Chronic Pelvic Pain and Sexual Symptoms in Men

Understanding Chronic Prostatitis/Chronic Pelvic Pain Syndrome, Pelvic-Floor Dysfunction, Sexual Problems, Diagnosis and Integrative Unani Management

By Dr. Nizamuddin Qasmi
Founder & Chief Physician, Saira Health Care
Focused Practice in Sexual Disorders & Infertility

Chronic pelvic pain in men is one of those conditions that can affect much more than one part of the body. A patient may initially come to me saying:

“Doctor, there is pain between my testicles and anus.”

Another may say:

“I have burning or pressure after urination.”

Someone else may complain:

“My erection has become weak since this pelvic problem started.”

And another patient may be most troubled by:

“I get pain during or after ejaculation.”

All of these complaints can sometimes belong to the same broad clinical problem.

Male chronic pelvic pain is not simply “prostate pain.” It can involve the prostate region, pelvic-floor muscles, nerves, bladder, urinary tract, genital structures and the nervous system's processing of pain. It can also significantly affect erection, ejaculation, desire, orgasm, sexual confidence, fertility concerns, emotional wellbeing and relationships.

Current international understanding has therefore moved away from the old idea that every man with pelvic pain has an infection of the prostate.

The 2025 American Urological Association guideline on male chronic pelvic pain emphasizes that the condition can have multiple contributing mechanisms and often requires a multidisciplinary approach rather than repeated courses of antibiotics. The current 2026 European Association of Urology chronic pelvic pain guideline similarly uses a biopsychosocial model and recognizes urinary, bowel, sexual, muscular, neurological and emotional components of chronic pelvic pain.

As a physician focused on sexual disorders and infertility, I consider this broader understanding extremely important.

My approach is not merely to ask:

“Is the prostate inflamed?”

I also ask:

“What is producing the pain, what is maintaining it, and how is it affecting the patient's urinary, sexual, reproductive and emotional health?”

What Is Chronic Pelvic Pain in Men?

Chronic pelvic pain refers to persistent or recurrent pain perceived in structures related to the pelvis.

The European Association of Urology describes chronic pelvic pain as pain perceived in pelvic structures that may be accompanied by urinary, sexual, bowel or pelvic-floor symptoms as well as emotional, cognitive and behavioural consequences.

In practical clinical terms, pain lasting or recurring for approximately three months or longer is generally considered chronic.

In men, the pain may occur in one or several locations, including:

• perineum,
• prostate region,
• penis,
• urethra,
• testicles,
• scrotum,
• groin,
• lower abdomen,
• suprapubic area,
• rectal region,
• coccyx,
• lower back.

The pain may be continuous or intermittent.

Some patients experience discomfort every day, while others have symptom-free periods followed by flare-ups.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome — CP/CPPS

One of the most important diagnoses within male chronic pelvic pain is chronic prostatitis/chronic pelvic pain syndrome, commonly abbreviated as CP/CPPS.

Historically, many patients with this condition were diagnosed simply as having “chronic prostatitis.”

However, modern research has shown that many of these men do not have an ongoing bacterial infection.

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases explains that the exact cause of chronic prostatitis is frequently unknown and that, in most cases, doctors do not find a bacterial infection. Possible mechanisms include effects of previous infection, nerve injury or irritation, inflammation and other abnormalities.

The modern concept is therefore much broader.

CP/CPPS may involve a combination of:

• pelvic-floor muscle dysfunction,
• inflammation,
• nerve sensitization,
• altered pain processing,
• urinary dysfunction,
• previous infection,
• stress-related amplification of symptoms,
• musculoskeletal abnormalities,
• sexual dysfunction,
• psychological distress.

Different patients may have different combinations of these factors.

This is one reason a single treatment rarely works for every man.

Chronic Pelvic Pain Is Not Always a Prostate Disease

This point is extremely important.

A man may feel pain close to the prostate and naturally assume that his prostate must be infected.

But the pelvis contains many structures packed into a relatively small area.

Pain can arise from the:

• pelvic-floor muscles,
• bladder,
• prostate,
• urethra,
• testes or epididymis,
• pudendal or other pelvic nerves,
• rectum or bowel,
• hip,
• lower spine,
• abdominal muscles,
• connective tissues.

The nervous system can also continue producing or amplifying pain even after the original trigger has resolved.

This means that chronic pelvic pain is sometimes better understood as a complex pain syndrome rather than a disease of one single organ.

The current EAU framework specifically recognizes the increasing understanding that the central nervous system may become important in the persistence of chronic pelvic pain.

What Does Chronic Pelvic Pain Feel Like?

Different patients use different words.

Common descriptions include:

• aching,
• burning,
• heaviness,
• pressure,
• pulling sensation,
• throbbing,
• tightness,
• stabbing pain,
• electric or shooting pain,
• irritation,
• fullness around the prostate,
• discomfort after ejaculation.

Some patients tell me:

“It feels like I am sitting on something.”

