Chronic Pelvic Pain Syndrome

Synonyms for Chronic Pelvic Pain Syndrome

• Non-bacterial Chronic Prostatitis
• CPPS (short for chronic pelvic pain syndrome)
• CP/CPPS (an English abbreviation for Chronic Prostatitis/Chronic Pelvic Pain Syndrome)

What is chronic pelvic pain syndrome?

Chronic pelvic pain syndrome is persistent pain in the pelvic region in men, without a detectable infection.¹ This syndrome may be accompanied by difficulty urinating, having a bowel movement, or engaging in sexual intercourse.² The clinical guide primarily describes pain in the urinary or genital region, urinary symptoms, psychological distress, and sexual difficulties as the main associated problems³. Despite its former name, “chronic prostatitis,” the prostate is not always the cause.⁴

Antibiotics are used to treat bacterial infections. Doctors avoid repeating these treatments when urine cultures and tests for sexually transmitted infections come back negative.⁵ High tension in the pelvic floor muscles, located at the base of the pelvis, and increased sensitivity of the nervous system may contribute to symptoms in some people. The literature lists these mechanisms among several possible causes. Interactions between stress, the body’s defenses, the nervous system, and hormones could contribute to the syndrome⁴.

The chronic pelvic pain syndrome described here affects adult men. Appropriate management can reduce symptoms and improve quality of life. Studies on medications are still limited and do not clearly establish their effectiveness. Clinical guidelines recommend combining several treatments tailored to your needs, with the help of various healthcare professionals as needed. Several treatments are still under^{investigation6, 5}.

What are the symptoms of chronic pelvic pain syndrome?

Symptoms include pain in the perineum, pubic area, anus, or penis. Frequent or urgent urination is common. The pain may also affect ejaculation and sexual function.^{7, 3}

Pelvic pain

Pain is the main symptom. It may be constant or come and go. You may feel it in several places:

• The perineum (the area between the skin surrounding the testicles and the anus)
• The pubic region, at the front of the pelvis, and the lower abdomen
• The anus and rectum
• The penis, especially its tip, known as the glans
• The testicles
• The lower back and the coccyx, the small bone at the end of the spine

The pain may worsen when you sit for a long time. It may also increase after a bowel movement or after ejaculation.

Urinary Symptoms

• Frequent need to urinate during the day and night
• Urgent need to go to the bathroom
• Feeling of not completely emptying the bladder
• Sometimes, pain or burning sensation when urinating

Sexual symptoms

• Pain during or after ejaculation
• Decreased sexual desire
• Possible difficulty in achieving or maintaining an erection⁸

Pain during ejaculation is a common symptom of the syndrome.⁷ High tension in the pelvic floor muscles can contribute to this pain in some men. Perineal physical therapy may then be part of the treatment.

What causes chronic pelvic pain syndrome?

The exact causes remain poorly understood. High tension in the pelvic floor muscles may contribute to symptoms in some men. However, the syndrome varies from person to person, and this muscular mechanism is not necessarily the primary factor⁹. Stress, pelvic trauma, and certain lifestyle habits may contribute to symptoms in some people, as may tailbone pain experienced during prolonged sitting.

Pelvic floor muscle tension

Your pelvic floor muscles can become overly tense. There may be areas of muscle that are sensitive to pressure, often called trigger points. Their presence is not always due to muscle tension. These sensitive areas can cause pain felt in various parts of the pelvis.

In some people, the pelvic muscles remain more tense at rest. This muscle activity can contribute to pain and urinary or sexual symptoms, particularly when it compresses the pudendal nerve, causing pudendal nerve pain that is often worsened by sitting.

Contributing factors

Several factors can contribute to the symptoms or make them worse in some people:

Central sensitization

When pain persists, your nervous system can become more sensitive. Sensations that are usually not very painful may then feel more painful. This does not mean that your pain is imaginary. This central sensitization can contribute to the persistence of pain, even when no active injury is found. The literature identifies this mechanism as one of several possible explanations, without establishing that it accounts for every case⁴.

