Pelvic tenderness is not limited to the prostate in chronic prostatitis/chronic pelvic pain syndrome (CPPS) type IIIA and IIIB: comparison of men with and without CP/CPPS
© Berger et al.; licensee BioMed Central Ltd. 2007
Received: 02 February 2007
Accepted: 02 October 2007
Published: 02 October 2007
We wished to determine if there were differences in pelvic and non-pelvic tenderness between men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) Type III and men without pelvic pain.
We performed the Manual Tender Point Survey (MTPS) as described by the American College of Rheumatology on 62 men with CP/CPPS Type IIIA and IIIB and 98 men without pelvic pain. We also assessed tenderness of 10 external pelvic tender points (EPTP) and of 7 internal pelvic tender points (IPTP). All study participants completed the National Institutes of Health Chronic Prostatitis Symptom Inventory (NIH CPSI).
We found that men with CPPS were significantly more tender in the MTPS, the EPTPS and the IPTPS. CPSI scores correlated with EPTP scale but not with IPTP scale or prostate tenderness. Prostatic tenderness was present in 75% of men with CPPS and in 50% of men without CPPS. Expressed prostatic fluid leukocytosis was not associated with prostatic tenderness.
Men with CP/CPPS have more tenderness compared to men without CPPS. Tenderness in men with CPPS is distributed throughout the pelvis and not specific to the prostate.
Idiopathic prostatitis (also called non-bacterial prostatitis) and prostatodynia have been renamed by a National Institutes of Health (NIH) consensus panel to Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) Types IIIA and IIIB, respectively. These syndromes are characterized by pelvic pain, a negative prostatic localization culture, and no specific diagnosis accounting for the pain. Voiding symptoms may or may not be present. Type IIIA is differentiated by leukocytes in the expressed prostatic secretions (EPS) and Type IIIB is characterized by a lack of inflammation in the EPS . Recently, a large multicenter study found that the symptoms of prostatitis were not associated with prostatic inflammation, casting doubt on prostatic inflammation as the direct cause of the pain.
Pelvic tenderness has not been investigated in normal men. In CP/CPPS, tenderness of the prostate is often present [3, 4], however its relationship to prostatic inflammation has not been investigated. Whether pain is localized to the prostate or is part of a more generalized tenderness has not been determined.
The quantification of tenderness is difficult and subject to considerable inter-rater variability[5, 6]. However, tenderness is extremely important in everyday clinical evaluation and is routinely used to identify pathological processes. The American College of Rheumatology has developed The Manual Tender Point Survey (MTPS) as a standardized method to evaluate fibromyalgia (FM). This instrument includes 18 examination points that are often tender and 3 control points that are infrequently tender in patients with FM. Fibromyalgia (FM)is distinguished by multiple tender sites and pain in four quadrants of the body. Patients with interstitial cystitis (IC), a condition that may be related to CP/CPPS, have been found to have increased tenderness in the pelvis and and in the MTPS as compared with patients without IC. The purpose of this study was to use the MTPS, expanded to include pelvic tender points, to test the hypothesis that men with CP/CPPS would show more overall tenderness than men without pelvic pain. We hypothesized that the location of tenderness in CP/CPPS may indicate the location of underlying pathology and the extent of the tenderness may indicate a localized or more systemic nature of the syndrome. We explored the relationship of prostatic secretion inflammation to tenderness. A finding of an association between prostatic inflammation and prostatic tenderness would support the possibility that inflammation produces tenderness and pain. More muscle tenderness in men with CP/CPPS IIIB than in men with CP/CPPS IIIA, as suggested by Segura, would support the continued distinction between the two syndromes. We also hypothesized that there would be a relationship between tenderness and CPSI scores.
The University of Washington's institutional review board approved the study reported here as part of a more comprehensive study of men with pelvic pain. All subjects signed written consents explaining study procedures. Other findings from the larger study have been reported previously[11–16]. Patients with CP/CPPS were identified from the University of Washington Prostatitis Clinic. Study inclusion criteria for CP/CPPS patients were age 18–65 years, diagnosis of CP/CPPS Type IIIA or IIIB made by a urologist at the clinic, negative prostatic localization cultures for pathogens, pelvic pain of at least 3 months duration, and no other identified pathology to account for symptoms. Controls were healthy volunteers without pelvic pain or history of any urologic disease, recruited from advertisements. Controls were not excluded for the presence of pain in other areas of the body. Controls were paid $250.00 for participation in the study, but patients were not paid. Evaluators were not blinded as to the patient or control status of the subjects.