Others describe:

“There is constant pressure between the testicles and anus.”

Another common complaint is:

“The pain becomes worse after ejaculation.”

These differences are diagnostically useful because burning or electric pain may suggest a stronger neuropathic component, while muscular tenderness, sitting-related discomfort and painful ejaculation may point toward pelvic-floor dysfunction.

Common Areas of Pain

Pain may occur in the:

Perineum

The area between the scrotum and anus is one of the most common locations.

Penis

Pain may affect the tip, shaft or deeper structures.

Testicles or Scrotum

Some patients develop bilateral or shifting testicular discomfort.

Lower Abdomen

Suprapubic or lower abdominal discomfort may occur.

Groin

Pain may radiate into one or both groins.

Rectal or Anal Region

Pressure or discomfort may be felt deep inside the rectal area.

Lower Back and Coccyx

Pelvic muscular and neurological conditions may cause pain extending toward the lower back or tailbone.

The 2025 AUA guideline specifically recognizes pelvic pain radiating to the lower abdomen, groin or coccyx as a possible feature of pelvic-floor myalgia.

Pelvic-Floor Dysfunction — An Important and Often Missed Cause

One of the most important developments in our understanding of chronic pelvic pain has been recognition of the role of the pelvic-floor muscles.

The pelvic floor is a group of muscles forming a supportive muscular structure at the base of the pelvis.

These muscles contribute to:

• urination,
• bowel function,
• erection,
• ejaculation,
• orgasm,
• pelvic stability.

Pelvic-floor muscles are not supposed to remain constantly tense.

In some men with chronic pelvic pain, however, these muscles become excessively tight, tender or poorly coordinated.

This is called pelvic-floor myalgia or, where increased resting muscle tone is present, pelvic-floor tension myalgia.

The 2025 AUA guideline notes that pelvic-floor muscle tenderness is common among men with chronic pelvic pain. Associated symptoms can include urinary hesitancy, constipation, slow urine stream, painful ejaculation and pelvic pain radiating toward the groin, abdomen or coccyx.

This is clinically important because repeatedly treating such a patient with antibiotics may completely miss the problem.

How Pelvic-Floor Tightness Can Affect Sexual Function

The pelvic-floor muscles actively participate in sexual response.

During erection and orgasm, these muscles contract in a coordinated fashion.

If the pelvic floor is already tense or painful, the powerful contractions associated with orgasm and ejaculation may worsen symptoms.

This can produce:

• painful ejaculation,
• pain after ejaculation,
• pelvic heaviness after intercourse,
• penile discomfort,
• difficulty maintaining erection,
• avoidance of sexual activity.

The European Association of Urology emphasizes that pelvic-floor muscle function contributes to sexual excitement and orgasm and that dysfunction of this muscular system can affect sexual function.

Sexual Problems Are Common in Men With CP/CPPS

Sexual symptoms should not be considered separate from chronic pelvic pain.

They are often part of the same clinical picture.

A major 2025 systematic review and meta-analysis analyzed 26 studies involving more than 20,000 men with CP/CPPS.

The researchers estimated that overall sexual dysfunction affected approximately 59% of studied patients. Erectile dysfunction was estimated at approximately 34% and premature ejaculation at approximately 35%.

However, there was very high variation between studies, meaning these percentages should be considered approximate rather than universal figures for every population.

The important message is clear:

Sexual dysfunction is common enough in chronic pelvic pain that doctors should routinely ask about it.

Erectile Dysfunction and Chronic Pelvic Pain

Some men with chronic pelvic pain notice that their erection quality gradually becomes poorer.

This does not necessarily mean that the penis itself has developed permanent disease.

Several mechanisms may contribute.

Pain itself interferes with sexual arousal.

If a man expects intercourse or ejaculation to cause pain, his attention moves from pleasure toward fear.

Pelvic-floor tension can further interfere with comfortable sexual response.

Chronic stress may increase sympathetic nervous-system activity.

Poor sleep and fatigue may reduce sexual interest.

Anxiety about performance can then make erection more difficult.

Some medications used for chronic pain may also influence sexual function.

EAU guidance recognizes erectile dysfunction as one of the most commonly reported sexual problems in men with primary prostate pain/chronic pelvic pain syndromes.

Painful Ejaculation

Pain during or after ejaculation is particularly important in male chronic pelvic pain.

A patient may experience pain in the:

• prostate region,
• perineum,
• penis,
• urethra,
• testes,
• lower abdomen.

The discomfort may last seconds, minutes or considerably longer.

Painful ejaculation is also an important clue to pelvic-floor dysfunction.

The 2025 AUA chronic pelvic pain guidance specifically highlights painful ejaculation as a symptom associated with pelvic-floor myalgia.

Premature Ejaculation

Premature ejaculation is also frequently reported among men with chronic prostatitis/chronic pelvic pain syndrome.

The reason is probably multifactorial.

