Barriers in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) management: perspectives from health practitioners

Arthur Sone-Wai Li; Aquina Lim Yim Wong; Mandy Matthewson; Leesa Van Niekerk; Michael Garry

doi:10.1515/sjpain-2022-0160

Article Publicly Available

Barriers in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) management: perspectives from health practitioners

Arthur Sone-Wai Li , Aquina Lim Yim Wong , Mandy Matthewson , Leesa Van Niekerk and Michael Garry

Published/Copyright: May 16, 2023

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From the journal Scandinavian Journal of Pain Volume 23 Issue 3

Abstract

Objectives

Chronic prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a complex condition which causes a significant burden on the diagnosed individuals. Assessment and management are perplexing, often resulting in unsatisfactory outcomes. Existing research has only focused on patients’ perspectives of pain experiences, but scant evidence is available to understand the barriers that undermine effective pain management. Using an exploratory approach, this study examined these barriers from practitioners’ perspectives.

Methods

Twelve semi-structured interviews were conducted with practitioners across disciplines who have experience in chronic pelvic pain management in males. Practitioners expressed their views and experiences in supporting men with CP/CPPS and what barriers they perceived when providing treatment for patients. Data were analysed using reflexive thematic analysis supported by NVivo software.

Results

Five broad and interrelated themes were identified: (1) Where to Start, (2) Insufficient Resources, (3) Prioritisation, (4) Training and Confident Practice and (5) Constraints in Help-Seeking.

Conclusions

Practitioners value multimodal management using a biopsychosocial approach; however, practical challenges prevent practitioners from choosing and applying this approach in clinical practice. The findings also identified some unique challenges faced by men with CP/CPPS consistent with previous evidence from patient perspective. Refining terminology, developing specific resources, and increasing psychosocial treatment options are urgently needed.

Keywords: chronic pelvic pain syndrome; chronic prostatitis; CP/CPPS; pain management; thematic analysis

Introduction

Chronic prostatitis or Chronic Pelvic Pain Syndrome (CP/CPPS) is the least understood but most common diagnosis in people with prostatitis, accounting for approximately 90 % of all cases [1, 2]. Men with CP/CPPS often show no local pathology (e.g. infection, inflammation) but report persistent pain in the pelvic region (e.g. pelvis, penis, prostate) and/or urinary difficulties (e.g. difficulty voiding, painful urination, an urgency to urinate) [2, 3]. CP/CPPS is prevalent across countries, with epidemiological studies estimating global prevalence rates between 2.2 % and 12 % [4], [5], [6], comparable to other non-communicable diseases such as diabetes mellitus or ischaemic heart disease.

In addition to the high prevalence of CP/CPPS, effective treatment remains challenging for practising clinicians [7]. It is related to the unclear picture of its aetiology and heterogeneous condition, meaning that symptoms and symptom severity vary among sufferers [8, 9]. The UPOINT phenotyping system [10] was established to assist physicians in classifying patients with CP/CPPS and interstitial cystitis into six clinical domains: [U] urinary symptoms, [P] psychosocial dysfunction, [O] organ-specific symptoms, [I] infection, neurological/systemic conditions and [T] tenderness of muscles. This system promotes the recognition of CP/CPPS as a multidimensional issue. It informs optimal therapeutic approaches, and its clinical utility has been validated [11, 12].

Despite physical problems such as persistent pain, muscle spasm and tenderness in the pelvic region [13], it has been found that men with CP/CPPS also experience various comorbid psychological difficulties, including depression and anxiety [14, 15], pain catastrophising [16, 17] and sexual dysfunction [18, 19]. Men with CP/CPPS also face challenges in social and intimate contexts. CP/CPPS sufferers often experience relationship difficulties [20], likely impacted by sexual dysfunctions such as erectile dysfunction [21] and/or depression [22]. Moreover, qualitative studies [23], [24], [25] that explored the experience of men with CP/CPPS have found that sufferers can feel disconnected from their health professionals, perceiving that their symptoms are not taken seriously or their experience has been invalidated. Ruptures in the therapeutic relationship between patients and professionals may increase patients’ shame and disrupt the therapeutic outcomes. Together, these biopsychosocial problems significantly interfere with quality of life (QoL) and daily activities in CP/CPPS sufferers [14, 26].

Research on CP/CPPS has been conducted using the subjective data collection method, either in qualitative or quantitative designs. Evidence obtained from patients’ perspectives has advanced knowledge in assessing, classifying, phenotyping and managing this condition [10, 11, 27], which facilitate the development of clinical guidelines for chronic pelvic pain [28, 29]. To better manage CP/CPPS, most clinical guidelines and reviews advocate input from a multidisciplinary team, including physicians, pain specialists, physiotherapists, psychologists, and others [30]. However, it is unclear what barriers or challenges practising professionals experience when providing treatment for CP/CPPS. Moreover, research is scarce exploring healthcare practitioners’ perspectives (especially from perspectives of a multidisciplinary team) on treating pelvic pain conditions, both males and females. Although the treatment strategy for CP/CPPS has been improved based on evidence from patients’ perspectives, there is a knowledge gap regarding how and what issues are experienced when healthcare practitioners operationalise treatment strategies for their patients, often resulting in unsatisfactory outcomes.

