A hard thing to talk about

This article is for men who have noticed pain deep in the pelvis, between the scrotum and the anus, or when urinating or ejaculating, and who may be putting off a doctor's visit because it feels awkward. That hesitation is common and understandable. But pain in this area is something doctors see often, and most causes can be managed once they are identified.

The prostate is a walnut-sized gland that sits just below the bladder and wraps around the urethra, the tube that carries urine out of the body. It helps produce the fluid in semen. Because of where it sits, problems with the prostate can affect urination, sexual function and comfort when sitting.

Where prostate-related pain is felt

• The perineum, the area between the scrotum and the anus
• The lower abdomen, just above the pubic bone
• The penis, especially the tip, or the testicles
• The lower back or rectum
• During or after urination, or during or after ejaculation

Pain may come with urinary symptoms such as needing to go often or urgently, getting up at night, a weak or interrupted stream, or a feeling that the bladder hasn't fully emptied.

The usual suspects

Prostatitis means inflammation of the prostate, and it is the most common cause of pain in this area. Doctors describe several types:

• Acute bacterial prostatitis comes on quickly, with pelvic pain, painful urination, fever and chills, and often feeling very unwell. It needs prompt medical care.
• Chronic bacterial prostatitis involves infections that keep coming back, with milder symptoms between flare-ups.
• Chronic prostatitis / chronic pelvic pain syndrome is the most common form. Pain lasts for months, but no infection is found. Muscle tension in the pelvic floor, nerve sensitivity, inflammation and stress may all play a part.

Other causes that can feel similar include urinary tract infections, sexually transmitted infections, kidney or bladder stones, pelvic floor muscle problems, and conditions of the rectum such as hemorrhoids or fissures.

Prostate enlargement (benign prostatic hyperplasia), which is common as men age, mainly causes urinary symptoms rather than pain. Prostate cancer often causes no symptoms in its early stages. That is one reason why decisions about screening are worth discussing with your doctor, separately from any pain you may have.

What a doctor may do

A doctor will ask about your symptoms, urination, sexual health and any recent infections. They may examine your abdomen and genitals and, in some cases, do a quick rectal exam to feel the prostate. Urine tests are common, and depending on the findings they might suggest blood tests, swabs for infections, or a referral to a urologist. If the cause is a bacterial infection, they may prescribe antibiotics. For chronic pelvic pain, care often involves a combination of approaches over time.

Self-care that many men find helpful

Alongside medical care, especially for chronic pelvic pain, these steps help many people:

• Warmth. Warm baths or a heating pad on the lower abdomen or perineum can relax tight muscles.
• A softer seat. A cushion, or a cut-out seat, can take pressure off the perineum. Take breaks from long periods of sitting, and from long cycling rides if they aggravate symptoms.
• Fluids, spread out. Drink enough water through the day, but cut back in the evening if you are up at night.
• Notice dietary triggers. Some men find that alcohol, caffeine or spicy foods make symptoms worse. A simple diary can show whether that is true for you.
• Avoid constipation, which can increase pelvic pressure. Fiber, fluids and regular movement help.
• Pelvic floor physical therapy. A specialist physical therapist can teach relaxation and stretching for the pelvic floor, which is often recommended for chronic pelvic pain.
• Manage stress. Stress and pain can feed each other. Relaxation techniques, regular exercise and good sleep may help lower the overall volume.

Living with long-term pelvic pain

Chronic prostatitis and pelvic pain can affect work, sleep, relationships and mood. It can be hard to explain to others, and some men feel embarrassed or isolated. It helps to know that this is a recognized condition, and that there are clinicians who specialize in it. Keeping a symptom diary, being honest with your partner, and working with a care team that takes the whole picture seriously all help. Many men also find it reassuring to hear from others who have dealt with similar symptoms and found ways to get their lives back on track.

The bottom line

Prostate pain is most often caused by prostatitis, including a chronic pelvic pain form without infection, but other conditions can feel similar. A doctor can help find the cause, and warmth, smart sitting, fluids, pelvic floor therapy and stress care help many men. Seek urgent care if you can't urinate, or have pain with fever and chills, and see a doctor about blood in urine or semen.