Possible contributors include:

• pelvic muscular hyperactivity,
• heightened genital sensitivity,
• anxiety,
• fear of pain,
• inflammation,
• altered autonomic nervous-system activity,
• attempts to complete intercourse quickly before pain develops.

The 2025 meta-analysis estimated premature ejaculation in approximately one-third of men with CP/CPPS, although results varied substantially among studies.

A patient should therefore not automatically assume that premature ejaculation represents an unrelated sexual weakness.

Reduced Sexual Desire

Chronic pain can gradually reduce interest in sex.

Patients may begin subconsciously associating sexual activity with:

• pain,
• pressure,
• burning,
• urinary symptoms,
• fear of ejaculation.

Eventually avoidance may develop.

Depression, anxiety, sleep disturbance and relationship strain may further reduce libido.

This does not mean the problem is “only psychological.”

It means that chronic pain affects the entire sexual response system.

Orgasmic Changes

Some patients report:

• weaker orgasm,
• uncomfortable orgasm,
• delayed orgasm,
• reduced pleasure,
• pelvic pain immediately after orgasm.

These symptoms deserve proper assessment because orgasm and ejaculation, although closely related, are not identical physiological processes.

A Cycle of Pain and Sexual Anxiety

One of the most difficult patterns I see is:

pelvic pain → fear of intercourse → increased pelvic tension → poorer erection → painful ejaculation → greater fear → avoidance of sex.

If this cycle continues, even improving the original pelvic inflammation may not immediately restore normal sexual confidence.

Treatment may therefore need to address both physical pain and the patient's response to pain.

European guidelines recommend addressing sexual difficulties alongside chronic pelvic pain and recognize a role for pelvic-floor treatment, behavioural approaches and sexual or relationship counselling when appropriate.

Urinary Symptoms

Many men with chronic pelvic pain also experience lower urinary tract symptoms.

These may include:

• urinary frequency,
• urgency,
• burning,
• hesitancy,
• weak urine stream,
• interrupted stream,
• straining to urinate,
• sensation of incomplete emptying.

Pelvic-floor tension can itself contribute to difficulty relaxing during urination.

This is why urinary hesitancy does not automatically mean an enlarged prostate.

Bowel Symptoms

The pelvic floor participates in bowel function as well.

Some patients have:

• constipation,
• straining during bowel movements,
• rectal pressure,
• pain after defecation,
• irritable bowel syndrome.

The presence of bowel symptoms may provide an important clue that the condition is broader than an isolated prostate disorder.

Current AUA guidance encourages assessment of bowel symptoms and associated chronic pain disorders during evaluation.

What Causes Chronic Pelvic Pain?

There is rarely one universal cause.

Potential contributors include several mechanisms.

Previous Infection

Some patients report symptoms beginning after a urinary or genital infection.

The original infection may resolve while inflammation or pain sensitization persists.

Pelvic-Floor Muscle Dysfunction

Persistent muscular contraction may produce pain and urinary or sexual symptoms.

Peripheral Nerve Irritation

Pelvic nerves can become irritated or sensitized.

Central Pain Sensitization

In chronic pain, the nervous system can become increasingly sensitive to signals that would not ordinarily be perceived as painful.

Musculoskeletal Problems

Problems involving the lower back, hip, abdominal wall or pelvic muscles may contribute.

Psychological Stress

Stress does not mean that the symptoms are imaginary.

Stress can alter muscle tension, nervous-system activity and pain perception, making an existing physical problem more severe.

Previous Surgery or Trauma

Pelvic, groin or spinal procedures and injuries can occasionally contribute to persistent pain.

Unknown Causes

In many patients, no single triggering event can be identified.

CP/CPPS Is Different From Bacterial Prostatitis

This distinction is extremely important.

Acute bacterial prostatitis

This usually develops rapidly and may cause:

• fever,
• chills,
• marked urinary symptoms,
• pelvic pain,
• difficulty urinating,
• systemic illness.

It requires prompt medical treatment.

Chronic bacterial prostatitis

A bacterial infection persists or repeatedly returns and may cause recurrent urinary infections.

Chronic prostatitis/chronic pelvic pain syndrome

This is different.

In most cases there is no proven ongoing bacterial infection.

That is why repeated antibiotics are often ineffective.

The 2025 AUA guidance specifically warns against repeatedly treating chronic pelvic pain as bacterial prostatitis when cultures remain negative.

Why Repeated Antibiotics Can Be a Problem

Many patients come to me after receiving several antibiotic courses.

Sometimes antibiotics are entirely appropriate—particularly when infection is documented.

But when cultures repeatedly show no infection, giving antibiotic after antibiotic may:

• fail to improve symptoms,
• produce gastrointestinal side effects,
• alter normal microbiota,
• contribute to antimicrobial resistance,
• delay identification of pelvic-floor or neurological pain.

Treatment must follow diagnosis.

Conditions That Can Mimic Chronic Pelvic Pain Syndrome

CP/CPPS is partly a diagnosis of exclusion.

