A Chinese expert consensus on prostate-pelvic syndrome

Chronic prostatitis (CP) is among the most prevalent disorders in young and middle-aged men. Clinically, it manifests as lower urinary tract symptoms, pain, and sexual dysfunction, significantly impairing quality of life. Traditional classifications of prostatitis include acute bacterial prostatitis, chronic bacterial prostatitis, chronic nonbacterial prostatitis (CNP), and prostatic pain (PD). According to the National Institutes of Health (NIH), the combination of CNP and PD constitutes type III prostatitis, also known as CP/chronic pelvic pain syndrome (CPPS), which accounts for approximately 90% to 95% of all prostatitis cases.1,2 Compared with traditional classifications, the NIH system has improved diagnostic accuracy and, to some extent, therapeutic efficacy for CP. However, both classification methods remain insufficiently integrated into routine clinical practice. Diagnostic approaches and efficacy assessment criteria, such as the “four-glass test” and the NIH Chronic Prostatitis Symptom Index, are infrequently applied in practice. A common misconception in clinical settings is overreliance on leukocyte counts in expressed prostatic secretion (EPS) for diagnosis and treatment monitoring. Consequently, inappropriate antibiotic use is frequent, despite limited clinical benefit. There is, therefore, an urgent need for simple, rapid, and clinically applicable diagnostic and efficacy assessment standards. In June 2011, the Chinese Collaborative Group for the Diagnosis and Efficacy Criteria of Chronic Prostatitis was established in Hefei, China, to develop symptom-based diagnostic and efficacy criteria through large-scale epidemiological surveys and multicenter studies.3 Experts in the Collaborative Group define type III prostatitis as a syndrome characterized by persistent or recurrent pain or discomfort in the perineum and lower abdomen lasting more than 3 months, lower urinary tract symptoms, varying degrees of sexual dysfunction, reduced fertility, and associated psychiatric or psychological symptoms. Based on these findings, the Collaborative Group recommends referring to type III prostatitis as “prostate syndrome,” emphasizing that it encompasses a cluster of prostate-related clinical manifestations, including lower abdominal, pelvic, and perineal pain and/or urinary abnormalities, not attributable to pathogenic microorganisms or other diseases. Following long-term multicenter studies and iterative expert discussions, the syndrome has been more precisely defined as “prostate-pelvic syndrome (PPS).”3 This consensus incorporates CNP and PD from traditional classifications and CP/CPPS from the NIH system. Its implementation aims to enhance clinicians’ and patients’ understanding of PPS, promote accurate diagnosis and evidence-based management, reduce overdiagnosis and unnecessary interventions, conserve healthcare resources, and ultimately improve patients’ quality of life. 1. Epidemiology Epidemiological studies indicate that 35% to 50% of men experience prostatitis at some point in their lives, with a subset experiencing substantial reductions in quality of life.4–6 The prevalence of prostatitis varies by region. In China, approximately 8.4% of men aged 15 to 60 years report prostatitis-related symptoms.7 Factors such as lifestyle, sexual activity, and psychosocial conditions are closely associated with the incidence of CP/CPPS.8–10 2. Pathogenesis The etiology of PPS remains incompletely understood and is largely extrapolated from studies on CP/CPPS. The syndrome is believed to arise from single, multiple, or interacting factors that contribute to disease onset.11 For example, psychological stress may provoke pelvic inflammation and muscle spasm through neuroendocrine activation. Conversely, neurosensory alterations and endocrine disruption may exacerbate psychological disorders, such as anxiety and depression, creating a self-perpetuating cycle that promotes PPS development. Inflammation-driven neuromuscular dysfunction of the pelvic floor and epithelial abnormalities of the lower urinary tract are considered primary pathogenic contributors, along with immunological, neuroendocrine, and psychosomatic factors.12 2.1. Lower urinary tract epithelial dysfunction The lower urinary tract microenvironment comprises epithelial protective and injurious factors, as well as urinary anions and cations, which collectively influence target organs such as the prostate, urethra, and bladder.13 Dysfunction of the lower urinary tract epithelium may arise from an imbalance between injurious and protective factors. Clinically, CP/CPPS shares similarities with interstitial cystitis, including overlapping symptoms, potassium sensitivity responses, and pharmacological treatment profiles, suggesting a potential shared pathogenic mechanism.14 Additionally, studies have indicated that abnormal potassium and calcium channel activity in prostate smooth muscle cell membranes may contribute to the development and progression of CP/CPPS.15–17 2.2. Abnormal urinary function In some patients, overcontraction of the urethral sphincter can obstruct bladder outflow, increase postvoid residual urine, and promote urine reflux into the prostate, potentially triggering “chemical prostatitis.” This mechanism contributes to lower urinary tract irritation and pain. 18 Additionally, CP/CPPS patients often exhibit reduced urinary flow rates, functional urethral obstruction, and impaired coordination between the urethral sphincter and peristaltic muscle activity, which may play a role in disease onset and progression. 