A simplified algorithm for management of CP/CPPS and associated entities: A summary table for general urologists

Abstract

Background: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) accounts for 25% urology clinic visits. Due to significant overlap with other conditions, CP/CPPS is frequently misdiagnosed and inadequately managed. Therefore, we provided a simplified diagnostic and treatment approach to CP/CPPS by subdividing it into distinct subcategories.

Materials and methods: We systematically reviewed the published literature about CP/CPPS and its “associated entities”, including interstitial cystitis/bladder pain syndrome, chronic bacterial vesiculitis, symptomatic prostate calcification, pudendal neuropathy, male accessory gland Inflammation, and Chlamydia trachomatis infection. We applied the UPOINTS system to differentiate CP/CPPS phenotypes, using male accessory gland inflammation solely to flag potential inflammatory-pelvic pain overlap.

Results: The review yielded an evidence base of 140 articles pertaining to CP/CPPS treatment antibiotics, α-blockers, anti-inflammatory drugs, phytotherapeutics, neuromodulators, physical therapy, local blocks, injections, and minimal invasive treatments. CP/CPPS, interstitial cystitis/bladder pain syndrome, chronic bacterial vesiculitis, symptomatic prostate calcification, pudendal neuropathy, and C trachomatis infection, and developed type-specific, step-by-step diagnostic and therapeutic algorithms. The proposed treatment model includes physiotherapy, minimally invasive options, and innovative interventions.

Conclusions: Dividing CP/CPPS into 6 distinct subtypes offers clinicians more targeted guidance when selecting appropriate diagnostic tools and therapeutic interventions. Sperm analysis is recommended for patients with a history of infertility, painful ejaculation, or hematospermia, whereas pyospermia warrants investigation using semen cultures, polymerase chain reaction testing, and transrectal ultrasound. Ct-infection should be ruled out in young patients with prostatitis-like symptoms, burning micturition, “penile tip irritation,” and a thick urethral discharge. Patients over 50 years of age who have failed conventional therapy may require cystoscopy. Transrectal ultrasound can help rule out clustered prostatic calcifications, especially in older, overweight patients with a persistently elevated International Prostate Symptom Score and an increased white blood cell count in postprostatic massage urine. This approach is recommended for guiding CP/CPPS treatment.

Keywords

Chronic pelvic pain syndrome / Chronic prostatitis / UPOINTS / Prostate

Acknowledgments

None.

Statement of ethics

The manuscript was prepared in full compliance with PRISMA 2020 reporting standards.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Funding source

None.

Author contributions

SK: Conceptualization and data collection;

DS, JGF: Manuscript editing and preparation for publication;

RMM: Editorial input;

LRK: Consultation;

SJP: Data collection, literature review, and editorial input;

GB: Conceptualization and consultation.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

References

[1] Krieger JN, Lee SW, Jeon J, Cheah PY, Liong ML, Riley DE. Epidemiology of prostatitis. Int J Antimicrob Agents 2008; 31(Suppl 1):S85-S90.

[2] Krieger JN, Nyberg L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999; 282(3):236-237.

[3] Pontari M. Inflammatory and pain conditions of the male genitourinary tract. In: Partin AW, Peters CA, eds. Campbell Walsh Wein Urology. 12th ed. Elsevier; 2020: 1213-1240.

[4] Yoon BI, Kim S, Han D-S, et al. Acute bacterial prostatitis: How to prevent and manage chronic infection? J Infect Chemother 2012; 18(4):444-450.

[5] Magistro G, Wagenlehner FM, Grabe M, Weidner W, Stief CG, Nickel JC. Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. Eur Urol 2016; 69(2):286-297.

[6] Anothaisintawee T, Attia J, Nickel JC, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: A systematic review and network meta-analysis. JAMA 2011; 305(1):78-86.

[7] Nickel JC, Shoskes DA, Wagenlehner FM. Management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): The studies, the evidence, and the impact. World J Urol 2013; 31(4):747-753.

[8] Zhang J, Liang C, Shang X, Li H. Chronic prostatitis/chronic pelvic pain syndrome: A disease or symptom? Current perspectives on diagnosis, treatment, and prognosis. Am J Mens Health 2020; 14(1):1557988320903200.

[9] Franco JVA, Turk T, Jung JH, et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome: A Cochrane systematic review. BJU Int 2019; 124(2):197-208.