Other conditions sometimes produce similar symptoms.

These include:

• urinary-tract infection,
• chronic bacterial prostatitis,
• sexually transmitted infection,
• epididymitis,
• testicular disorders,
• inguinal hernia,
• urinary stones,
• benign prostatic enlargement,
• urethral stricture,
• bladder pain syndrome,
• neurological disease,
• spinal problems,
• pudendal neuralgia,
• colorectal disorders,
• pelvic malignancy.

Current AUA guidance emphasizes ruling out relevant alternative causes before diagnosing CP/CPPS.

Bladder Pain Syndrome Can Resemble CP/CPPS

Some men experience pain that becomes stronger as their bladder fills and improves after urination.

This pattern may suggest interstitial cystitis/bladder pain syndrome rather than classic CP/CPPS.

The distinction is clinically important because treatment may differ.

Current AUA recommendations specifically encourage clinicians to consider bladder pain syndrome in men whose pain relates strongly to bladder filling or emptying.

Pudendal Neuralgia and Nerve Pain

The pudendal nerve supplies sensation to important pelvic and genital regions.

Pain involving this nerve may cause:

• burning perineal pain,
• pain aggravated by sitting,
• genital discomfort,
• rectal discomfort,
• sexual dysfunction.

Neuropathic pelvic pain can sometimes feel like burning, electrical shock, stabbing or abnormal sensitivity.

The EAU recommends using established neuropathic-pain principles when pudendal neuralgia is diagnosed.

Is Chronic Pelvic Pain Dangerous?

CP/CPPS itself is usually not life-threatening.

However, symptoms should not automatically be attributed to CP/CPPS without assessment because other conditions can occasionally produce similar symptoms.

Particularly important warning signs include:

• high fever or chills,
• inability to urinate,
• visible blood in urine,
• sudden severe testicular pain,
• significant testicular swelling,
• a testicular lump,
• rapidly worsening symptoms,
• unexplained weight loss,
• progressive neurological weakness or numbness,
• loss of bladder or bowel control.

For example, inability to urinate is an indication for urgent medical attention.

How I Assess a Patient With Chronic Pelvic Pain

When someone has suffered for months or years, I do not believe the consultation should begin and end with:

“Your tests are normal.”

Normal investigations can be reassuring, but they do not mean the patient's pain is imaginary.

A proper assessment begins by understanding the pattern.

Pain History

I ask:

• Where exactly is the pain?
• When did it begin?
• Is it continuous or intermittent?
• What makes it worse?
• Does sitting worsen it?
• Does ejaculation worsen it?
• Does urination relieve or aggravate it?
• Does bowel movement affect it?
• Does pain radiate into the penis, testes, groin or back?

This detailed pain map is extremely useful.

Urinary History

I also ask about:

• frequency,
• urgency,
• urinary burning,
• hesitancy,
• weak stream,
• intermittent stream,
• incomplete emptying,
• night-time urination.

Sexual History

Sexual assessment is essential.

I specifically ask about:

• erection quality,
• premature ejaculation,
• delayed ejaculation,
• painful ejaculation,
• orgasm quality,
• reduced desire,
• semen abnormalities,
• intercourse-related pain,
• avoidance of sexual activity.

The EAU recommends assessment of sexual function in chronic pelvic pain and identifies erectile and ejaculatory problems among the most common sexual complaints in men with prostate pain syndromes.

Fertility History

If the patient is trying to conceive, I ask about:

• duration of infertility,
• previous pregnancies,
• semen analysis,
• ejaculation frequency,
• semen volume,
• infections,
• testicular problems.

Chronic pelvic pain does not automatically mean infertility.

However, fertility assessment becomes appropriate when the couple is experiencing difficulty conceiving.

Medication and Medical History

I review:

• previous antibiotics,
• pain medicines,
• antidepressants,
• urinary medicines,
• supplements,
• previous surgery,
• urinary infections,
• STIs,
• diabetes,
• neurological disease,
• spinal disorders.

Medications can sometimes influence libido, erection or ejaculation and should therefore be considered.

Psychological and Emotional Assessment

Chronic pelvic pain can be exhausting.

Some men spend years worrying that they have an undiagnosed infection or sexual weakness.

Repeated treatment failures can increase:

• anxiety,
• frustration,
• depression,
• sexual fear,
• health anxiety,
• relationship stress.

Current EAU recommendations state that patients with significant psychological distress associated with chronic pelvic pain should be offered appropriate pelvic-pain-focused psychological treatment.

This does not suggest that their pain is imaginary.

Psychological care is part of modern chronic-pain medicine.

Physical Examination

Depending upon the patient's symptoms, examination may include:

• abdomen,
• groin,
• penis,
• testes,
• scrotum,
• prostate,
• pelvic floor,
• lower back,
• hip,
• neurological assessment.

One particularly important development is examination of the pelvic-floor muscles.

The AUA guideline emphasizes assessment for pelvic-floor muscle tenderness as part of appropriate evaluation.

