Chronic Pelvic Pain & Prostatitis

Medically reviewed by David Shusterman, MD · Updated September 11, 2026

Chronic pelvic pain in men is pain in the perineum, the area between the scrotum and the anus, the lower abdomen, the testicles, the tip of the penis, or the lower back, lasting three months or more, often with urinary symptoms and discomfort during or after ejaculation. For decades it has been called prostatitis, and men who have it often arrive with that word already attached, along with a history of several courses of antibiotics that did not help.

The word is the problem. True bacterial prostatitis exists, and it is treated with antibiotics chosen from a culture. But most men with chronic pelvic pain do not have an infection. Their pain comes from the prostate, the pelvic floor muscles, the nerves that run through the pelvis, or somewhere outside the urinary tract altogether, and antibiotics do nothing for any of those. At NYMD Center we treat chronic pelvic pain as a diagnostic problem first. We find out where the pain is coming from before deciding what to do about it, and we do not prescribe repeated antibiotics without a culture that justifies them. Dr. Shusterman's approach to this condition is the subject of his book, Inside the Fire.

Who it affects and the symptoms that bring people in

Chronic pelvic pain affects men of every age. It often begins after a real event, an infection, intense cycling, a period of stress, an injury, and persists long after the trigger has gone. Men describe aching or burning in the perineum, pain at the tip of the penis, testicular pain, pain with sitting or ejaculation, urgency and frequency, and a hesitant stream. Many have sexual difficulty and disturbed sleep, and most are frustrated and worried by the time they reach us.

A few patterns deserve mention because they point away from the prostate. Pain that starts in the scrotum and travels down the leg is probably not urologic at all; it is more likely a nerve or musculoskeletal problem, and we would say so and direct you appropriately. Pain that is sharp, constant and worsening, with fever, may be an abscess near the rectum, which can mimic prostatitis and needs to be found quickly. Pain at the penile tip, which men with this condition often insist is the site of the problem, is usually referred from the prostate: the nerves that supply both converge, and the brain places the sensation at the end of the line.

How we evaluate it at NYMD Center

The evaluation is built on demonstrating rather than asserting. We begin with a detailed history and ask you to point to exactly where it hurts. Then we examine: the abdomen, the testicles, the penis, the perineum, the pelvic floor muscles through the rectum, and the prostate itself, noting whether pressing on each reproduces your pain. A tender, tight pelvic floor that recreates the pain when pressed tells us one thing; a boggy, tender prostate tells us another; a normal exam with pain that cannot be reproduced anywhere tells us a third.

Office testing follows the same first-visit pattern we use for every urinary complaint: a uroflow study, a bladder scan for post-void residual, and a urine dip with culture if there is any suggestion of infection. When infection is genuinely suspected we culture properly, including after prostate massage when appropriate, so that any antibiotic prescribed is aimed at an organism we have found. Blood work and a renal and pelvic ultrasound are added when indicated.

Cystoscopy is central to this evaluation, and we use it to show rather than tell. When a man is certain the pain is at the tip of the penis and the cystoscope shows a normal urethra and a normal bladder, he has seen for himself that the tip is not the source, and the conversation about referred pain becomes real instead of abstract. Cystoscopy also excludes the things that must not be missed: a stricture, a stone in the urethra or bladder, and, rarely, a tumor. Urodynamics is used when the voiding pattern suggests the bladder or pelvic floor is not coordinating properly.

Treatment options

Treating a confirmed infection

When a culture grows bacteria, a course of the right antibiotic, long enough to penetrate the prostate, is the treatment. This is the minority of cases. Antibiotics given "just in case," course after course, produce side effects, resistance, and a man who has lost months.

Pelvic floor physical therapy

For men whose pain is reproduced by pressing on the pelvic floor, the most effective treatment is specialized pelvic floor rehabilitation that releases the tight muscles and retrains them, combined with heat, stretching, and changes such as a cut-out bicycle seat or avoiding prolonged sitting. It takes weeks to months, and it works for many men.

Medication for the prostate and bladder

Alpha-blockers relax the bladder neck and prostate and help men whose pain is tied to voiding. Anti-inflammatory medication helps in flares. Medications aimed at nerve pain are used when the pattern suggests a neuropathic component. None of these is a cure, and we use them as tools alongside the physical treatment rather than in place of it.

Pain management referral

Some men have pain we cannot explain or relieve with urologic treatment. We say so, and we refer to pain management specialists, who have nerve blocks, targeted injections and medication strategies that a urologist does not. That referral often helps a great deal, and it is not a way of getting rid of you; we remain involved and follow up.

What we do not do

We do not prescribe repeated antibiotics without a culture, and we do not tell you the pain is in your head. Chronic pain changes the nervous system, and stress amplifies it, but that is a consequence of the problem and a target for treatment, not a dismissal of it.

What to expect at your visit

Bring any prior cultures, imaging and a list of the antibiotics you have already taken, with dates if you have them. Expect a longer first visit than usual, with a full examination including a prostate and pelvic floor exam, and office testing. If cystoscopy is appropriate it is usually done at the same visit, with a numbing gel, in a few minutes. You will leave with a working diagnosis, a plan that names what we think is causing the pain, and a follow-up to measure progress against it.

When to seek care urgently

Fever with pelvic or rectal pain, inability to urinate, or pain that is rapidly worsening needs same-day evaluation. An abscess or acute bacterial prostatitis is uncommon but serious, and it is one of the few forms of this condition where antibiotics, and sometimes drainage, are urgently needed.