In health research, there is an increased recognition that a qualitative approach is well suited to closely examining the experience, perspective, and meaning of illness and well-being from the patient’s viewpoint [31]. Qualitative research is an exploratory approach suitable for developing a new understanding or producing original insights [32]. Arguably, the qualitative approach is applicable from the viewpoint of health practitioners. Therefore, this study adopted a qualitative approach that interviews various health practitioners who manage chronic (pelvic) pain. This study aimed to explore and understand the potential barriers that health practitioners perceive when delivering or suggesting various treatment options for patients with CP/CPPS.

Methods

Ethical approval was granted by The University of Tasmania Human Research Ethics Committee (HREC) (Reference: H0024970).

Participants

The participants included health practitioners with clinical experience treating males with chronic (pelvic) pain in Australia. As most clinical guidelines for chronic pelvic pain recommend multidisciplinary team management for patients with chronic pelvic pain [28, 29], this study recruited health practitioners beyond the medical field, including health practitioners who work in urology, pain medicine, general practice, nursing, physiotherapy and psychology.

Recruitment procedure

A quota-purposive sampling method was used [33, 34]. A sample size of 12 practitioners with two in each discipline was considered sufficient to generate meaningful themes within the data, given that this study was exploratory, had a moderately narrowed objective (perceived barriers) and included a relatively homogeneous population (experienced experts in chronic pain management) [35]. Potential participants were identified using a combination of strategies, including searches on social media, web search engines, websites of private practices and hospitals in Australia and nominations by health practitioners. A recruitment list was established that included the contact details of potential participants, and health practitioners who expressed a clinical interest in male pelvic pain, chronic pain or relevant pain areas. An invitation email, including the participant information sheet and consent form, was sent to the practitioners on the list. A follow-up email was sent two weeks later if the required number (two practitioners) in each discipline had not been reached. When more respondents contacted than were required sample size, practitioners were purposefully selected to ensure a breadth and depth of perspectives across different work contexts, experience levels, and geographic locations. Practitioners who were not selected were contacted, and the limitations of the recruitment process were explained. Researchers contacted potential participants to discuss a venue and time convenient for them for the interview, and the interview schedule was sent subsequently for participants’ reference.

Table 1 shows demographics, professional background, years of clinical experience and estimates of CP/CPPS cases for each participant. Participants reported varying years of clinical practice in different settings, ranging from 11 to 46 years. Most participants reported CP/CPPS cases below the global prevalence rates estimated in the current literature.

Table 1:

Demographics, profession, work setting, years of experience in clinical practice, and estimate of male patients with CP/CPPS.

Participants ID	Age	Gender	Profession	Work setting	Years of clinical practice	% Of male patients with CP/CPPS
P1	50	Male	Urologist	Hospital	17	∼1 %
P2	38	Male	Psychologist	Private pain clinic	11	∼5 %
P3	53	Female	Nurse	Hospital	32	<5 %
P4	34	Male	Urologist	Hospital	11	2–3 %
P5	57	Female	Nurse	Hospital	30	∼1 %
P6	58	Male	General practitioner	Private clinic	35	∼1 %
P7	69	Male	Pain specialist	Hospital pain clinic	46	∼1 %
P8	∼60	Female	Psychologist	Hospital pain clinic	38	2–5 %
P9	33	Female	Physiotherapist	Private clinic	11	∼1 %
P10	37	Female	Physiotherapist	Private clinic	15	∼15 %
P11	66	Male	Pain specialist	Private pain clinic	42	∼5 %
P12	72	Male	General practitioner	Hospital pain clinic	45	∼1 %

∼ =approximately.

Data collection

All participants provided informed consent. This study employed a semi-structured interview method to ensure the research questions were addressed while allowing for emerging and unexpected themes. Participants were invited to a face-to-face interview using the interview schedule. The interview schedule (see Supplementary Material 1) was designed by authors AL, LVN and MM. It included eight open-ended questions to ensure consistency in data collection and allow for comparative data analysis. All interviews were audio-recorded with the permission of interviewees and transcribed verbatim, with identifiable information removed.

Data analysis

Thematic analysis (TA) was used to identify and develop themes across the dataset, and we followed the Braun and Clarke’s [36, 37] reflexive TA method for data coding and analysis. Reflexive TA is theoretically flexible and acknowledges the subjectivity of participants’ and researchers’ understanding of the phenomenon under study [36, 37]. We adopted an inductive orientation in coding, analysis and theme development, given that there is no existing theory to fit the data, allowing researchers to capture and develop themes strongly linked to the data [36, 37]. Also, researchers adopted the philosophical framework of pragmatism as a research paradigm for design and data analysis [38, 39]. While accepting that there can be a single or multiple realities open for enquiry, pragmatism focuses on what is practical and significant in the real world. Pragmatism also recognises that knowledge is explicitly linked with experience, which is constructed based on the reality of the world we experience and live in [38, 40]. Therefore, this study focused on understanding participants’ experiences to reflect the reality. Reflexive journaling was also performed as an audit trail to support the study’s trustworthiness [41], which recorded the researchers’ experiences of data processing, emerging impressions of the data and how they relate to each other.

Braun and Clarke’s [36, 37] reflexive TA six phases were followed, and NVivo 12 software was used [42]. The process of each phrase is summarised in Table 2.