Urine Tests

Urinalysis and urine culture may be useful to identify or exclude:

• urinary infection,
• blood,
• other urinary abnormalities.

When infection is repeatedly absent, the treatment strategy should be reconsidered rather than simply continuing antibiotics.

STI Tests

Testing may be appropriate when there is:

• urethral discharge,
• painful urination,
• a new sexual partner,
• unprotected sexual exposure,
• other risk factors.

Blood Tests

Blood investigations depend upon the patient's individual history.

They may be used to investigate:

• systemic illness,
• metabolic disorders,
• endocrine problems,
• inflammatory or other suspected abnormalities.

No single blood test diagnoses CP/CPPS.

PSA and Prostate Investigation

PSA testing should be based upon the patient's age, prostate findings and general prostate-cancer screening indications rather than chronic pelvic pain alone.

An enlarged or tender prostate is not by itself proof of infection.

Ultrasound and Imaging

Imaging is selected according to clinical findings rather than ordered automatically.

Depending upon the situation, investigation may include:

• urinary ultrasound,
• scrotal ultrasound,
• prostate imaging,
• MRI,
• CT,
• spinal imaging.

For example, scrotal ultrasound may be appropriate if there is a testicular mass or focal testicular abnormality.

NIH Chronic Prostatitis Symptom Index

One useful clinical tool is the NIH Chronic Prostatitis Symptom Index, commonly called NIH-CPSI.

It assesses three important areas:

• pain,
• urinary symptoms,
• quality-of-life impact.

The EAU recognizes the NIH-CPSI as a validated instrument for assessing symptoms and monitoring outcomes in prostate pain syndrome.

It is particularly useful for following improvement over time rather than relying only on statements such as “better” or “worse.”

Treatment of Chronic Pelvic Pain

The central principle is:

There is no single treatment that works for every patient.

The 2025 AUA guideline strongly reflects a multimodal and multidisciplinary approach, potentially involving lifestyle measures, behavioural treatment, medicines, physical therapy and selected procedures depending upon the patient's clinical phenotype.

Treatment should target the factors identified in the individual patient.

Pelvic-Floor Physical Therapy

If pelvic-floor myalgia or excessive tension is present, specialized pelvic-floor physiotherapy can be extremely important.

Treatment may involve:

• myofascial release,
• muscle relaxation,
• breathing training,
• improved pelvic coordination,
• posture correction,
• biofeedback,
• home exercises.

It is important to understand that this is not always about performing more Kegel exercises.

Some men already have an overactive, excessively tense pelvic floor.

Strengthening these muscles without proper assessment may potentially worsen tension.

The EAU recommends pelvic-floor muscle therapy as part of treatment when dysfunction is present and recognizes evidence supporting myofascial treatment and biofeedback.

Lifestyle Modification

Some patients identify clear symptom triggers.

These may include:

• prolonged sitting,
• constipation,
• poor sleep,
• stress,
• particular forms of exercise,
• sexual activity during severe flare-ups.

Treatment may therefore involve:

• regular gentle physical activity,
• reducing prolonged sitting,
• treating constipation,
• appropriate hydration,
• improving sleep,
• stress management,
• avoiding personally identified triggers.

This should be individualized rather than turning chronic pelvic pain into a long list of unnecessary lifestyle restrictions.

Medicines

Medication should be chosen according to the patient's symptom pattern.

Possible options used within conventional management can include:

• analgesic or anti-inflammatory medicines,
• alpha-blockers in selected men with urinary symptoms,
• neuropathic-pain medicines in appropriate patients,
• selected phytotherapeutic preparations,
• treatments directed at sexual dysfunction.

Current evidence does not identify one medicine that universally cures CP/CPPS.

The 2025 AUA guideline therefore emphasizes individualized multimodal treatment rather than a one-drug approach.

Antibiotics

Antibiotics are indicated when a bacterial infection is documented or strongly suspected.

They are not a universal treatment for chronic pelvic pain.

A key message from contemporary urology is to avoid repeatedly treating men with negative cultures and chronic pain as though they have an ongoing bacterial infection.

Management of Erectile Dysfunction

When erectile dysfunction is present, I assess whether it is related to:

• pain,
• pelvic-floor dysfunction,
• vascular factors,
• diabetes,
• hormone abnormalities,
• medications,
• anxiety,
• relationship factors.

Treatment is then individualized.

Improving pain alone may substantially improve erectile function in some men, while others require dedicated ED treatment.

Management of Ejaculatory Problems

Painful ejaculation may improve as pelvic inflammation, pelvic-floor tension or neuropathic pain improves.

Premature ejaculation should be assessed separately rather than automatically attributed to “weak nerves.”

Treatment may include management of the pelvic condition together with specific sexual therapy where needed.

Sexual Counselling and Relationship Support

When pain begins interfering with intimacy, I encourage patients not to allow every sexual encounter to become a test of performance.