Patients and controls were evaluated during a screening visit to the clinic. Study participants were requested not to take anti-microbial agents within six weeks of examination and were instructed to abstain from ejaculation for 48 hours prior to their appointment. All subjects provided demographic information on questionnaires and the NIH Chronic Prostatitis Symptom Index (CPSI), a measure of pain severity, urinary symptoms and quality of life[17, 18]. Following a standardized history and physical examination, patients and controls underwent four-glass urine localization cultures and urethral cultures for C. trachomatis, U. urealyticum, M. hominis, and T. vaginalis. Expressed prostatic secretions (EPS) were assessed for leukocyte concentration by hemocytometer counts using a phase contrast microscope. We defined CP/CPPS Type IIIB as less than and Type IIIA as more than 500 leukocytes/microliter. Patients and controls were excluded from further study participation if any of the following conditions were present: active urinary tract infection or infection localized to the prostate from a four-glass urine sample, positive cultures for C. trachomatis or N. gonorrhoeae, genitourinary malignancy, evidence of suicidal ideation or psychosis, post-surgical pain, pain from another source in the genitourinary tract (e.g., renal calculi), history of radiation therapy, or history of genitourinary tuberculosis.
Each of the three examiners (two urologists and one nurse practitioner; R.E.B, J.C.L., I.R.) practiced until he could apply 4 ± .25 kg ten times in a row on a "Chatillon" dolorimeter.(Amtek, Largo, FL.) Study participants were examined with the MTPS, then the EPTPS, then the IPTPS and prostate. Each examiner recalibrated the force of his finger at least weekly. Examiners 1, 2, and 3 examined 18, 32, and 48 control subjects, and 7, 33, and 22 pain patients, based on logistical scheduling considerations.
A few pain patients and controls had missing tenderness measure values for some points (but not all) because of omissions in record keeping. The three examiners examined patients comparable in symptom severity according to the NIH CPSI scores (p = 0.996, Kruskal-Wallis test).
Definition of the dichotomous transformation of the tender point examination scale severity scores
Dichotomous variable defined as
0 if value in range
1 if value in range
MTPS Tender points
Total Prostate Score
We calculated Spearman correlations to examine the association between the tenderpoint scores and the NIH CPSI. Inflammation (defined by EPS leukocytes count) was compared to tenderness (as defined in Table 1) by Chi-square test.
Sample Demographic Characteristics and NIH CPSI Scores
Pain Patients n = 62
Controls n = 98
Age, years, mean (SD)
Marital Status, % **
Married/living with significant other
Some HS, HS/GED, or Vocational/Technical
Full time work
School (full or part-time)
Retired, homemaker, unemployed
NIH Chronic Prostatitis Symptom Index***
Total Score, mean (SD)
Urinary Symptoms, mean (SD)
Pain, mean (SD)
Quality of Life, mean (SD)
Proportion of high scores (according to definitions in Table 1) for control and pain subjects
Proportion of High Score (# missing)
Controls (n = 98)
Pain Patients (n = 62)
MTPS Tender points
Common Odds Ratio Estimates (Mantel-Haenszel Method) for Examiners in Dichotomized Tenderness Severity Scores, Controlling for Differences across examiners.
Estimated Odds Ratio*
Asymptotic 95% Confidence Interval
P-value for Odds Ratio
0.17 – 5.67
MTPS Tender points
0.93 – 7.51
3.40 – 27.06
2.87 – 13.61
2.21 – 11.24
Median scores by group and examiner.