How is chronic pelvic pain syndrome diagnosed?

The diagnosis is based on your symptom history and a physical examination. Medical tests can rule out an infection or other conditions.^{10, 1} An examination of the pelvic floor by a specialized physical therapist completes the evaluation.

Medical evaluation

Your doctor will first rule out treatable causes such as a urinary tract infection or bacterial prostatitis. This generally includes:

• A urine test
• A urine culture to test for bacteria
• A physical examination that may include a digital rectal exam, performed with a gloved and lubricated finger to examine the prostate and pelvic muscles

The doctor makes the diagnosis based on the patient's overall symptoms, a physical examination, and tests used to rule out other causes. Symptoms that last longer than three months are among the factors taken into account.

Physiotherapy evaluation

Your physical therapist specializing in pelvic floor rehabilitation will conduct a comprehensive evaluation:

• Your lifestyle and stress factors
• Your posture and breathing patterns
• The condition of your pelvic floor muscles (tension, trigger points)
• The mobility of your back and hips

This evaluation helps identify factors that may be contributing to your symptoms and tailor the treatment plan accordingly.

How does physiotherapy help chronic pelvic pain syndrome?

Perineal physical therapy can help manage symptoms through exercises and advice tailored to the results of your evaluation. The available evidence mainly focuses on people with hypertonicity—that is, pelvic muscles that are overly active at rest. The evidence is of low to moderate quality and does not cover all cases of the syndrome¹¹. The physical therapist may use manual techniques, breathing exercises, coordination exercises, relaxation exercises, or strengthening exercises, depending on the results of the assessment.

Treatment Techniques

What you will learn

• Relaxation, coordination, or strength-building exercises selected based on the assessment
• Breathing techniques to reduce tension
• How to manage stress and aggravating factors
• Advice for your lifestyle and posture

When to seek physiotherapy for chronic pelvic pain syndrome?

Seek medical attention if pelvic pain persists, recurs, or interferes with your daily activities—with or without urinary or sexual symptoms. You don’t need to wait three months.¹⁰ You do not need a doctor’s referral. Perineal physical therapy is one of the treatment options.

Signs You Should Consult

• Persistent or recurring pelvic pain, or pain that limits your activities
• Frequent or urgent need to urinate, or pain when urinating
• Pain during ejaculation or intercourse
• Your symptoms affect your quality of life
• Medication has not been effective

You do not need to see a doctor before starting physical therapy. If your condition requires a medical evaluation, your physical therapist will be able to tell you and refer you to the appropriate professional.

Signs That Call for Prompt Medical Attention

The following symptoms require prompt medical evaluation:

• Blood in the Urine
• Fever accompanied by pelvic pain
• Complete inability to urinate
• Sudden and very intense pain

Go to the emergency room if you can no longer urinate or if pain appears suddenly and becomes very severe. If you notice blood in your semen but have no other concerning symptoms, make an appointment with a doctor; this symptom generally does not require a visit to the emergency room.^{13, 14}

What to do at home for chronic pelvic pain syndrome?

You can try relaxing activities, stay active, and adjust your habits based on how they affect your symptoms. Stay active, vary your positions, and avoid sitting for too long. Certain foods and drinks may worsen your symptoms.

Manage stress

Chronic stress can worsen symptoms. Research suggests that psychological stress may influence several mechanisms of the syndrome, though it does not confirm that it keeps the pelvic muscles tense in every person⁴. Find activities that help you relax:

• Mindfulness meditation
• Gentle yoga, with poses adapted to avoid aggravating your symptoms
• Daily walking
• Enjoyable activities that take your mind off things

Adjust your habits

• Vary your posture throughout the day and avoid sitting for long periods without getting up.
• A cushion with an opening or cutout can help reduce pressure on the perineum.
• Adjust the bike: If riding a bike makes your symptoms worse, adjust the length of your rides, your riding position, or your saddle. A center cut isn't necessarily right for everyone.