Table 2:

Summary of the six phrases of thematic analysis.

Phrase	Description of process	Summary of the process
1. Familiarising yourself with the dataset	Transcribing data, reading and re-reading the data	–AL transcribed the interview data; two researchers (AL and AW) read and re-read the twelve transcripts and made reflexive notes to ensure data familiarisation
	–Noting down initial ideas
2. Coding	–Coding interesting features of the data in a systematic way	–AL and AW performed the semantic coding independently and systematically.
	–Collating data relevant to each code	–Initial code labels were applied to data relevant to and meaningful for the research questions: ‘perceived barriers in CP/CPPS management’, which were then refined with complied data extracts through collaborative discussion
3. Generating initial themes	–Collating codes into potential themes	–AL (mental health researcher and practitioner in pain management) and AW (mental health researcher and practitioner) grouped the code labels and searched for core concepts within the groups.
	–Gathering all data relevant to each potential theme	–Researchers then constructed initial themes based on research questions, researchers’ knowledge and clinical experience in pain management, and prior experience in conducting qualitative research
4. Developing and reviewing themes	–Checking if the coded extracts reflect the themes and dataset	–AL and AW assessed the fits of the initial themes to the data.
	–Generating a thematic map	–The broad themes and subthemes were further developed, and the thematic map was created to reflect the relationship between the themes and subthemes
5. Refining, defining and naming themes	–Refining the specific content of each theme	–AL and AW reviewed the themes and subthemes to ensure their coherence and distinction.
	–Generating clear definitions and names for each theme.	–Refinement was made to ensure the names of each theme were concise, punchy and informative.
		–The final version of the thematic framework was further discussed with and reviewed by the author (MM)
6. Writing up	–Selecting vivid, compelling extract examples to reflect the themes	–The first author (AL) summarised the analysis into a written report, which was then circulated and approved by all the authors.
	–Analysing selected extracts	–For each theme, direct supporting quotations are provided and anonymised using participant numbers
	–Relating back of the analysis to the research question and literature
	–Producing a report of the analysis.

Results

Five broad themes were generated from the data (see Figure 1 for a thematic map): Where to Start, Insufficient Resources, Prioritisation, Training and Confident Practice and Constraints in Help-Seeking. Table 3 shows the data extracts for each theme and subtheme.

Figure 1:

The thematic map.

Table 3:

Data extracts in support of each theme and subtheme

Themes	Subthemes	Data extracts
1. Where to start	1.1 Lack of shared understanding and diagnosis	(a) I can’t necessarily link their chronic pelvic pain to chronic prostatitis. From memory, I don’t think that link was clear cut. So there are other causes of pelvic pain. So we see people with pelvic pain but, ‘is it chronic prostatitis?’ is another question (P12)
		(b) … The gaps that will exist right from the starting point from the person who is suffering from the problem and the barriers to them… the barriers that come at the level of the GP who doesn’t understand or is dismissive or whatever (P7)
	1.2 Difficult referral/management pathway	(a) We don’t have is clear referral patterns. So we don’t know who to send these people to … we would send back to the GP to commence neuropathic pain agents. Sometimes we send them to physios, sometimes psychology, sometimes chronic pain specialists. It’s really fragmented about how to manage these people. (P4)
		(b) Sitting in one of the silos that manages this, that gets referred these patients, and then feeling the onus to then refer them on and not knowing, and admitting that I don’t refer them on appropriately is sad (P4)
		(c) I found GPs were pretty reluctant to refer and most of my referrals would have been because I was in the pain clinic and it would’ve come from the consultants in the pain clinic. And when the GPs would refer men in to the pain clinic, they would never mention psychology (P8)
		(d) In referring men to urologists for chronic pelvic pain, and they usually come back with a long four-week course of antibiotics. And so it’s an ineffective problem, which the majority of times does very little (P6).
	1.3 Delayed treatment	(a) Patients that are presenting describing pelvic pain are having quite a delayed diagnosis or an incorrect diagnosis (P9)
		(b) At the point when we get referred these patients, the barriers that we get is they’re categorised typically as a category three. And so there are long waits to get into clinic. That can be three years, four years to get the initial appointment (P4).
		(c) Often they don’t turn up to physio first, they go via their GP, because they’re looking at the medical stream … so sometimes they don’t end up here until it’s already become quite a chronic issue (P10)
		(d) It’s possibly some internal resistance… thinking that psychology would have anything to do with it … there’s a resistance to that because there’s, ‘oh, if you tell me to go see a psychologist, it means it must be in my head. My pain’s not real’. Or something like that. (P2)
2. Insufficient resources	2.1 Limited professionals, services and materials specific for CP/CPPS	(a) Most psychologists, as you well know, are very busy with all manner of problems, particularly in the last 12 months or so, let alone those who have an interest in pain as such. Likewise physiotherapists, again, a very limited number and limited access (P6)
		(b) There’s just so few staff in pain management to the number of people that need help. (P8).
		(c) It would be good to have something we could give them [patients with CP/CPPS]. I give them nothing. I don’t have written information. I don’t have contacts for websites or anything …. The resources that I have, which was quite in-depth study about this, is all at high level, non-patient specific. It’s clinician-based resources …. EAU [European association of urology] guidelines are very good for this from a clinician perspective, but I don’t know where the patient equivalent of that is (P4)
	2.2 Gender differences in resources	(a) The continence Foundation of Australia has a whole set of bladder and bowel and pelvic floor resources, specifically aimed at women. They have at least one or two of them for men (P10).
		(b) If GPs are going to hand out materials to men for their pelvic pain management, but if it has a lot of things in there about vaginas and uterus and periods, men are going to go, ‘oh, yeah, okay. What’s in there for me?’ … I think there’s a lack of materials all around, but I think particularly for men (P2)
	2.3 Socioeconomic barriers	(a) You don’t have multidisciplinary services in rural areas and small places (P12)
3. Prioritisation	3.1 Medical mindset	(a) We don’t get replies from the urologist saying, ‘I’ve sorted out. There are no physical disease. There’s no red flags. I’ve done what I need to do. Now deal with the biopsychosocial’ …. They’ll just say, ‘I’m treating this person with A, B and C. Back to the GP’, but they don’t suggest to the GP a biopsychosocial as a pain syndrome, and the GP doesn’t see it as a pain entity in its own right. They see it as a prostatitis entity. So it’s a mindset (12).
		(b) When no problem is specifically identified on testing and then it’s sort of all, that the urologist tends to lose interest, and it’s back to the GP, and it’s all a very unsatisfactory sort of outcome (P6)
		(c) It’s pretty easy to slap a label on these people, but it’s very hard for us to treat it. And it’s really hard, and we don’t like to talk to patients and say … In a surgical clinic where we’re used to fixing problems or diagnosing things and treating it, that I can’t treat this and it’s going to be a long, prolonged course (P4)
		(d) One of the biggest issues is that it [CP/CPPS] ’s seen as such a medical issue. And I think it tends to be treated pretty much in the medical model domain. And even though there are psychological issues and distress that go with it for quite a lot of people… it’s not really seen by them or referrers as being part of the picture (P8)
		(e) I feel like potentially physiotherapy is considered as the last resort, not a primary treatment option or a secondary treatment option (P9)
	3.2 Time/priority	(a) From my perspective, that comes down to time. We just don’t have. There’s no one that has the time to do that [CP/CPPS management] (P4)
		(b) It [CP/CPPS] will not be a high priority. We’ve got other more common on what we consider to be equally significant pain syndromes (P11)
	3.3 Low incentives for professionals	(a) I Think men with pelvic pain … I Think men with persistent pain in the pelvic area, whether it’s from the hernia operation, whether it’s proctalgia, whether it’s prostatitis is very much not on the horizon, politically, socially, media wise, doctors training. It’s just something that’s … seems to be a very low priority, funding wise (P12)
4. Training and confident practice	4.1 Lack of specific training on CP/CPPS	(a) In all my years of general practice and looking at GP training, and I ran GP training for many years, and I’ve participated in so many activities over such a long time at professional development, I can’t remember any professional development activity at a conference, in the literature, in any form which specifically deals with men with chronic pelvic pain (P12)
		(b) Specific to male pelvic pain, no. Female pelvic pain, yes, there’s some courses. But there’s definitely not enough, and there needs to be some better pathways in place for physios to get more formal training in this area (P9)
	4.2 Lacking confidence in CP/CPPS management	(a) I would say there’s also lots of physios that are either uncomfortable asking awkward questions or don’t feel confident in their skills and assessment or training … they haven’t done enough to really know where to go. So they don’t ask the questions to start off with, so they don’t find out more. So then they don’t know what to do (P10)
5. Constraints in help-seeking	5.1 Stigma and misunderstanding	(a) They’re men. That’s a huge barrier. Males are much less likely to go and seek help for a medical problem (P7).
		(b) There’s stigma associated with it [CP/CPPS] from our perspective … it’s poorly understood by patients (P4)
	5.2 Difficult topic, reluctance to talk and seek help	(a) Men will come and see me if they’ve got back pain, or arm pain, or head pain. I just think there’s a reluctance in Australia for men to talk about anything to do with their sexual function or pain that maybe relates specifically to that part of the body (P11)
		(b) They don’t want to talk about their symptoms … and don’t often volunteer information very quickly that’s really informative in a subjective history (P10)
	5.3 Emotional barriers	(a) Because of the nature of it [CP/CPPS], there may be some emotional barriers, embarrassment, particularly if they feel that their prostatitis may have been as the consequence of behaviours that they don’t want to talk about (P7)
		(b) The thing that has struck me most with the men with pelvic pain that I’ve worked with has been their level of anxiety and the fear about what’s going on with their bodies … it just consumed them, their thinking, couldn’t sleep, lying awake at night worrying about will it get better? … Just being really anxious and fearful. I remember one guy who, he was convinced that his specialists were holding information from him and they were covering up for each other … so he was really, almost paranoid about his management (P8)
	5.4 Low awareness	(a) One of the big barriers is the lack of recognition about how common or how often doctors might see that, the lack of training in the area, the lack of awareness, just simple awareness raising. And in all the urology professional development there’s been a lot of emphasis on things like erectile dysfunction, other areas of urology, but men with chronic pelvic pain, under recognised. Women with chronic pelvic pains is another matter completely and this interstitial cystitis and that kind of pain syndrome, but I think there’s nothing in the GP’s mind from professional development in literature, thinking of gender with chronic pelvic pain (P12)
		(b) I Think male pelvic pain is under reported. So, the patients themselves are not presenting for assessment and treatment … and I think that the lack of evidence that we have and the lack of awareness of male pelvic pain really affects the widespread treatment of it (P9)

Theme 1: where to start

Lack of shared understanding and diagnosis

All practitioners found that the condition of CP/CPPS is ‘so poorly understood’ (P4), and there is ‘a lack of knowledge’ (P7) and ‘a lack of understanding of the condition’ (P6). In particular, most practitioners found the terminology confusing and have trouble linking chronic prostatitis to chronic pelvic pain (see 1.1 (a) in Table 3 for data extracts).