2.3. Psychosomatic factors Patients with refractory CP/CPPS often exhibit significant alterations in psychosomatic and personality traits,19,20 including depression, hypochondriasis, anxiety, dysthymia, and suicidal tendencies.21,22 These psychosomatic disturbances can contribute to neuromuscular dysfunction of the posterior urethra,23 resulting in perineal pain, abnormal voiding patterns, and other lower urinary tract symptoms.24 Moreover, dysregulation of the hypothalamic–pituitary–gonadal axis may occur, adversely affecting sexual function.25 2.4. Neuroendocrine factors Altered perineal sensitivity to thermal and pain stimuli in CP/CPPS patients suggests involvement of neuroendocrine mechanisms in disease pathogenesis.26 Prostate pain is often visceral in nature, with poor localization. Experimental evidence indicates that physicochemical stimulation of the prostate, urethra, and surrounding tissues activates afferent nerves, triggering spinal reflexes that stimulate astrocytes in the lumbar and sacral spinal cord.27,28 This, in turn, activates sympathetic nerve endings, which release bioactive substances, including norepinephrine, prostaglandins, calcitonin gene-related peptide, and substance P, via the genitofemoral and ilioinguinal nerves.29 These processes lead to abnormal activity of the perineal and pelvic floor muscles and contribute to referred and persistent pain in the corresponding regions.30,31 2.5. Abnormal immune response Patients with CP/CPPS exhibit alterations in both cellular and humoral immunity, including reduced CD8+ T-cell levels and elevated IgG concentrations, indicating immune system involvement in disease progression.32 Additionally, changes in key cytokines, such as MCP-1, MIP-1α, tumor necrosis factor-α, interleukin (IL)-2, IL-6, IL-8, and IL-10, have been observed in seminal plasma, prostatic fluid, blood, and prostate tissue of affected individuals.33–36 These cytokine profiles suggest that immune mediators may serve as potential biomarkers for the diagnosis and therapeutic monitoring of CP/CPPS. 2.6. Imbalance in redox balance Patients with CP/CPPS exhibit impaired clearance of reactive oxygen species (ROS) in prostate tissue. Key antioxidant enzymes, including superoxide dismutase and glutathione peroxidase, often show reduced activity or expression, diminishing the prostate’s capacity to counteract oxidative stress. Concurrently, infiltration of inflammatory cells, such as macrophages and neutrophils, generates additional ROS, including superoxide anions and hydroxyl radicals, through processes such as respiratory bursts, further exacerbating oxidative damage. Excessive ROS induces lipid peroxidation, protein oxidation, and DNA damage, while sensitizing local nerve endings. These events collectively contribute to persistent inflammation, interstitial fibrosis, and heightened pelvic nerve sensitivity, suggesting that oxidative stress imbalance is a key pathogenic mechanism in CP/CPPS.37,38 2.7. Other pelvic-related disease factors In some patients with CP/CPPS, dilation or tortuosity of the prostatic venous plexus, hemorrhoidal veins, and spermatic venous plexus has been observed. These vascular abnormalities suggest that impaired pelvic venous return may contribute to clinical symptoms by reducing the clearance of metabolic byproducts and inflammatory mediators. Persistent pelvic venous congestion not only compromises microcirculatory perfusion within prostate tissue but may also, via venous anastomoses, maintain a chronic hypoxic and proinflammatory microenvironment. This state perpetuates ongoing inflammation and sensitization of prostatic nerve endings, potentially serving as a key mechanism underlying recurrent symptoms.39 2.8. Microbiome imbalance Patients with CP/CPPS exhibit significant alterations in both gut and urinary microbiomes, implicating microbial imbalance as a pathogenic factor. CP/CPPS is associated with reduced protective gut microbiota and increased pathogenic species, which may disrupt Th17/Treg immune cell differentiation via the gut–brain–prostate axis. In the urinary tract, enrichment of anaerobic bacteria promotes biofilm formation, stimulating immune responses in the prostate and surrounding tissues. These immune responses release bioactive mediators such as IL-17 and tumor necrosis factor-α, contributing to pelvic pain, urinary dysfunction, and other clinical manifestations.40–44 3. Diagnosis of prostate-pelvic syndrome The consensus recommends a symptom-based approach for diagnosing PPS, classifying clinical manifestations into main and secondary symptoms. Main symptoms include pain in the perineum, lower abdomen, testicles, penis, and lumbosacral region, as well as pain during urination or after sexual intercourse. Micturition abnormalities, such as urinary frequency, urgency, and incontinence, are also considered main symptoms. Secondary symptoms encompass sexual dysfunction (e.g., decreased libido, premature ejaculation, and erectile dysfunction), mental and psychological disturbances (e.g., anxiety, depression, insomnia, and memory impairment), reduced male fertility (e.g., semen nonliquefaction, low sperm