P-value for Mann-Whitney test
MTPS Control (0–30)
MTPS Tender points (0–180)
Additionally, Spearman correlation was calculated for the tenderness points scores and the NIH CPSI for the pain patients. All tender point scales were statistically significant at 0.001 level, varying from estimated correlations of r = 0.29 (IPTPS and Control) to 0.73 (IPTPS with prostate score). The NIH CPSI Pain scale was correlated significantly with the FM and EPTPS, but not the IPTPS or prostate score suggesting that the CPSI pain score is more related to external than internal tenderness. However, plots of NIH CPSI versus each scale (graphs not shown here), showed that the associations are not necessarily linear, and therefore, they have limited value in describing the association between the variables.
EPS was obtained for 64 controls and 40 patients. Inflammation was defined as having leukocyte counts > 500/mm3 in the EPS sample. There was no association between inflammation in EPS and the dichotomous prostatic tenderness (p = 0.42) or FM, IPTPS, and EPTPS dichotomous variables (all p-values > 0.23).
Prostatic tenderness has been described in men with prostatitis and CP/CPPS and is considered to be a characteristic of both CP/CPPS Type IIIA and IIIB. However, the findings of this study indicate that not all men with CP/CPPS have prostate tenderness, and about 30% of men without CP/CPPS have such tenderness. Tenderness in the internal and external pelvis as well as extra-pelvic regions in men with CP/CPPS has not been described. To our knowledge, this is the first study that has demonstrated that men with CP/CPPS have increased tenderness in FM tender points and in specific internal and external non-prostatic pelvic locations. For example, men with CP/CPPS were 9.59 and 4.98 times more likely than men without pelvic pain to have scores in the higher 90% of the EPTPS and prostate scales, respectively. This suggests that CP/CPPS Type III is a pan-pelvic pain syndrome and that tenderness is not limited to the prostate. For each point in the pelvis that we tested, the CPPS group had more tenderness than the control group. Furthermore, increased tenderness even extended outside of the pelvis to FM points suggesting a systemic component. The labeling of chronic pelvic pain in men as "prostatitis" may well mislead both patients and physicians into thinking that the syndrome has a more limited focus and etiology than it actually may have.
The finding of increased tenderness in MTPS tender points in men with CP/CPPS is in accord with findings of diffusely increased tenderness in women with interstitial cystitis, a syndrome possibly related to CP/CPPS. We hypothesize that central and/or peripheral pain sensitization in the pelvis may account for the diffuse symptoms and tenderness found in pelvic pain syndromes[21–25]. We have previously shown that there is sensitization to perineal heat sensation in some men with CP/CPPS[12, 26] and that men with CP/CPPS often have abnormalities of pelvic and abdominal muscular function and sensation . The diffuse tenderness on pelvic examination in our present study may be a manifestation of mechanical sensitization to pressure with the development of allodynia and hyperesthesia mediated via the CNS. If prostatic inflammation was the source of prostatic pain and the non-prostate pelvic tenderness was secondary to muscle guarding, we would have expected to find a relationship of prostatic secretion inflammation to prostatic and muscle tenderness. Since we found no such associations, we hypothesize that prostatic and other pelvic tenderness may both be related to an another more dominant process such as central or peripheral neural sensitization and that inflammation in prostatic secretion may be incidental.
Limitations of this study should be acknowledged. The sample came from a university tertiary care population and the study findings may not generalize to other populations. The control group was a convenience sample of volunteers and could have selection bias. Controls were younger, and although we found no relationship of tenderness scores to age, other unknown differences may have contributed to the differences found between patients and controls in examination findings. Furthermore, we did not assess test-retest stability of the tender point examination scores, and there were interrater differences. The determination of tenderness is a standard part of clinical examination, although variation from examiner to examiner is well known clinically and experimentally[5, 6]. Although some of our examiners consistently found more tenderness, each examiner separately found more tenderness in CPPS patients in the areas examined.
We found that men with CP/CPPS have generalized internal and external pelvic tenderness. The pathophysiology of CP/CPPS involves the entire pelvis and not only the prostate. Our findings suggest that further research involving the assessment of intra-and extra-pelvic tender points may prove fruitful in increasing scientific understanding of, and developing more effective treatments for, male chronic pelvic pain syndromes.
Manual tender point scale
Internal pelvic tender point scale
External pelvic tender point scale
Chronic prostatitis/chronic pelvic pain syndrome
- NIH CPSI:
National Institutes of Health Chronic Prostatitis Symptom Index
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/7/17/prepub