Intercourse may temporarily be adapted according to what is comfortable.

Couples may benefit from:

• communication,
• reduced performance pressure,
• avoiding activities that reliably provoke major flare-ups,
• gradually restoring comfortable intimacy.

EAU guidance recognizes behavioural strategies, pelvic-floor treatment and appropriate sexual or relationship counselling as components of care for chronic pelvic pain-associated sexual dysfunction.

Stress Management and Pain Psychology

Chronic pain changes the way a person thinks about movement, sex and bodily sensations.

Fear of pain can itself increase muscular guarding.

Modern pain-management approaches may therefore use:

• cognitive behavioural strategies,
• relaxation techniques,
• diaphragmatic breathing,
• stress-management techniques,
• chronic-pain counselling.

The purpose is not to tell the patient that the pain is imaginary.

The purpose is to interrupt the physiological cycle between stress, muscle tension, nervous-system activation and pain.

Can Chronic Pelvic Pain Be Cured?

There is no universal answer.

Some men experience complete resolution.

Others experience substantial long-term improvement but occasional flare-ups.

Some patients require ongoing symptom management.

The prognosis depends on:

• underlying mechanisms,
• duration of symptoms,
• pelvic-floor involvement,
• neurological sensitization,
• associated urinary or sexual dysfunction,
• treatment adherence,
• other chronic pain conditions.

Early recognition of all contributing factors is often more useful than searching repeatedly for one hidden infection.

Chronic Pelvic Pain and Fertility

Another common question is:

“Doctor, will chronic pelvic pain make me infertile?”

Not necessarily.

CP/CPPS does not automatically mean infertility.

Most men with chronic pelvic pain are still capable of producing sperm.

However, fertility evaluation may be appropriate when:

• pregnancy is not occurring,
• semen volume appears abnormal,
• there is a history of infection,
• ejaculation is severely painful,
• another reproductive disorder is suspected.

A semen analysis can assess:

• semen volume,
• sperm concentration,
• motility,
• morphology.

The results should be interpreted in the context of the couple rather than assuming that pelvic pain alone explains infertility.

The Unani Understanding of Chronic Pelvic Pain

As a physician trained in Unani medicine, I consider chronic pelvic pain from a broader constitutional and functional perspective.

Unani medicine traditionally gives importance to the balance and functioning of the urinary and reproductive organs, inflammatory states, temperament, digestion, elimination, nervous function, sleep, physical activity and general health.

This broad approach can be particularly relevant to a chronic condition in which several body systems may interact.

However, I strongly believe that responsible Unani practice should begin with a correct clinical diagnosis.

A patient with bacterial prostatitis, urinary obstruction, STI, testicular disease, stone, neurological disorder or another structural condition should not have that diagnosis overlooked while being treated simply for “sexual weakness.”

How Unani Medicine May Be Useful

After appropriate assessment, Unani treatment may be considered as part of an individualized integrative plan aimed at supporting:

• relief of pelvic discomfort,
• management of inflammatory symptoms,
• urinary comfort,
• pelvic muscular relaxation,
• digestive and bowel regulation,
• general vitality,
• associated sexual symptoms,
• reproductive health,
• sleep and lifestyle balance.

Treatment should be selected according to the patient's presentation rather than prescribing exactly the same formula to every man with pelvic pain.

Evidence for Unani Treatment

It is important to distinguish traditional clinical use from high-quality scientific evidence.

Research specifically evaluating Unani therapy for CP/CPPS is still limited.

A published 2019 case report involving researchers from institutions including Jamia Hamdard and Aligarh Muslim University evaluated a Unani regimenal therapy called Nutool in a 30-year-old man with CP/CPPS and painful ejaculation. The investigators reported improvement in pain and NIH-CPSI measurements after treatment.

However, this was one patient, not a randomized controlled trial, and the authors themselves described the findings as preliminary and requiring additional research.

Therefore, this report should be regarded as an indication that further scientific investigation may be worthwhile—not as proof that one Unani therapy will cure every case.

That distinction is important for evidence-based Unani medicine.

My Integrative Approach at Saira Health Care

At Saira Health Care, I prefer an individualized and integrative approach.

My first objective is to understand the clinical phenotype.

Does the patient primarily have:

• pelvic-floor tension?
• urinary symptoms?
• inflammatory symptoms?
• neuropathic pain?
• sexual dysfunction?
• fertility concerns?
• psychological distress?
• a combination?

I then consider what investigations are genuinely necessary.

When conventional medical treatment, physiotherapy, specialist urological assessment or sexual counselling is indicated, these should be incorporated appropriately.

Unani management can then be individualized as part of the overall plan rather than being used as a substitute for diagnosis.

Why This Approach Is Important

Chronic pelvic pain is one of the conditions where patients can become trapped between specialties.

One doctor examines the prostate.

Another looks only at the testicles.

Another treats the urinary symptoms.

Another treats erection.

But the patient experiences all these symptoms within one body.