[10] La Vignera S. Male accessory gland infections: Anatomical extension of inflammation and severity of symptoms evaluated by an original questionnaire. Andrologia 2012; 44(Suppl 1):739-746.

[11] La Vignera S. Seminal vesicles of infertile patients with male accessory gland infection: Ultrasound evaluation after prolonged treatment with tadalafil, a selective phosphodiesterase-5 inhibitor. Andrologia 2013; 45(6):386-391.

[12] Rowe PJ, Comhaire FH, Hargreave TB. WHO manual for the standardized investigation and diagnosis of the infertile male. Cambridge Univ Press; 2000.

[13] Calogero AE, Duca Y, Condorelli RA, La Vignera S. Male accessory gland inflammation, infertility, and sexual dysfunctions: A practical approach to diagnosis and therapy. Andrology 2017; 5(6):1064-1072.

[14] Park SH, Ryu JK, Choo GY, et al. Chronic bacterial seminal vesiculitis as a potential disease entity in men with chronic prostatitis. Int J Urol 2015; 22(5):508-512.

[15] Krieger JN, Ross SO, Deutsch L, Riley DE. Seminal fluid analysis in chronic prostatitis/chronic pelvic pain syndrome. Andrologia 2003; 35(5):266-270.

[16] Motrich RD, Salazar FC, Breser ML, et al. Implications of prostate inflammation on male fertility. Andrologia 2018; 50(11):e13093.

[17] Wagenlehner FM, Diemer T, Naber KG, Weidner W. Chronic bacterial prostatitis (NIH type II): Diagnosis, therapy and influence on the fertility status. Andrologia 2008; 40(2):100-104.

[18] Motrich RD, Maccioni M, Molina R, et al. Reduced semen quality in chronic prostatitis patients that have cellular autoimmune response to prostate antigens. Hum Reprod 2005; 20(9):2567-2572.

[19] Minhas S, Bettocchi C, Boeri L, et al. EAU Working Group on Male Sexual and Reproductive Health. European association of urology guidelines on male sexual and reproductive health: 2021 update on male infertility. Eur Urol 2021; 80(5):603-620.

[20] Gill BC, Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis 2016; 29(1):86-91.

[21] Furuya R, Takahashi S, Furuya S, Kunishima Y, Takeyama K, Tsukamoto T. Is seminal vesiculitis a discrete disease entity? Clinical and microbiological study of seminal vesiculitis in patients with acute epididymitis. J Urol 2004; 171(4):1550-1553.

[22] Dagur G, Warren K, Suh Y, Singh N, Khan SA. Detecting diseases of neglected seminal vesicles using imaging modalities: A review of current literature. Int J Reprod Biomed 2016; 14(5):293-302.

[23] Li YF, Liang PH, Sun ZY, et al. Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia. J Androl 2012; 33(5):906-916.

[24] Kaplan SA. Re: Hematospermia—the added value of transrectal ultrasound to clinical evaluation: Is transrectal ultrasound necessary for evaluation of hematospermia? J Urol 2015; 193(4):1333.

[25] Ahmad I, Krishna NS. Hemospermia. J Urol 2007; 177(5):1613-1618.

[26] Guideline developed in collaboration with the American College of Radiology; Society of Radiologists in Ultrasound. AIUM practice guideline for the performance of an ultrasound evaluation of the prostate (and surrounding structures). J Ultrasound Med 2015; 34(8):1-6.

[27] EAU Guidelines Office. EAU Guidelines. Edn. Presented at the EAU Annual Congress, Barcelona, 2019. ISBN 978-94-92671-04-2. Available at: https://uroweb.org/guidelines. Accessed June 1, 2025.

[28] Graziani A, Grande G, Martin M, et al. Chronic prostatitis/chronic pain pelvic syndrome and male infertility. Life (Basel) 2023; 13(8):1700.

[29] Galosi AB, Montironi R, Fabiani A, Lacetera V, Gallé G, Muzzonigro G. Cystic lesions of the prostate gland: An ultrasound classification with pathological correlation. J Urol 2009; 181(2):647-657.

[30] Wang XS, Li M, Shao GF, et al. Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of patients with persistent hematospermia: A single-center, prospective, observational study. Asian J Androl 2020; 22(5):507-512.

[31] Worischeck JH, Parra RO. Chronic hematospermia: Assessment by transrectal ultrasound. Urology 1994; 43(4):515-520.

