The first consultation

At first visit, an in-depth review of symptoms is vital.

• Review of symptoms, including a detailed history of any urinary voiding problems.

• Any precipitating factors to symptoms.

• Any relieving factors, including any therapeutic interventions.

• Past medical, sexual, drug and social history including details of their support network should also be recorded.

• Specific anxieties or concerns, including persistent unidentified infection, cancer or infertility.

• Detailed explanation of how increased pelvic floor tone can cause referred pain elsewhere in the pelvis and affect urinary flow and cause dysuria and pain on ejaculation (see below).

This requires an ‘active’ listening technique and an ability to empathise with the patient’s often-manifest distress. Finally, one should enquire as to whether they have the ability to focus on solving problems for longer than the majority of their peers but with a tendency for circular trains of thought to occur if no solution is evident—‘driven problem-solver’ and/or they have an anxious persona as, in our experience, both personas are associated with CPPS secondary to increased pelvic floor tone. If the patient is a problem-solver, this should be acknowledged as a positive characteristic which can sometimes have a negative impact when no solution to the problem can be found.3 This helps the patient to actively engage with the detailed explanation about the likely cause of their symptoms as detailed below and what they can do to make their symptoms better.

Patients should also complete the National Institutes of Health – Chronic Prostatitis Symptom Index score (NIH-CPSI) (online supplemental appendix 1, figure 2) to evaluate their symptoms, which should be undertaken at each subsequent visit.^A11 This allows objective assessment of the severity of their symptoms and evaluation of their response to therapy.6 7 9 10

Examination should include:

• Lower abdominal region and hernial orifices.

• Genital examination including testicles, penis and perineum.

• Digital rectal examination (DRE) to assess pelvic floor muscle tone and tenderness, prostate size, shape and tenderness.

Investigation should include:

• Urethral smear.^A2

• Repeat chlamydia nucleic acid amplification test (NAAT) if initially chlamydia NAAT-positive and >5 weeks post treatment.^A2

• Test for Mgen and possibly trichomoniasis using a NAAT if urethritis is detected and if not already undertaken.^{A2 A9 A12}

• We have not found the four glass urine test of clinical value if there is no evidence of urinary tract infection (UTI).2

Management

The primary aim is to exclude all potential and treatable causes and in so doing address the patients underlying anxieties which often centre on unknown (potentially transmissible) infection or cancer. The goal is not to cure the patient but to improve their symptoms so that they become manageable—it is important to be realistic. In our experience, patients understand that most people have intermittent aches or pains.

The basic pelvic floor anatomy should be discussed using online supplemental appendix 1 figure 3 in conjunction with its innervation using online supplemental appendix 1, figure 4 and introducing the concept of referred pain using the analogy of angina and/or having a heart attack (online supplemental appendix 1, figure 4). The analogy with the heart and how pain can be experienced (referred) elsewhere is very helpful for patients in enabling them to understand and accept that referred pain is ‘real’ and is not psychological. There should then be a discussion about how increased pelvic tone can result in (1) back flow/pressure of urine (and/or semen during ejaculation) into the prostate, resulting in referred pelvic pain and may cause non-infective prostatitis which may explain why some men with CPPS have urethritis detectable on urethral smear; (2) muscle spasm resulting in referred pain experienced elsewhere in the pelvic area, for example, tip of the penis, testicles, perineum (area behind the testicles), lower abdomen and may also cause difficulties/pain when passing water and ejaculating.1 3 4