The modern AUA guideline emphasizes exactly this challenge: CP/CPPS often requires management beyond a conventional organ-specific urological approach.

This fits well with my clinical philosophy at Saira Health Care:

understand the complete patient before deciding how to treat an individual symptom.

What Patients Should Avoid

I generally advise patients to avoid:

• repeatedly taking antibiotics without evidence of infection,
• self-prescribing steroids,
• unregulated sexual-strength products,
• excessive fear about masturbation or semen loss,
• aggressive prostate massage without medical indication,
• excessive Kegel exercises when the pelvic floor may already be tight,
• repeatedly checking the genital region for abnormalities,
• stopping prescribed medicines without medical advice,
• assuming every symptom means permanent sexual damage.

These behaviours can sometimes worsen physical symptoms or anxiety.

Does Masturbation Cause Chronic Pelvic Pain?

Normal masturbation does not generally cause chronic pelvic pain syndrome.

However, if ejaculation repeatedly causes pain during a flare-up, temporary modification of frequency may make the patient more comfortable while the underlying problem is being assessed.

Patients should not develop guilt or fear around normal sexual behaviour.

Should Men Avoid Sex?

Not automatically.

Sexual activity should generally be guided by comfort.

If intercourse or ejaculation consistently triggers severe pain, temporary modification may be appropriate.

On the other hand, complete long-term avoidance caused by fear can contribute to anxiety, relationship difficulties and loss of sexual confidence.

The goal is comfortable sexual function—not forced sexual activity and not unnecessary abstinence.

Sitting and Chronic Pelvic Pain

Many patients notice that symptoms become worse after sitting for several hours.

This can occur because sitting loads the:

• perineum,
• pelvic floor,
• hip muscles,
• pelvic nerves.

Taking regular movement breaks and addressing posture can help selected patients.

Pain that is particularly severe during sitting may also prompt assessment for muscular or nerve-related causes.

Exercise

Appropriate exercise is generally beneficial for health.

However, individual patients may notice that particular activities worsen symptoms.

Examples can include prolonged cycling or very intense exercises producing sustained pelvic-floor contraction.

Rather than stopping all exercise, I prefer modifying the activity while the underlying mechanism is addressed.

Constipation

Constipation is often overlooked.

Straining increases pressure across the pelvic floor and may worsen muscle dysfunction.

Therefore, bowel regularity can become part of chronic pelvic pain management.

Frequently Asked Questions

Is chronic pelvic pain the same as prostatitis?

Not always.

Chronic prostatitis/chronic pelvic pain syndrome is one important form of male chronic pelvic pain, but symptoms may also originate from the pelvic floor, nerves, bladder, scrotal structures, bowel or musculoskeletal system.

Does CP/CPPS mean there is a prostate infection?

Usually not.

Most CP/CPPS patients do not have a proven ongoing bacterial infection.

Can chronic pelvic pain cause erectile dysfunction?

It can be associated with erectile dysfunction. Pain, muscle dysfunction, nervous-system mechanisms, psychological distress and other health factors may contribute. A 2025 meta-analysis estimated ED in roughly one-third of studied CP/CPPS patients, although estimates varied substantially.

Can CP/CPPS cause premature ejaculation?

Premature ejaculation is commonly reported. The relationship is likely multifactorial and should be individually assessed rather than automatically attributed to psychological weakness.

Can chronic pelvic pain cause pain during ejaculation?

Yes.

Painful ejaculation is a recognized symptom of CP/CPPS and can be particularly suggestive of pelvic-floor involvement.

Can pelvic-floor physiotherapy help men?

Yes, particularly when pelvic-floor myalgia or excessive muscular tension is identified. Current European and American guidance recognizes pelvic-floor physical therapy and myofascial approaches as part of management in appropriate patients.

Should I do Kegel exercises?

Not automatically.

If the muscles are weak, strengthening may sometimes be appropriate.

If they are already overactive and tense, repeated strengthening may be inappropriate. A qualified pelvic-floor professional should determine what type of therapy is needed.

Does stress make pelvic pain worse?

It can.

Stress may increase muscle guarding and nervous-system sensitivity. This does not mean that the pain is imaginary.

Do I need antibiotics?

Only when infection is reasonably suspected or documented.

Repeated antibiotics are not recommended simply because chronic pelvic pain has historically been called “prostatitis.”

Can CP/CPPS affect fertility?

It does not automatically cause infertility. Men experiencing infertility should receive appropriate fertility evaluation rather than assuming pelvic pain is the cause.

Can Unani medicine help?

Unani treatment can potentially serve as part of an individualized integrative approach aimed at symptoms, lifestyle and overall reproductive and urinary health. However, clinical research specifically proving Unani therapies for CP/CPPS remains limited, so important infections, neurological disease, urinary obstruction and structural disorders should be investigated appropriately.

When Should You Seek Urgent Medical Care?