[32] Yagci C, Kupeli S, Tok C, Fitoz S, Baltaci S, Gogus O. Efficacy of transrectal ultrasonography in the evaluation of hematospermia. Clin Imaging 2004; 28(4):286-290.

[33] Zhao H, Luo J, Wang D, et al. The value of transrectal ultrasound in the diagnosis of hematospermia in a large cohort of patients. J Androl 2012; 33(5):897-903.

[34] Zhao WP, Li YT, Chen J, et al. Prostatic calculi influence the antimicrobial efficacy in men with chronic bacterial prostatitis. Asian J Androl 2012; 14(5):715-719.

[35] Combaz-Söhnchen N, Kuhn A. A systematic review of mycoplasma and ureaplasma in urogynaecology. Geburtshilfe Frauenheilkd 2017; 77(12):1299-1303.

[36] Vicari E. Effectiveness and limits of antimicrobial treatment on seminal leukocyte concentration and related reactive oxygen species production in patients with male accessory gland infection. Hum Reprod 2000; 15(12):2536-2544.

[37] Nickel JC, Costerton JW. Bacterial localization in antibiotic‐refractory chronic bacterial prostatitis. Prostate 1993; 23(2):107-114.

[38] Velez D, Ohlander S, Niederberger C. Pyospermia: Background and controversies. F S Rep 2021; 2(1):2-6.

[39] Liu B, Li J, Li P, et al. Transurethral seminal vesiculoscopy in the diagnosis and treatment of intractable seminal vesiculitis. J Int Med Res 2014; 42(1):236-242.

[40] Han WK, Lee SR, Rha KH, Kim JH, Yang SC. Transutricular seminal vesiculoscopy in hematospermia: Technical considerations and outcomes. Urology 2009; 73(6):1377-1382.

[41] Xu B, Li P, Niu X, et al. A new method of chronic and recurrent seminal vesiculitis treatment. J Endourol 2011; 25(11):1815-1818.

[42] Dessombz A, Méria P, Bazin D, Daudon M. Prostatic stones: Evidence of a specific chemistry related to infection and presence of bacterial imprints. PLoS One 2012; 7(12):e51691.

[43] Shoskes DA, Lee CT, Murphy D, Kefer J, Wood HM. Incidence and significance of prostatic stones in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 2007; 70(2):235-238.

[44] Geramoutsos I, Gyftopoulos K, Perimenis P, et al. Clinical correlation of prostatic lithiasis with chronic pelvic pain syndromes in young adults. Eur Urol 2004; 45(3):333-7; discussion 337.

[45] Park SW, Nam JK, Lee SD, Chung MK. Are prostatic calculi independent predictive factors of lower urinary tract symptoms? Asian J Androl 2010; 12(2):221-226.

[46] Zhao Z, Xuan X, Zhang J, He J, Zeng G. A prospective study on association of prostatic calcifications with sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). J Sex Med 2014; 11(10):2528-2536.

[47] Harada K, Igari D, Tanahashi Y. Gray scale transrectal ultransonography of the prostate. J Clin Ultrasound 1979; 7(1):45-49.

[48] Kim WB, Doo SW, Yang WJ, Song YS. Influence of prostatic calculi on lower urinary tract symptoms in middle-aged men. Urology 2011; 78(2):447-449.

[49] Mazzoli S. Biofilms in chronic bacterial prostatitis (NIH-II) and in prostatic calcifications. FEMS Immunol Med Microbiol 2010; 59(3):337-344.

[50] Shoskes DA, Thomas KD, Gomez E. Anti-nanobacterial therapy for men with chronic prostatitis/chronic pelvic pain syndrome and prostatic stones: Preliminary experience. J Urol 2005; 173(2):474-477.

[51] Zhou Z, Hong L, Shen X, et al. Detection of nanobacteria infection in type III prostatitis. Urology 2008; 71(6):1091-1095.

[52] Mazzoli S, Cai T, Rupealta V, et al. Interleukin 8 and anti-chlamydia trachomatis mucosal IgA as urogenital immunologic markers in patients with C. trachomatis prostatic infection. Eur Urol 2007; 51(5):1385-1393.

[53] Bielecki R, Ostaszewska-Puchalska I, Zdrodowska-Stefanow B, Baltaziak M, Skawrońska M, Sokołowska M. The presence of Chlamydia trachomatis infection in men with chronic prostatitis. Cent European J Urol 2020; 73(3):362-368.

