the perineum), the testicles, the tip of the penis, the lower abdomen or the lower back
• Burning or discomfort when passing urine, needing to go often, or a weak stream
• Pain during or after ejaculation
• Erection problems, low mood, poor sleep and stress, which often build up the longer the pain goes on

Symptoms tend to come and go in flares. Sitting for long periods, stress, cycling and some foods or drinks can make them worse.

Why is it so often missed?

1. It is labelled as an infection. The word prostatitis suggests infection, so many men are treated with antibiotics again and again. But in most men with long term symptoms no bacteria are found. In a large NIH funded trial, the antibiotic ciprofloxacin worked no better than placebo for established CPPS, and a separate trial found the same for levofloxacin.

2. The tests look normal. Urine tests, blood tests and scans are often clear, because CPPS is a pain condition rather than a structural one. Normal results can leave men feeling dismissed, or worried that something has been overlooked.

3. The pain comes from more than one place. Tight and tender pelvic floor muscles, irritated nerves, the bladder and the way the nervous system processes pain can all play a part. A single test or single tablet rarely captures that.

4. Men do not talk about it. Pain in the genital area and sexual symptoms are hard to talk about. Many men wait a long time before seeing a specialist, and some never do.

5. It overlaps with other conditions. Men with CPPS are more likely to also have irritable bowel syndrome, chronic fatigue or other pain conditions, which can send them down several different paths before the pieces are put together.

How is CPPS diagnosed?

CPPS is diagnosed by taking a careful history and ruling out other causes. A urologist will usually:

• Ask about your symptoms, how long they have lasted and how they affect your life, often using the NIH Chronic Prostatitis Symptom Index questionnaire
• Examine the abdomen, genitals and pelvic floor muscles
• Check urine for infection and blood, and arrange other tests only when they are needed to exclude conditions such as infection, an enlarged prostate, stones or cancer

What does good treatment look like?

Because CPPS has several possible drivers, guidelines recommend matching treatment to each man rather than using one treatment for everyone. A common way to do this is the UPOINT approach, which looks at six areas: Urinary symptoms, Psychosocial factors, Organ specific symptoms, Infection, Neurological or body wide pain, and Tenderness of the pelvic muscles. Published series using this tailored approach report meaningful improvement in about three in four men.

Depending on your symptoms, a plan may include alpha blockers for urinary symptoms, pain relief, pelvic floor physiotherapy, lifestyle changes, support for stress and sleep, antibiotics only when an infection is genuinely suspected, and in selected patients low intensity shockwave therapy. Dr Datesh has published research on shockwave therapy in men with CPPS and erectile dysfunction, which showed improvement in pain, urinary symptoms and quality of life scores. It is one option within a wider plan, not a stand alone cure.

If you have had pelvic pain, burning or urinary symptoms for three months or more, a proper assessment is the first step. Book a consultation with Dr Datesh.

References

1. Daneshwar D. Chronic pelvic pain syndrome: the most common urological disease medicine chose to forget. BJU International. 2025.
2. Bryk DJ, Shoskes DA. Using the UPOINT system to manage men with chronic pelvic pain syndrome. Arab Journal of Urology. 2021;19(3):387 to 393.
3. Alexander RB, et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double blind trial. Annals of Internal Medicine. 2004;141(8):581 to 589.
4. Nickel JC, et al. Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo controlled multicenter trial. Urology. 2003;62(4):614 to 617.
5. Rodríguez MAB, Afari N, Buchwald DS. Evidence for overlap between urological and nonurological unexplained clinical conditions. Journal of Urology. 2009;182(5):2123 to 2131.
6. European Association of Urology. EAU Guidelines on Chronic Pelvic Pain. 2025 edition.
7. Daneshwar D, Nordin A. Low intensity extracorporeal shockwave therapy for chronic pelvic pain syndrome patients with erectile dysfunction. Investigative and Clinical Urology. 2022. PMID 35029213.

Content by Uroheal, the practice of Dr Datesh Daneshwar, Consultant Urologist, Prince Court Medical Centre, Kuala Lumpur. Published 5 November 2026. This article is general information and does not replace a consultation with a doctor.