What is the treatment for chronic pelvic pain syndrome?

Question

Hello doctor,

I am a 29-year-old male with prostatitis. My prostatitis symptoms flared up a few months ago, after eight months of partial remission. Last week, the pain worsened, accompanied by cramping over my pubic bone. Now, the discomfort and cramping occur simultaneously in multiple areas (perineum, penis, rectum, and over the pubic bone). They leave me feeling very tired and stressed, and I tend to feel cold. I also experience pressure at the base of the penis, as well as pressure and itching in the urethra and the outside of the penis. I had not experienced pain in so many areas before. I am quite concerned about this and am unsure of the cause. What should be the next course of action?

In the past four months, I have also noticed that the veins in my urethra occasionally darken and inflate slightly, particularly if I sit for a long time on an uncomfortable seat. Is this normal? What could be causing it? Does my pelvic MRI (magnetic resonance imaging) show any abnormalities? I have also attached two images of the urethra; please note that the colors of the veins in the images may not be accurate.

Prostatitis symptoms, including penile pain, pain during and after ejaculation, pain while starting urination, perineum pain, rectal pain, and lower back pain, began more than three years ago. A few months after a sexual encounter, I experienced a sharp sensation at the tip of the penis. I was treated with Ciprofloxacin, Doxycycline, and Trimethoprim/Sulfamethoxazole. While these antibiotics provided slight improvement, the symptoms returned immediately after stopping the medication. I had to discontinue all antibiotics due to adverse stomach-related side effects, but these effects became negligible after three to four weeks. For the next six months, my prostatitis symptoms were minimal, though they would flare up with physical activity. During this period, I also experienced severe stomach issues, including bloating, constipation, and food sensitivities. As my stomach issues improved and I became more active, I experienced a similar pinch at the tip of the penis during sex, and within two months, all my symptoms returned.

After this, I endured discomfort for four months, during which I noticed that the color of my semen had changed to yellow. I managed to reduce my discomfort through dietary changes and by avoiding sitting on regular chairs. Four months ago, my symptoms resurfaced after sitting on a regular chair for an hour and having a sexual encounter; this time, the symptoms did not subside. I began experiencing pain after walking and a frequent sensation of an unemptied bladder. I started internal pelvic floor therapy, which alleviated some lower back pain, but my pelvic floor became very sensitive. On two occasions, physical activities triggered severe spasms in my pelvis that lasted for days.

Four weeks ago, I felt pain over my pubic bone. However, after trying magnesium supplements last week, the pain worsened. The day after ejaculation, my urethra was extremely sore, and the pain over my pubic bone became unbearable at night. The following day, I was in so much pain that I could not stand. Since then, I have been experiencing simultaneous spasms in multiple areas: my pelvis, pubic bone, base of the penis, and lower abdomen, which triggers severe sensations throughout my body.

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

I have reviewed your MRI (magnetic resonance imaging) images and other reports (attachments removed to protect the patient’s identity), and all findings are normal. Based on your clinical features and investigation results, it appears you are experiencing chronic pelvic pain syndrome (CPPS). It is important to understand that, although the symptoms may be severe, this condition will not cause any physical harm to your body. Minor infections or stress can sometimes exacerbate these symptoms.

I recommend the following medications, but please consult your local physician before starting them. Take Levofloxacin 500 mg once in the morning for four weeks, and Amitriptyline 10 mg once at night for two weeks, then increase to 25 mg for an additional ten weeks. After that, you can taper the Amitriptyline back to 10 mg for two weeks before discontinuing it.

I hope this helps you.

Answer 2

Hello,

Welcome back to icliniq.com.

I am unable to comment on the angulation of your coccyx based on the images provided (attachments removed to protect the patient’s identity). An orthopedic specialist would be better suited to guide you on this matter. Levofloxacin is currently preferred because it has a once-daily dosing regimen, fewer side effects, and better sensitivity compared to other fluoroquinolones like Ciprofloxacin. Standard alternatives with better prostate penetration include Trimethoprim/sulfamethoxazole and Doxycycline, both of which you have tried previously. Other options with minimal side effects include Cephalexin (500 mg twice or three times daily) and Cefixime (200 mg twice daily).

Amitriptyline at a dosage of 10 mg usually has minimal side effects. Since your condition is related to neural sensitivity, the most effective medications will have some impact on mental function. Nortriptyline 25 mg may have fewer side effects than Amitriptyline. Additionally, Pregabalin 75 mg or Gabapentin 300 mg can also be effective for this condition. Consult your specialist doctor, discuss with him or her, and take the medicines with take the medicines with their consent. Weekly prostatic massages by a urologist can also be an effective therapeutic measure.

I hope this helps you.

Thank you.