[54] Cai T, Verze P, Mazzoli S, et al. Chlamydial infections in urological disease: A challenging management. World J Clin Urol 2014; 3(1):38-43.

[55] Walz J, Perrotte P, Hutterer G, et al. Impact of chronic prostatitis-like symptoms on the quality of life in a large group of men. BJU Int 2007; 100(6):1307-1311.

[56] Mazzoli S, Cai T, Addonisio P, Bechi A, Mondaini N, Bartoletti R. Chlamydia trachomatis infection is related to poor semen quality in young prostatitis patients. Eur Urol 2010; 57(4):708-714.

[57] Ochsendorf FR, Ozdemir K, Rabenau H, et al. Chlamydia trachomatis and male infertility: Chlamydia-IgA antibodies in seminal plasma are C. trachomatis specific and associated with an inflammatory response. J Eur Acad Dermatol Venereol 1999; 12(2):143-152.

[58] Kent CK, Chaw JK, Wong W, et al. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis 2005; 41(1):67-74.

[59] McNagny SE, Parker RM, Zenilman JM, Lewis JS. Urinary leukocyte esterase test: A screening method for the detection of asymptomatic chlamydial and gonococcal infections in men. J Infect Dis 1992; 165(3):573-576.

[60] Cantor A, Dana T, Griffin JC, et al. Screening for chlamydial and gonococcal infections: Updated evidence report and systematic review for the US preventive services task force. JAMA 2021; 326(10):957-966.

[61] Chernesky MA. The laboratory diagnosis of Chlamydia trachomatis infections. Can J Infect Dis Med Microbiol 2005; 16(1):39-44.

[62] Lanjouw E, Ossewaarde JM, Stary A, Boag F, van der Meijden WI. 2010 European guideline for the management of Chlamydia trachomatis infections. Int J STD AIDS 2010; 21(11):729-737.

[63] Naber KG, Bergman B, Bishop MC, et al. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). EAU guidelines for the management of urinary and male genital tract infections. Urinary tract infection (UTI) working group of the health care office (HCO) of the European Association of Urology (EAU). Eur Urol 2001; 40(5):576-588.

[64] WHO Guidelines for the Treatment of Chlamydia Trachomatis. World Health Organization; 2016.

[65] Magri V, Wagenlehner FM, Montanari E, et al. Semen analysis in chronic bacterial prostatitis: Diagnostic and therapeutic implications. Asian J Androl 2009; 11(4):461-477.

[66] Suskind AM, Berry SH, Ewing BA, Elliott MN, Suttorp MJ, Clemens JQ. The prevalence and overlap of interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome in men: Results of the RAND Interstitial Cystitis Epidemiology male study. J Urol 2013; 189(1):141-145.

[67] Clemens JQ, Markossian TW, Meenan RT, O’Keeffe Rosetti MC, Calhoun EA. Overlap of voiding symptoms, storage symptoms and pain in men and women. J Urol 2007; 178(4 Pt 1):1354-8; discussion 1358.

[68] Clemens JQ, Meenan RT, Rosetti MC, Gao SY, Calhoun EA. Prevalence and incidence of interstitial cystitis in a managed care population. J Urol 2005; 173(1):98-102; discussion 102.

[69] Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: Enigmas and opportunities. Urology 2007; 69(4 Suppl):60-63.

[70] Teichman JM, Parsons CL. Contemporary clinical presentation of interstitial cystitis. Urology 2007; 69(4 Suppl):41-47.

[71] Lai HH, Krieger JN, Pontari MA, Buchwald D, Hou X, Landis JR; MAPP Research Network. Painful bladder filling and painful urgency are distinct characteristics in men and women with urological chronic pelvic pain syndromes: A MAPP research network study. J Urol 2015; 194(6):1634-1641.

[72] Koziol JA. Epidemiology of interstitial cystitis. Urol Clin North Am 1994; 21(1):7-20.

[73] Gupta P, Gallop R, Spitznagle T, et al. Is pelvic floor muscle tenderness a distinct urologic chronic pelvic pain syndrome phenotype? Findings from the multidisciplinary approach to the study of chronic pelvic pain research network symptom pattern study. J Urol 2022; 208(2):341-349.

[74] Forrest JB, Schmidt S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: A common and frequently identical clinical entity. J Urol 2004; 172(6 Pt 2):2561-2562.