count, and poor motility), and other complaints such as scrotal dampness or urinary dribbling. A diagnosis of PPS is established when a patient presents with at least one main symptom, with or without accompanying secondary symptoms, and symptoms persist for more than 3 months despite self-management, as illustrated in Figure 1 below. At the initial visit, digital rectal examination, routine urinalysis, urinary system evaluation, and prostate ultrasonography are recommended to rule out urologic tumors, urinary tract infections, or a history of acute bacterial prostatitis. The PPS Scoring Criteria prioritize symptom assessment for both diagnosis and evaluation of therapeutic efficacy, shifting away from traditional reliance on leukocyte counts in EPS/VB3. Treatment efficacy is determined by the degree of improvement in main and secondary symptoms, as outlined in Table 1. Prostate imaging may further support the diagnosis by enabling quantitative evaluation of prostatic lesions.45,46 Table 1 - Scoring criteria for prostate-pelvic syndrome. Symptom type Specific symptoms Degree of impact on the patient’s life Mild Moderate Severe Main symptoms ① Pain-related symptoms 1–5 6–10 11–15 ② Micturition symptoms 1–5 6–10 11–15 Secondary symptoms ① Psychiatric and psychological symptoms (e.g., anxiety, depression, insomnia, and memory loss) 1 point if present ② Sexual dysfunction (e.g., decreased libido, premature ejaculation, and erectile dysfunction) 1 point if present ③ Reproductive dysfunction (e.g., nonliquefying semen, oligospermia, and asthenozoospermia) 1 point if present ④ Other symptoms (e.g., scrotal dampness and urethral discharge) 1 point if present 1. The symptom scoring system was developed based on the NIH Chronic Prostatitis Symptom Index to facilitate diagnosis and evaluation of treatment efficacy.2. A score >1 in any of the main symptom categories (① or ②) is sufficient for a diagnosis of prostate-pelvic syndrome.3. Secondary symptom scores are used only to grade disease severity and assess treatment outcomes; they are not diagnostic criteria by themselves.4. Disease severity is classified according to the main symptom score: mild (1–5), moderate (6–10), and severe (>10). Figure 1.: Diagnostic flowchart for PPS. PPS = prostate-pelvic syndrome.4. Treatment of prostate-pelvic syndrome 4.1. Therapeutic principles The management of PPS should be individualized and integrative, with treatment strategies tailored to each patient’s specific symptoms.47 Therapeutic approaches include pharmacological therapy, psychotherapy, localized microenergy treatments, and analgesia. Patient education and the dissemination of knowledge regarding PPS are also essential. The overall treatment process is shown in Figure 2. Antibiotic therapy is generally not recommended unless there is evidence of bacterial infection.Figure 2.: Treatment flowchart for PPS. PPS = prostate-pelvic syndrome.4.2. Selection of symptomatic treatments The primary objective of treatment is to alleviate pain, improve urinary symptoms, and enhance the patient’s quality of life. The effectiveness of therapy should be evaluated based on the degree of symptom improvement. 4.2.1. General treatment Healthcare providers should offer comprehensive health education, psychological counseling, and behavioral guidance. Patients should be advised to: avoid alcohol consumption and spicy or irritant foods, refrain from holding urine or remaining seated for prolonged periods, maintain adequate protection against cold exposure, engage in regular, moderate physical activity, and follow a balanced and consistent lifestyle routine. 4.2.2. Medication Common pharmacological interventions include α-blockers, nonsteroidal anti-inflammatory drugs, plant-based preparations, and muscarinic (M) receptor antagonists. These agents are typically administered orally; however, transrectal administration may be effective in selected patients. α-Blockers Grade of recommendation: Strong recommendation based on moderate-quality evidence (1B). α-Blockers alleviate lower urinary tract symptoms and pain by reducing smooth muscle spasms in the prostate and surrounding tissues. They should be administered for at least 12 weeks.48,49 During treatment, clinicians should monitor for potential adverse effects, including dizziness and postural hypotension. Nonsteroidal anti-inflammatory drugs Grade of recommendation: Weak recommendation based on moderate-quality evidence (2B). The use of these medications, nonsteroidal anti-inflammatory drugs, in this context is generally considered largely empirical. They may be administered for short durations in patients with severe pain; however, caution is advised in older adults and in those with gastrointestinal disorders or renal impairment.50 5α-Reductase inhibitors 5α-Reductase inhibitors, such as finasteride, are generally not recommended for patients with prostatitis-like pelvic pain syndrome. Although they may improve urinary and pain symptoms, their use should be carefully evaluated in younger men and those with desiring fertility needs, as male patients receiving 5α-reductase inhibitors may suffer, because these agents may cause adverse effects such as decreased libido and erectile dysfunction. In older patients presenting with obstructive symptoms or recurrent, persistent hematospermia, their use may be considered after excluding prostate