The increased pelvic floor tone often arises as a result of anxiety which can unconsciously cause some men to increase their pelvic floor muscle tone (they do not realise they are doing this as normally we cannot ‘feel’ our pelvic floor). The CPPS reinforcement feedback loop^A8 detailed in online supplemental appendix 2, figure 2 is a helpful visual educational tool for explaining this. It should be explained that often the precipitating factor has resolved, as indicated by the history and/or specific investigations which are/have been carried out and/or treatment given. As the men are not aware that they are tensing their pelvic floor, the symptoms they experience are attributed to disease in those parts of the pelvis where they are experiencing the pain. This often exacerbates their anxiety, particularly if no cause can be found, further increasing their pelvic floor tone and therefore their symptoms. Conversely, when they are relaxed and not thinking about their symptoms the pain is much improved. Patients often describe good and bad ‘days’ which patients on gentle prompting often map to being on holiday (low stress) or stressful situations respectively. This facilitates patients (1) accepting the above concept as the cause of their pain in the absence of no other causes being identified; (2) taking ownership of the central role they need to play in reducing their symptoms.

The majority (>90%) of men at Unity have increased pelvic floor tone7 and pelvic floor relaxation through relaxation exercises with or without the use of an alpha blocker2 with identification and discussion about reducing stressors3 8 and the biological principles and evidence informing their use is the main stay treatment.1 The observation of a tense and tender/painful pelvic floor on DRE in the absence of other causes in our experience is important in getting the patient to accept that this may indeed be the cause of their symptoms. A leaflet on pelvic floor relaxation should be provided and discussed (online supplemental appendix 3) and advice about distraction techniques when the pain is present. Mindfulness may also have a role here.2 In our experience, exercise can be an effective distraction technique and may have other beneficial properties.^{A13 A14} Accurate and concise written information in the form of a patient leaflet, with online resources and references should also be provided (online supplemental appendices 2 and 3).

The role of the urethral smear for detecting urethritis in the absence of chlamydia, gonorrhoea, Mgen and trichomonas is to guide treatment strategies. Antibiotics have been demonstrated to be of benefit in men with CPPS but the mechanism is unclear in the absence of infection.2 6 ^{, A13 A14} Possible aetiologies of urethritis include intra-prostatic urinary reflux4 or a proinflammatory urethral mucosa secondary to persistent epithelial to mesenchymal transition as a result of epigenetic changes following chlamydia infection.^A15–A17 Macrolides have an anti-inflammatory immunomodulatory action and 3 weeks of a macrolide have been demonstrated to be effective in chronic NGU and CPPS.3 ^{, A18 A19} With the increasing focus on antimicrobial stewardship,^A20 we now restrict the use of clarithromycin 500 mg twice daily for 3 weeks to men with infection-negative urethritis. The proposed mechanism of action should be discussed with the patient.

In our experience men can be divided into four broad categories based on the initial clinical findings.

• Category 1. Increased pelvic floor tone and/or tender; urethral smear-positive.

• Category 2. Increased pelvic floor tone and/or tender; urethral smear-negative.

• Category 3. Pelvic floor tone normal and not tender; urethral smear-positive.

• Category 4. Pelvic floor tone normal and not tender; urethral smear-negative.

See figure 1 for management pathways. Many patients improve after the first session which, in our experience, is associated with a good understanding of the underlying mechanism with subconscious tensing of the pelvic floor resulting in a positive feedback loop (see above). MC now undertakes first follow-up consultation at 6 weeks by telephone for many patients, if clinically appropriate, due to the high success rate of the initial consultation.7

For those with a poor response, as judged by the NIH-CPSI score^A11 (figure 1), having reviewed the diagnosis to ensure other causes have been excluded, it is important to check they understand (1) that there is no evidence of other pathology, (2) the underlying principles of why pelvic floor relaxation is likely to be of benefit and (3) how to correctly relax their pelvic floor muscles. Are there complicating factors in the persons’ persona, social history and/or medical history which may be contributing to their increased pelvic floor tension and lack of response? Can these be addressed more effectively? Consider additional pharmacological treatment options, see figure 1.1–3 ^{, A8} Referral for pelvic floor physiotherapy should also be considered, as some patients have difficulty with undertaking pelvic floor relaxation exercises and benefit from specialist input. Further follow-up whether by telephone or in clinic is dependent on the clinical assessment and patient discussion at the first follow-up appointment.