The knowledge gap and unstandardised terminology create a considerable barrier for practitioners to determine appropriate treatment strategies for men with CP/CPPS (see 1.1 (b)).

Difficult referral/management pathway

Most practitioners reported that there is ‘no defined pathway’ (P12) for the management of CP/CPPS (see 1.2 (a)).

All practitioners considered CP/CPPS as a complex, chronic problem requiring management using the ‘multidisciplinary approach’ (P1). However, without a clear pathway guiding practitioners to access this approach, practitioners may hesitate to refer patients and instead offer treatments that could be deemed ineffective, thus contributing to unsatisfactory patient outcomes (see 1.2 (b), (c) and (d)).

Delayed treatment

Medical practitioners perceived that the management plan for patients with CP/CPPS is ‘really fragmented’ (P4), and patients may be delayed in receiving treatment from various health professionals because of lengthy diagnostic procedures (see 1.3 (a) & (b)).

Moreover, treatment by allied health professionals, such as psychotherapy or physiotherapy, may not always the priority from the patients’ perspective. This may further delay patients receiving multidisciplinary management. This was recognised by all participants (see 1.3 (c) & (d)).

Theme 2: insufficient resources

Limited professionals, services and materials specific for CP/CPPS

Most practitioners described the difficulty in finding appropriate resources to support their clinical practice and the management for men with CP/CPPS. Practitioners generally perceived that ‘there’s not a lot of people dedicated to trying to sort these problems [chronic pelvic pain] out’ (P7) and ‘there’s only very few people who have that sort of special interest in’ (P6), and therefore, practitioners indicated ‘a lack of knowledge about who to refer them [men with CP/CPPS]’ (P4) (see 2.1 (a)).

Moreover, several practitioners described a lack of ‘specialised men’s health services’ (P12), and there is ‘no central clinical service that can be thought of as the gold standard or known for its special expertise in men with persistent pelvic pain’ (P12) and no ‘men’s pelvic pain service’ (P8). It appears that male patients with chronic pelvic pain are referred to persistent pain services within the public system and practitioners working in this setting expressed concern over limited staffing to meet patients’ needs (see 2.1 (b)).

Participants also described a lack of informative or educational materials that can be provided to male patients with pelvic pain to increase their understanding of their pain condition (see 2.1 (c)).

Gender differences in resources

Most practitioners indicated that ‘pelvic pain materials often are targeting women’ (P2), and only a limited resource was developed for men (see 2.2 (a)).

Because of limited choice, practitioners sometimes choose to provide materials for female pelvic pain to male patients. However, these materials may be deemed inappropriate and confusing for male patients with pelvic pain (see 2.2 (b)).

Socioeconomic barriers

Several practitioners mentioned the ‘socioeconomic factors’ (P7) that may influence patients to get access to the services needed, including ‘cost’ (P6) and availability of services within living areas. Therefore, these factors could limit the opportunity for patients with CP/CPPS to receive adequate, comprehensive treatment (see 2.3 (a)).

Theme 3: prioritisation

Medical mindset

Some practitioners perceived that the ‘medical model’ (P8) may still be used predominantly in the management of CP/CPPS. Medical practitioners described a ‘strong disease focus’ (P12) between doctors and urologists, and it appears to have a set pathway of ‘doctor refers to another doctor’ (P12) to exchange medical opinions rather than seeking opinions from multidisciplinary services. Both general practitioners indicated that they ‘rely on urologists to manage patients with Chronic Prostatitis or pelvic pain’ (P12), but they do not often receive clinical suggestions about how to manage this population using a biopsychosocial approach (see 3.1 (a) and (b)).

The ‘disease focus’ (P12) may also reflect how medical practitioners approach this condition. Sometimes, practitioners treat CP/CPPS as a disease or surgical problem rather than a pain syndrome that requires biopsychosocial management (see 3.1 (c)).

Moreover, allied health professionals perceived that their services might not be considered simultaneously in the management plan for CP/CPPS (see 3.1 (d) and (e)).

Time/priority

Time allocation is difficult for several practitioners, influencing their clinical practice in managing men with CP/CPPS (see 3.2 (a)).

Moreover, given the complex nature of CP/CPPS and time limitations, practitioners explained that CP/CPPS might not be considered a priority in their practice compared to other pain conditions (see 3.2 (b)).

Low incentives for professionals

Two practitioners described the viewpoints for increased funding on promotion, training and management for men with pelvic pain, which can ‘incentivise the doctors who have done extra training in pain medicine’ (P6) and ‘subsidise services’ (P12). However, this has not been the case, and professionals may be discouraged from devoting time to managing this complex condition (see 3.3 (a)).