cancer. Botanical preparations Botanical preparations may alleviate symptoms by reducing nonspecific inflammation, contracting the bladder detrusor muscle, relaxing urethral smooth muscle, and modulating immune function.51 M-blockers Grade of recommendation: Weak recommendation based on moderate-quality evidence (2B). In patients with overactive bladder symptoms—such as urinary urgency, frequency, or nocturia—without evidence of urinary tract obstruction, treatment with M-blockers may be considered.52 Therapy should be continued if a clear symptomatic benefit is observed. Analgesics If monotherapy with an analgesic fails to achieve adequate symptom control, neuroleptic agents may be considered. Referral to a pain management center is recommended for further evaluation and multimodal treatment. Antidepressants and anxiolytics Grade of recommendation: Weak recommendation based on moderate-quality evidence (2B). Patients with PPS accompanied by depression or anxiety may benefit from concomitant treatment with selective serotonin reuptake inhibitors, tricyclic antidepressants, or benzodiazepines.53,54 Traditional Chinese medicine Traditional Chinese medicine should be administered according to evidence-based principles. Commonly used agents include those with properties that clear heat, eliminate dampness, promote blood circulation, resolve blood stasis, induce diuresis, and treat gonorrhea-related symptoms. 4.2.3 Other treatments Prostate massage In selected patients, prostate massage may be considered under appropriate indications.55 When combined with other therapeutic approaches, it may help shorten the disease course. Biofeedback Biofeedback therapy, including electromagnetic therapy, acupuncture, posterior tibial nerve stimulation, and transcutaneous electrical nerve stimulation, can alleviate perineal discomfort and improve urinary symptoms by relaxing hypertonic pelvic floor muscles and enhancing muscular coordination.56–58 Physical therapy Physical therapy is useful for managing pelvic floor muscle lesions and myofascial pain. Common approaches include thermotherapy and low-energy extracorporeal shock wave therapy. Thermotherapy utilizes heat generated by physical methods to act on the prostate and surrounding tissues. This promotes local blood circulation, reduces pelvic congestion, facilitates the resolution of inflammation and edema, and relieves pelvic muscle spasms. Common delivery routes include the transurethral, transrectal, and transperineal approaches. The heat sources are typically microwaves or radiofrequency energy. Clinical studies have shown that thermotherapy significantly improves symptoms in patients with PPS in the short term; however, its long-term efficacy requires further validation.59–61 Low-energy extracorporeal shock wave therapy is a noninvasive technique that exerts mechanical and thermal effects to induce favorable physiological responses in tissues.62 Low-energy shock waves can attenuate local prostate inflammation by reducing the release of inflammatory mediators and redox pain. Additionally, low-energy extracorporeal shock wave therapy promotes blood flow and tissue Its and efficacy have been in patients with poor response to therapy nonsteroidal anti-inflammatory drugs, and Psychiatric and psychological treatment Grade of recommendation: Strong recommendation based on moderate-quality evidence (1B). For patients experiencing chronic pain, psychological interventions can improve overall and contribute to effective pain Health management of prostate-pelvic syndrome syndrome is characterized by a prolonged and recurrent and affected patients often exhibit poor lifestyle and the health education and health management are of for these in moderate physical activity, sexual and a balanced with limited spicy and stimulating are all effective In such as prolonged and holding urine can help alleviate symptoms and Moderate and reduced may also lower the of the substantial influence of psychological factors on disease interventions that promote a and are to treatment are recommended to monitor treatment efficacy, therapeutic strategies in a and patients to self-management, disease This expert consensus PPS as a that the traditional classifications of and type III prostatitis according to the NIH system. The of this is to clinical management with therapeutic that prioritize symptom and improvement in quality of life. diagnostic approaches based on or leukocyte the PPS Scoring Criteria diagnosis and treatment evaluation based on symptom severity and the etiology of PPS, should on further of its to the underlying pathogenic mechanisms and the among key pathogenic factors and their role in disease onset and progression. the and of PPS clinical manifestations, multicenter studies from both and are to diagnostic and treatment This is the and of The Chinese on which was in of of General of of Experts in and The of of The of General of The of The of The of The of General of General of of of of and The of of General of The of The of The of Chinese of The of The of of The of The of of of This consensus is a and secondary dissemination of a of patient and additional has been applied of The that they have of This consensus was by the and Sexual of Chinese Chinese of Chinese Collaborative Group on Diagnosis and Efficacy for Chronic The generated during and/or during the are from the corresponding on