Seek prompt medical attention if pelvic or genital pain is accompanied by:

• fever or chills,
• inability to pass urine,
• sudden severe testicular pain,
• rapidly increasing testicular swelling,
• visible blood in urine,
• severe systemic illness,
• loss of bladder or bowel control,
• new weakness or numbness involving the legs or genital region.

These findings may represent a condition different from ordinary chronic pelvic pain and require urgent evaluation.

A Message From Dr. Nizamuddin Qasmi

Many men who come to me with chronic pelvic pain have already suffered for months or even years.

Some have been told repeatedly that they have prostatitis.

Some have taken many antibiotics.

Some become afraid to have sex.

Others begin thinking that their sexual strength has permanently disappeared.

And some are told that nothing is wrong because routine investigations are normal.

My message to these patients is:

Normal routine tests do not mean your pain is imaginary.

At the same time:

Chronic pelvic pain does not automatically mean that your prostate remains infected.

Modern medicine increasingly understands this condition as a complex interaction involving the pelvic organs, muscles, nerves, nervous system, sexual function and sometimes emotional health.

That understanding creates better treatment possibilities.

The aim should not simply be to search endlessly for infection.

The aim should be to identify which mechanisms are active in your particular case and treat them appropriately.

Saira Health Care's Contribution to Sexual Disorders and Infertility Care

At Saira Health Care, we focus extensively on patients with sexual and reproductive concerns.

Men with chronic pelvic pain often present with several interconnected complaints:

• pelvic pain,
• painful ejaculation,
• erection difficulty,
• premature ejaculation,
• urinary problems,
• fertility concerns,
• sexual anxiety.

Our approach is to evaluate these problems together rather than treating each complaint in isolation.

Where appropriate, Unani principles are integrated with contemporary medical assessment, laboratory investigation, imaging, pelvic-floor management, sexual-health counselling and specialist referral.

Our objective is not to promise a quick cure.

Our objective is to identify the underlying pattern as accurately as possible and build a rational, individualized treatment strategy.

Conclusion

Chronic Pelvic Pain and Sexual Symptoms in Men represents a complex group of conditions rather than one simple prostate disease.

Chronic prostatitis/chronic pelvic pain syndrome is among the most important causes, but the symptoms may also involve pelvic-floor muscle dysfunction, neurological pain, bladder disorders, musculoskeletal problems and other conditions.

Patients may experience:

• perineal pain,
• penile or testicular discomfort,
• lower abdominal or groin pain,
• urinary symptoms,
• painful ejaculation,
• erectile dysfunction,
• premature ejaculation,
• reduced sexual desire,
• altered orgasm,
• anxiety and sexual avoidance.

Current 2025 AUA guidance and the 2026 EAU chronic pelvic pain framework emphasize an individualized, multidisciplinary and biopsychosocial approach rather than treating every patient as though he has bacterial prostatitis.

The relationship with sexual health is particularly important. A recent 2025 systematic review involving more than 20,000 participants confirmed that sexual dysfunction is common among men with CP/CPPS, although prevalence varies widely across studies and populations.

Pelvic-floor dysfunction should also receive careful attention. Painful ejaculation, urinary hesitancy, constipation and pain radiating toward the groin or coccyx can be clues to pelvic-floor myalgia.

In my practice, I believe Unani medicine can form a useful part of an integrative treatment plan when selected according to the patient's overall clinical picture. At the same time, current direct evidence for Unani therapy specifically in CP/CPPS remains limited, and important infections, structural disorders, neurological disease and other identifiable causes must be investigated and treated appropriately.

The most important message is:

Chronic pelvic pain is real, sexual symptoms are common, and neither should be dismissed as simple “weakness.”

A detailed diagnosis and individualized treatment plan offer a far better path than repeated self-medication.

About the Author

Dr. Nizamuddin Qasmi

Founder & Chief Physician, Saira Health Care
Focused Practice in Sexual Disorders & Infertility

Qualifications & Professional Training

BUMS — Hamdard University, Delhi
MD
CGO
Certificate in Infertility — MGBIMS, Delhi
Certificate in Urology — London, UK
Masters in Male Infertility — MasterHealthPro (HealthPro)
Integrated Sexual and Reproductive Health (ISRH) — UNFPA

Dr. Nizamuddin Qasmi's clinical work at Saira Health Care focuses on male and female sexual-health concerns, sexual disorders, reproductive health and infertility, with particular attention to individualized assessment and an integrative approach incorporating Unani medicine and contemporary clinical evaluation.

Medical Disclaimer

This article is intended for education and general health awareness and does not establish an individual diagnosis or replace consultation, examination or treatment by a qualified healthcare professional.

Chronic pelvic pain can have many causes. Appropriate evaluation is particularly important when symptoms are new, severe, progressively worsening or accompanied by fever, urinary retention, visible blood in urine, testicular swelling, neurological symptoms or other warning signs.

Medicines—including antibiotics, hormonal treatments, pain medicines, sexual-health medicines and herbal preparations—should be used only after appropriate professional assessment.