Theme 4: training and confident practice

Lack of specific training on CP/CPPS

Most practitioners described having no training for managing male pelvic pain conditions. Some participants indicated that they could not find any specific training opportunities for CP/CPPS, even if they wanted to participate in upskilling their knowledge (see 4.1 (a)).

One practitioner indicated that he only learned about CP/CPPS when preparing for the ‘fellowship exam’ (P4), but did not receive any specific training. Two practitioners with some training indicated that they only learned this condition through studying ‘postgraduate degree’ (P9) and attending ‘hips, pelvis and low back focus courses’ (P10). They perceived that these training opportunities are not specific enough for CP/CPPS but general knowledge about pain in the pelvic floor. Also, they explained that these opportunities often focus on female pelvic pain but not male (see 4.1 (b)).

Lacking confidence in CP/CPPS management

Some practitioners expressed their observations about the inadequacy in managing male pelvic pain among most healthcare professionals. One practitioner explained that medical specialist often feels ‘not fully equipped to be able to look after [male] chronic pelvic pain’ (P7). Another practitioner described the gender difference in pelvic pain management and perceived that many professionals might ‘struggle in the men’s area because they’re mainly familiar with vaginas, and pelvic floor, and childbirth, and incontinence’ (P12).

Additionally, one practitioner described the lack of confidence and adequate skills in assessing men with CP/CPPS among allied health professionals. Therefore, practitioners often experience difficulty forming management plans for male patients with CP/CPPS (see 4.2 (a)).

Theme 5: constraints in help-seeking

Stigma and misunderstanding

All practitioners acknowledged the impact of male gender on patients’ help-seeking behaviours to manage pain-related problems (see 5.1 (a)).

Moreover, practitioners indicated that male gender could influence patients’ perception of the symptoms of CP/CPPS, and male patients often ‘struggle with their masculinity if they’re getting continence issues or erectile issues’ (P10). There is also a perception that men struggle with the psychosocial issues associated with the pelvic pain problem, as these often ‘seem to be fairly mysterious to patients, and it is an area that’s difficult for men to manage’ (P12) (see 5.1 (b)).

Difficult topic, reluctance to talk and seek help

As described by most practitioners, pain in the pelvic area is almost viewed as a ‘taboo’ (P5 and P10), and male patients often do not want to talk about this pain condition. Also, CP/CPPS is often associated with symptoms relating to sexual function, which may impose additional barriers for male patients to elaborate on their condition (see 5.2 (a)).

One practitioner indicated that men might not have the opportunity to talk about their pelvic pain compared to women, who ‘talk about pelvic pain a lot more readily because of babies and periods’ (P5). Practitioners also indicated that men are usually very closed in the therapeutic session and do not proactively provide information relating to their symptoms of CP/CPPS (see 5.2 (b)).

Emotional barriers

Embarrassment often occurs in men with CP/CPPS, which affects their willingness to discuss the potential cause and the associated symptoms, as described by practitioners (see 5.3 (a)).

One practitioner also indicated a high level of fear and anxiety in men with pelvic pain, contributing to excessive worry about the symptoms and distrust of their treating professionals (see 5.3 (b)).

Patients also express ‘grief and frustration’ (P10), as described by practitioners, because of persistent symptoms of continence, erection and pain issues.

Low awareness

Most practitioners indicated that chronic pelvic pain in males is under-recognised as a problem within the ‘medical’ (P12) and ‘community’ (P6) level, which is in sharp contrast to chronic pelvic pain in females (see 5.4 (a)).

Some practitioners explained that male pelvic pain is often underreported because of the low recognition, which likely affects how treatments are delivered to manage this pain condition (see 5.4 (b)).

Discussion

The current study explored multidisciplinary practitioners’ perspectives and experiences in managing CP/CPPS in males, with a particular focus on the perceived barriers when encountering and managing this complex pain condition. CP/CPPS is poorly understood by professionals, the scientific literature and the community. The findings show that cross-disciplinary professionals encountered similar multitude of barriers in CP/CPPS management. One striking result is that all practitioners described the difficulty in defining and differentiating the chronic pelvic pain problems experienced by males, potentially attribute to unstandardised terminology. Despite acknowledging the biopsychosocial approach for pain management, the confusing terminology may prolong the diagnostic procedure and affect practitioners in choosing appropriate clinical pathway, such as biomedical or biopsychosocial management. These barriers echo the arguments in the current literature on pelvic pain and urology guidelines, considering the term ‘prostatitis’ misleading as people with CP/CPPS can experience pain in muscles and organs other than the prostate and has no infection or other local pathology identified [8, 28]. Recently, the European Association of Urology (EAU) proposed the term ‘chronic primary pelvic pain syndrome’ (CPPPS) to implicate pelvic pain as a primary indicator with no proven pathology, which differs from specific disease-associated pelvic pain. Using this term can reduce confusion and facilitate clinical decision-making on pelvic pain management in males [28].