Diet: Pay attention to how your body reacts

The foods that worsen symptoms vary from person to person. Keep track of your reactions before cutting back on any food or drink; these restrictions aren't necessary for everyone.⁵

What to Avoid

• Inappropriate exercises: Avoid adding repetitive contractions without knowing whether your muscles need relaxation, coordination, or strengthening
• Straining to urinate or have a bowel movement: Avoid straining too hard. If you often have to strain, talk to a healthcare professional.
• Inappropriate urination habits: If you often feel a strong urge to urinate, discuss your habits with your physical therapist. He or she can help you adjust them without requiring you to hold your urine until it becomes painful.²

Where can I listen to a podcast about pelvic floor rehabilitation?

You can listen to the podcast on pelvic floor rehabilitation on YouTube, Spotify, or Apple Podcasts. Episode #23 focuses specifically on pelvic floor rehabilitation.

• Listen to Episode 23 of "Parle-moi de santé" on perineal rehabilitation on YouTube
• Listen to Episode 23 of "Parle-moi de santé" on pelvic floor rehabilitation on Spotify
• Listen to Episode 23 of "Parle-moi de santé" on perineal rehabilitation on Apple Podcasts

Sources

The sources for this article include the studies, clinical guidelines, and patient information materials listed below.

1. Bowen DK, Dielubanza E, Schaeffer AJ. Chronic bacterial prostatitis and chronic pelvic pain syndrome. BMJ Clin Evid. 2015;2015. ↩ Back to text: 1st, 2nd citations
2. Male Chronic Pelvic Pain. ↩ Back to text: 1st, 2nd references
3. Rees J, Abrahams M, Doble A, Cooper A, Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015;116(4):509-25. ↩ Back to text: 1st, 2nd citations
4. Pontari MA, Ruggieri MR. Mechanisms in prostatitis/chronic pelvic pain syndrome. J Urol. 2008;179(5 Suppl):S61-7. ↩ Back to text: 1st, 2nd, 3rd, 4th references
5. Lai HH, Pontari MA, Argoff CE, Bresler L, Breyer BN, Chou R, et al. Male Chronic Pelvic Pain: AUA Guideline: Part II—Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Urol. 2025;214(2):127-137. ↩ Back to text: 1st, 2nd, 3rd citations
6. Qin Z, Zhang C, Guo J, Kwong JSW, Li X, Pang R, et al. Oral pharmacological treatments for chronic prostatitis/chronic pelvic pain syndrome: A systematic review and network meta-analysis of randomized controlled trials. EClinicalMedicine. 2022;48:101457. ↩ Back to text
7. Krieger JN, Egan KJ, Ross SO, Jacobs R, Berger RE. Chronic pelvic pain is the most prominent urogenital symptom of "chronic prostatitis." Urology. 1996;48(5):715-21; discussion 721-2. ↩ Back to text: 1st, 2nd citations
8. Li HJ, Kang DY. Prevalence of sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis. World J Urol. 2016;34(7):1009-17. ↩ Back to text
9. Anderson RU, Wise D, Nathanson BH. Chronic Prostatitis and/or Chronic Pelvic Pain as a Psychoneuromuscular Disorder—A Meta-analysis. Urology. 2018;120:23-29. ↩ Back to text
10. Lai HH, Pontari MA, Argoff CE, Bresler L, Breyer BN, Chou R, et al. Male Chronic Pelvic Pain: AUA Guideline: Part I—Evaluation and Management Approach. J Urol. 2025;214(2):116-126. ↩ Back to text: 1st, 2nd citations
11. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev. 2022;10(2):209-230. ↩ Back to text
12. Dal Farra F, Aquino A, Tarantino AG, Origo D. Effectiveness of Myofascial Manual Therapies in Chronic Pelvic Pain Syndrome: A Systematic Review and Meta-Analysis. Int Urogynecol J. 2022;33(11):2963-2976. ↩ Back to text
13. nhs.uk. Blood in semen. 2018. ↩ Back to text
14. nhs.uk. Blood in Urine. 2017. ↩ Back to text

Our physical therapists defined the research strategy, plan, and clinical content of this article. An AI tool assisted with the literature review and text editing to ensure consistency in content and writing style.