[75] Evans RJ, Sant GR. Current diagnosis of interstitial cystitis: An evolving paradigm. Urology 2007; 69(4 Suppl):64-72.

[76] Clemens JQ, Erickson DR, Varela NP, Lai HH. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 2022; 208(1):34-42.

[77] Henry RA, Morales A, Cahill CM. Beyond a simple anesthetic effect: Lidocaine in the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Urology 2015; 85(5):1025-1033.

[78] Nigro DA, Wein AJ, Foy M, et al. Associations among cystoscopic and urodynamic findings for women enrolled in the Interstitial Cystitis Data Base (ICDB) Study. Urology 1997; 49(5A Suppl):86-92.

[79] Turner KJ, Stewart LH. How do you stretch a bladder? A survey of UK practice, a literature review, and a recommendation of a standard approach. Neurourol Urodyn 2005; 24(1):74-76.

[80] Foster HE Jr, Hanno PM, Nickel JC, et al. Interstitial Cystitis Collaborative Research Network. Effect of amitriptyline on symptoms in treatment naïve patients with interstitial cystitis/painful bladder syndrome. J Urol 2010; 183(5):1853-1858.

[81] Theoharides TC. Hydroxyzine in the treatment of interstitial cystitis. Urol Clin North Am 1994; 21(1):113-119.

[82] Hanno PM, Erickson D, Moldwin R, Faraday MM; American Urological Association. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. J Urol 2015; 193(5):1545-1553.

[83] Hung MJ, Chen YT, Shen PS, Hsu ST, Chen GD, Ho ES. Risk factors that affect the treatment of interstitial cystitis using intravesical therapy with a dimethyl sulfoxide cocktail. Int Urogynecol J 2012; 23(11):1533-1539.

[84] Stav K, Beberashvili I, Lindner A, Leibovici D. Predictors of response to intravesical dimethyl-sulfoxide cocktail in patients with interstitial cystitis. Urology 2012; 80(1):61-65.

[85] Cox M, Klutke JJ, Klutke CG. Assessment of patient outcomes following submucosal injection of triamcinolone for treatment of Hunner’s ulcer subtype interstitial cystitis. Can J Urol 2009; 16(2):4536-4540.

[86] Pinto R, Lopes T, Frias B, et al. Trigonal injection of botulinum toxin A in patients with refractory bladder pain syndrome/interstitial cystitis. Eur Urol 2010; 58(3):360-365.

[87] Van Ophoven A, Rossbach G, Oberpenning F, Hertle L. Hyperbaric oxygen for the treatment of interstitial cystitis: Long-term results of a prospective pilot study. Eur Urol 2004; 46(1):108-113.

[88] Van Ophoven A, Rossbach G, Pajonk F, Hertle L. Safety and efficacy of hyperbaric oxygen therapy for the treatment of interstitial cystitis: A randomized, sham controlled, double-blind trial. J Urol 2006; 176(4 Pt 1):1442-1446.

[89] Tanaka T, Kawashima H, Makino T, Kamikawa S, Kato N, Nakatani T. Hyperbaric oxygen therapy for interstitial cystitis resistant to conventional treatments. Int J Urol 2007; 14(6):563-565.

[90] Levesque A, Bautrant E, Quistrebert V, et al. Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus. Eur J Pain 2022; 26(1):7-17.

[91] Dickson E, Higgins P, Sehgal R, et al. Role of nerve block as a diagnostic tool in pudendal nerve entrapment. ANZ J Surg 2019; 89(6):695-699.

[92] Amarenco G, Ismael SS, Bayle B, Denys P, Kerdraon J. Electrophysiological analysis of pudendal neuropathy following traction. Muscle Nerve 2001; 24(1):116-119.

[93] Alevizon SJ, Finan MA. Sacrospinous colpopexy: Management of postoperative pudendal nerve entrapment. Obstet Gynecol 1996; 88(4 Pt 2):713-715.

[94] Moszkowicz D, Alsaid B, Bessede T, et al. Where does pelvic nerve injury occur during rectal surgery for cancer? Colorectal Dis 2011; 13(12):1326-1334.

[95] Engeler D, Baranowski A.P, Berghmans B, et al. EAU Guidelines on Chronic Pelvic Pain, EAU Guidelines. Edn. presented at the EAU Annual Congress Paris 2024. ISBN 978-94-92671-12-3. EAU Guidelines Office. Available at: http://uroweb.org/guidelines/compilations-of-all-guidelines. Accessed June 1, 2025.