The lack of resources specific to male pelvic pain, including professionals, services and educational materials, as indicated by most practitioners, is considered the common factor underlying all themes of barriers, which can significantly affect how practitioners and patients manage this condition, leading to unsatisfactory outcomes. Also, most resources on pelvic pain are disproportionally designed for females, with limited options available for males. The gender difference in resources may fuel the stigmatisation of pelvic pain in men, leading to low recognition of male pelvic pain as a problem in both the community and among professionals. This situation has also been reported in literature. In a meta-ethnography study that synthesised patients’ experiences of chronic pelvic pain, the authors only found two studies exploring men’s experiences out of thirty-two included studies [43]. With the scarcity of research on men with chronic pelvic pain, there have been calls for more research on the men population with chronic pelvic pain by clinicians, researchers and even sufferers [25, 43]. This call should also be directed to developing resources specific to male pelvic pain.

Practitioners across disciplines have the impression that CP/CPPS is predominately managed through the lens of a biomedical approach, and inputs from allied health professionals may not always be considered simultaneously by medical professionals, but as the last management option. Considering the unclear diagnostic/treatment procedures, insufficient resources, limited time capacity and low incentives, men with CP/CPPS may not always receive the full therapeutic attention from professionals across disciplines, leading to poorer outcomes. This situation is in line with the findings of a meta-ethnography study of healthcare professionals’ experience in treating chronic pain, which found that some healthcare professionals would shift abruptly to explain psychosocial attributes to patients after biomedical reasoning has been exhausted, contributing to a rupture in the therapist-client relationship and unsatisfactory outcomes [44].

Evidence has shown that pharmacological treatment (e.g. antibiotics) alone is ineffective for men with CP/CPPS [45, 46]. However, it remains the predominant approach even though no infection/bacteria is detected [47, 48]. These findings highlight the need to reflect on current clinical practice for CP/CPPS management. As professionals across disciplines for pain management value the biopsychosocial approach, practitioners are encouraged to attend to biopsychosocial constructs routinely and simultaneously when working with male patients with pelvic pain. The UPOINT is a phenotyping system worth integrating into clinical practice for patients with pelvic pain. It embraces the principle of the biopsychosocial model, and increasing research has demonstrated the clinical benefits of UPOINT-guided multimodal therapy [49, 50].

Training opportunities in male pelvic pain are scant within the professional field, with most practitioners in the study expressing difficulty in searching for and receiving specific training to upskill their knowledge. The lack of training may affect practitioners’ confidence in clinical practice for males with CP/CPPS, such as gathering clinically-relevant information, making a diagnosis or suggesting options for pain/symptom management. The findings converge with a qualitative study by Jonsson and Hedelin [24], who found that male participants with CP/CPPS perceive their healthcare providers as ignorant and unassertive in clinical judgment and often provide uncertain and varying information relating to their symptoms, which may instigate worry and fear regarding the threat value of the disease [24]. These findings imply a need to increase the opportunity for professional education in male pelvic pain, which is vital for healthcare practitioners to translate skills and knowledge into clinical practice and achieve better management.

There is consensus among practitioners that the social construct of male gender is an influential factor that affects patients’ emotions and behaviours and perception of CP/CPPS symptoms. Pain and urinary symptoms in the pelvic area – a private area – can threaten men’s masculinity and social identity, instigating CP/CPPS sufferers to employ coping strategies of ‘concealing’ in managing their pain and symptoms [24, 25, 51]. Also, most practitioners recognise the intense emotions experienced by men with pelvic pain, including embarrassment, fear and frustration. These emotions may constrain men from disclosing their symptoms and associated dysfunctions and/or triggering suspicious thoughts towards healthcare providers. The understanding of CP/CPPS patients’ emotional experiences and the associated impacts echo patients’ narratives in both qualitative [24, 25, 51] and quantitative studies [14, 15]. Given the dynamics among CP/CPPS symptoms (bio-), emotional distress (psycho-) and gender identity issues (socio-), male pelvic pain should always be viewed as a multidimensional problem, and each dimension should be attended to and addressed simultaneously by practitioners rather than hierarchically. CP/CPPS management should include practitioners across disciplines, with each professional offering targeted treatments to address different biopsychosocial problems. For psychosocial problems in men with CP/CPPS, treatment strategies based on Acceptance and Commitment Therapy (ACT) could be beneficial, with multiple meta-analytic reviews demonstrating its clinical benefits in pain levels and various psycho-cognitive difficulties in various chronic pain conditions [52], [53], [54], [55]. Also, growing evidence has shown the clinical benefits of ACT in reducing self-stigma, self-criticism and internalised shame associated with various health issues, including substance use, obesity, sexuality and human immunodeficiency virus (HIV) status [56, 57].

Clinical implications

Most practitioners in this study have the impression that the biopsychosocial management approach has not been routinely used in the management of CP/CPPS. The barriers identified include perplexing diagnostic terms and procedures, lack of clear treatment pathways and guidelines, and limited resources and training opportunities, likely preventing practitioners from adopting the lens of the biopsychosocial model when assessing and working with their patients. These barriers are similar to the findings reported in a qualitative systematic review that synthesised evidence from clinicians’ perspectives concerning barriers and enablers influencing the application of the biopsychosocial approach to musculoskeletal pain [58].

To address this phenomenon, the UPOINT system is recommended for routine integration into diagnostic procedures for patients presenting with CP/CPPS. The system is a helpful assessment resource designed specifically for CP/CPPS and embraces the principle of the biopsychosocial model [10, 49, 59]. CP/CPPS patients with multidimensional difficulties can be categorised into six UPOINT domains, and practitioners assign patients to receive targeted interventions or refer them to specific professionals according to the endorsed domains. Several prospective studies have demonstrated the clinical benefits of UPOINT-guided multimodal treatment in the management of CP/CPPS [11, 50, 60].

Psychosocial difficulties such as pain catastrophising cognition, depression, anxiety, and stress are prevalent in the CP/CPPS population [14], [15], [16], [17]. Simultaneously attending to and validating patients’ psychosocial difficulties associated with CP/CPPS potentially enhance the therapeutic relationship and increase patients’ receptiveness to the biopsychosocial multimodal management approach [24, 51, 61]. Healthcare practitioners are encouraged to admit to limits of knowledge and stay honest to discover with their patients, which helps them express their difficulties and facilitate the development of therapeutic alliances [58, 61]. Moreover, using validated psychometric measures enables clinicians to detect these difficulties more reliably and endorse the P domain under the UPOINT, informing the treatment options for patients with CP/CPPS. The psychometric measures with optimal validity and reliability include, but are not limited to, Pain Catastrophizing Scale (PCS) [62], Depression, Anxiety and Stress Scales – 21 items (DASS-21; [63], Patient Health Questionnaire – 9 (PHQ-9) [64] or Generalised Anxiety Disorder Scale – 7 (GAD-7) [65]. The P domain is considered positive if patients with CP/CPPS indicate a clinical or moderate level in these measures, and a referral to psychological or psychiatric services is recommended.

Strengths and limitations

This is the first study to explore practitioners’ perspectives and experiences of CP/CPPS management in males, focusing on the perceived barriers that undermine optimal management. Practitioners with differing lengths of experience in chronic (pelvic) pain management were recruited from various professional backgrounds, allowing a wide range of perspectives to be considered. Also, there was a diversity in the work settings among practitioners, which allowed us to examine the common barriers professionals encountered in different settings. However, the majority of practitioners interviewed have a relatively lower percentage of male patients with CP/CPPS compared to the prevalence rates reported in the current literature. Although most practitioners have a good number of female patients with pelvic pain problems, they may not be the most representative of practitioners working predominately with men’s pelvic health. Together with the Australian focus of this study, the generalisability of these findings is limited due to the global variations in pelvic pain treatment provisions and pathways [49, 66], [67], [68].

Additionally, the research process (interviews and analysis) was performed by researchers (AL and AW) who were new to qualitative research design and analyses. However, our approach followed rigorous steps for conducting the thematic analysis [36, 37], and researchers maintained regular meetings with experienced clinical researchers. Also, tremendous efforts were made to adhere to guiding principles to maintain the trustworthiness of the findings, e.g. semi-structured interview strategy, ongoing researcher reflexivity, collaborative discussion, reflexive journaling as an audit trail, and detailed methodology [41].

Conclusions

This study provides insight into practitioners’ perspectives on barriers that undermine the optimal management for men with CP/CPPS and identifies five common themes described by practitioners from different professional backgrounds and work settings. Our findings show that perplexing diagnostic terms and procedures, lack of clear treatment pathways and guidelines, and limited resources and training opportunities have prevented practitioners from confidently applying the biopsychosocial approach in CP/CPPS management. We recommend urgent action to refine and standardise the terminology and clinical guidelines for chronic pelvic pain in men. Also, investment is needed to develop resources to support practitioners and incentivise more professionals to participate in men’s pelvic health.

Our findings converge with previous studies from CP/CPPS patients’ perspectives that illustrate the dynamic relationship between the male gender and masculinity, perception of symptoms, emotional distress, coping strategies and social identity. This complex picture of CP/CPPS suggests a need for a management plan beyond the mono-biomedical approach, and some psychological treatment modalities (such as ACT) should be considered to target the unique psychosocial constructs in men with CP/CPPS. It also highlights the need for further research on the efficacy of multimodal treatment for CP/CPPS management.

Corresponding author: Arthur Sone-Wai Li, School of Psychological Sciences, College of Health and Medicine, University of Tasmania, Churchill Ave, Hobart, 7005, Tasmania, Australia, Phone: +61 3 6226 2241, Fax: +61 3 6226 2883, E-mail: sonewai.li@utas.edu.au

Acknowledgements

We would like to thank all practitioners who took part in this research and shared their views on this pain area. I would also like to thank the practitioners who expressed interest in this research and the organisations that helped to advertise the research.

Research funding: We have no support or funding for the reporting.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interest: We declare that no competing interests exist.
Informed consent: Informed consent has been obtained from all individuals included in this study.
Ethical approval: Ethical approval was granted by The University of Tasmania Human Research Ethics Committee (HREC) (Reference: H0024970).

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Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/sjpain-2022-0160).

Received: 2022-11-10

Accepted: 2023-04-18

Published Online: 2023-05-16

Published in Print: 2023-07-26

Supplementary Material

Articles in the same Issue

https://doi.org/10.1515/sjpain-2022-0160

Keywords for this article

chronic pelvic pain syndrome; chronic prostatitis; CP/CPPS; pain management; thematic analysis