[96] Filler AG. Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: Imaging, injections, and minimal access surgery. Neurosurg Focus 2009; 26(2):E9.

[97] Guo KK, Wang L, Liu F, et al. Sacral nerve stimulation in patients with refractory pudendal neuralgia. Pain Physician 2022; 25(4):E619-E627.

[98] Sharma N, Rekha K, Srinivasan JK. Efficacy of transcutaneous electrical nerve stimulation in the treatment of chronic pelvic pain. J Midlife Health 2017; 8(1):36-39.

[99] Eker HE, Cok OY, Aribogan A, Arslan G. Management of neuropathic pain with methylprednisolone at the site of nerve injury. Pain Med 2012; 13(3):443-451.

[100] Hibner M, Desai N, Robertson LJ, Nour M. Pudendal neuralgia. J Minim Invasive Gynecol 2010; 17(2):148-153.

[101] Labat JJ, Riant T, Lassaux A, et al. Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: A randomised, double-blind, controlled trial. BJOG 2017; 124(2):251-260.

[102] Zhu D, Fan Z, Cheng F, Li Y, Huo X, Cui J. The efficacy of an ultrasound-guided improved puncture path technique of nerve block/pulsed radiofrequency for pudendal neuralgia: A retrospective study. Brain Sci 2022; 12(4):510.

[103] Robert R, Labat JJ, Bensignor M, et al. Decompression and transposition of the pudendal nerve in pudendal neuralgia: A randomized controlled trial and long-term evaluation. Eur Urol 2005; 47(3):403-408.

[104] Waxweiler C, Dobos S, Thill V, Bruyninx L. Selection criteria for surgical treatment of pudendal neuralgia. Neurourol Urodyn 2017; 36(3):663-666.

[105] Erdogru T, Avci E, Akand M. Laparoscopic pudendal nerve decompression and transposition combined with omental flap protection of the nerve (Istanbul technique): Technical description and feasibility analysis. Surg Endosc 2014; 28(3):925-932.

[106] Mylle T, De Corte R, Hervé F, Everaert K, Bou Kheir G. Surgical approaches for pudendal nerve entrapment: Insights from a systematic review and meta-analysis. Surg Endosc 2024; 38(8):4160-4170.

[107] Clemens JQ, Calhoun EA, Litwin MS, et al. Rescoring the NIH chronic prostatitis symptom index: Nothing new. Prostate Cancer Prostatic Dis 2009; 12(3):285-287.

[108] Litwin MS, McNaughton-Collins M, Fowler FJ Jr, et al. The National Institutes of Health chronic prostatitis symptom index: Development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999; 162(2):369-375.

[109] Wagenlehner FM, van Till JW, Magri V, et al. National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) symptom evaluation in multinational cohorts of patients with chronic prostatitis/chronic pelvic pain syndrome. Eur Urol 2013; 63(5):953-959.

[110] Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology 1997; 49(6):822-830.

[111] Polackwich AS, Shoskes DA. Chronic prostatitis/chronic pelvic pain syndrome: A review of evaluation and therapy. Prostate Cancer Prostatic Dis 2016; 19(2):132-138.

[112] Truzzi JC, Almeida FM, Nunes EC, Sadi MV. Residual urinary volume and urinary tract infection—when are they linked? J Urol 2008; 180(1):182-185.

[113] Doiron RC, Shoskes DA, Nickel JC. Male CP/CPPS: Where do we stand? World J Urol 2019; 37(6):1015-1022.

[114] Alexander RB, Propert KJ, Schaeffer AJ, et al. Chronic Prostatitis Collaborative Research Network. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: A randomized, double-blind trial. Ann Intern Med 2004; 141(8):581-589.

[115] Engeler DS, Baranowski AP, Dinis-Oliveira P, et al. European Association of Urology. The 2013 EAU guidelines on chronic pelvic pain: Is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol 2013; 64(3):431-439.

[116] 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):509-525.

[117] Franco JV, Turk T, Jung JH, et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev 2018; 1(1):CD012551.

[118] Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: A preliminary prospective, double-blind, placebo-controlled trial. Urology 1999; 54(6):960-963.

[119] Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brähler E, Weidner W. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: A multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol 2009; 56(3):544-551.

[120] Pontari MA, Krieger JN, Litwin MS, et al. Chronic Prostatitis Collaborative Research Network-2. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: A randomized controlled trial. Arch Intern Med 2010; 170(17):1586-1593.

[121] Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol 2005; 174(1):155-160.

[122] Fitzgerald MP, Anderson RU, Potts J, et al. Urological Pelvic Pain Collaborative Research Network. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol 2013; 189(1 Suppl):S75-S85.

[123] Anderson RU, Sawyer T, Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol 2009; 182(6):2753-2758.

[124] Shoskes DA, Zeitlin SI. Use of prostatic massage in combination with antibiotics in the treatment of chronic prostatitis. Prostate Cancer Prostatic Dis 1999; 2(3):159-162.

[125] Nickel JC, Downey J, Feliciano AE Jr, Hennenfent B. Repetitive prostatic massage therapy for chronic refractory prostatitis: The Philippine experience. Tech Urol 1999; 5(3):146-151.

[126] Mishra VC, Browne J, Emberton M. Role of repeated prostatic massage in chronic prostatitis: A systematic review of the literature. Urology 2008; 72(4):731-735.

[127] Zeng XY, Liang C, Ye ZQ. Extracorporeal shock wave treatment for non-inflammatory chronic pelvic pain syndrome: A prospective, randomized and sham-controlled study. Chin Med J (Engl) 2012; 125(1):114-118.

[128] Pajovic B, Radojevic N, Dimitrovski A, Vukovic M. Comparison of the efficiency of combined extracorporeal shock-wave therapy and triple therapy versus triple therapy itself in Category III B chronic pelvic pain syndrome (CPPS). Aging Male 2016; 19(3):202-207.

[129] Zimmermann R, Cumpanas A, Miclea F, Janetschek G. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: A randomised, double-blind, placebo-controlled study. Eur Urol 2009; 56(3):418-424.

[130] Vahdatpour B, Alizadeh F, Moayednia A, Emadi M, Khorami MH, Haghdani S. Efficacy of extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome: A randomized, controlled trial. ISRN Urol 2013;2013:972601.

[131] Levesque A, Ploteau S, Michel F, et al. Botulinum toxin infiltrations versus local anaesthetic infiltrations in pelvic floor myofascial pain: Multicentre, randomized, double-blind study. Ann Phys Rehabil Med 2021; 64(1):101354.

[132] Soares A, Andriolo RB, Atallah AN, da Silva EM. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev 2014; 2014(7):CD007533.

[133] Falahatkar S, Shahab E, Gholamjani Moghaddam K, Kazemnezhad E. Transurethral intraprostatic injection of botulinum neurotoxin type A for the treatment of chronic prostatitis/chronic pelvic pain syndrome: Results of a prospective pilot double-blind and randomized placebo-controlled study. BJU Int 2015; 116(4):641-649.

[134] Abdel-Meguid TA, Mosli HA, Farsi H, et al. Treatment of refractory category III nonbacterial chronic prostatitis/chronic pelvic pain syndrome with intraprostatic injection of onabotulinumtoxinA: A prospective controlled study. Can J Urol 2018; 25(2):9273-9280.

[135] Chuang YC, Chancellor MB. The application of botulinum toxin in the prostate. J Urol 2006; 176(6 Pt 1):2375-2382.

[136] Lewis GK, Carrubba AR, Stanton AP, Craver EC, Li Z, Chen AH. OnabotulinumtoxinA injections for the treatment of myofascial pelvic pain: 12-year experience at a tertiary care academic center. Gynecol Obstet Invest 2023; 88(1):37-46.

[137] Halder GE, Scott L, Wyman A, et al. Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain. Investig Clin Urol 2017; 58(2):134-139.

[138] Dessie SG, Von Bargen E, Hacker MR, Haviland MJ, Elkadry E. A randomized, double-blind, placebo-controlled trial of onabotulinumtoxin A trigger point injections for myofascial pelvic pain. Am J Obstet Gynecol 2019; 221(5):517.e1-517.e9.

[139] American College of Obstetricans and Gynecologist’ Committee on Practice Bulletins -Gynecology. Chronic pelvic pain: ACOG practice bulletin, number 218. Obstet Gynecol 2020; 135(3):e98-e109.

[140] Makarov DV, Chrouser K, Gore JL, et al. AUA white paper on implementation of shared decision making into urological practice. Urol Pract 2016; 3(5):355-363.