Dr. med. Dirk Manski



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Treatment of Chronic Prostatitis and Chronic Pelvic Pain Syndrome


Review literature: (Nickel et al, 2003) (Schaeffer et al, 2002). EAU guidelines (Fall et al, 2010).

Algorithm of Chronic Prostatitis Treatment

The treatment algorithm of chronic prostatitis/CPPS differs between the NIH-categories of chronic prostatitis.

Treatment of chronic bacterial prostatitis (Category II):

Treatment of chronic bacterial prostatitis consists of an antibiotic therapy over 4–6 weeks. The antibiotic is chosen depending on the culture results.

Gram-negative bacteria: fluoroquinolones like ofloxacin 200–400 mg 1-0-1 or ciprofloxacin 250–500 mg 1-0-1 are most suitable.

Chlamydia trachomatis: azithromycin for 4 weeks (1 g every 7 days) or doxycycline 100 mg 1-0-1 for 28 days.

Ureaplasma urealyticum: 500 mg of erythromycin 1-1-1-1 or fluoroquinolones.

Lack of improvement or recurrence of chronic bacterial prostatitis:

Long-term low-dose antibiotic treatment is a possibility. TURP is done sometimes in refractory cases, controlled studies are lacking. Further treatment options: see below.

Treatment of Chronic Pelvic Pain Syndrome (Category IIIA and Category IIIB CPPS)

The first therapeutic trial should be done with a course of antibiotic therapy over 4–6 weeks. Despite the lack of evidence for a bacterial infection, there are randomized studies, which show high response rates in the early stages of chronic "abacterial" prostatitis.

If antibiotic treatment does not improve the symptoms, alpha-blocker are most suitable in the treatment of category III chronic prostatitis. Furthermore, treatment options with proven success in randomized trials are 5α-reductase inhibitors, pentosan and phytotherapy with quercetin or pollen extract. For NSAIDs and the rest of phytotherapy, successful randomized trials are not available. Further treatment options are physical therapy and transurethral microwave therapy (TUMT). Invasive treatment options like transurethral prostate resection (TURP) are usually not indicated.

Long-term antibiotic treatment:

Fluoroquinolones like ofloxacin 200–400 mg 1-0-1 or ciprofloxacin 250–500 mg 1-0-1 are most suitable.

Alpha-blocker:

Alpha blocker lead to an improvement in subvesical obstruction due to the muscular relaxation of the prostate, this may reduce intraprostatic reflux. Several randomized studies have demonstrated the effectiveness of alpha-blocker for chronic pelvic pain syndrome in 40–60% of the patients. Dosage: e.g. terazosine 2–10 mg/d, tamsulosin 0.4 mg/d. Pharmacology and side effects please see section alpha blocker.

5α-reductase inhibitors:

5α-reductase inhibitors lead to an improvement in subvesical obstruction due to the shrinkage of the prostate, this may reduce intraprostatic reflux. Several randomized trials have shown a significant improvement of subjective symptoms after 6–12 months.

Phytotherapeutics:

Quercetin, a plant flavonoid with antioxidant activity, has shown in a randomized study the effectiveness compared with placebo, dosage 500 mg 1-0-1. The pollen extract Pollstimol has showed in a randomized trial effectiveness (70 vs. 50% improvement) at a dosage of 2-2-2 capsules per day. Saw palmetto extract had no efficacy in direct comparison with finasteride.

Nonsteroidal anti-inflammatory drugs (NSAID)

NSAIDs are often used for symptomatic therapy of CPPS, only half of the patients show a significant response. The side effects of continuous administration of NSAID are a major draw back.

Zinc substitution:

Zinc substitution improved symptoms in one randomized trial.

Mepartricin:

Mepartricin is an antifungal agent with effect on the estrogen hormone balance. It showed efficiency in a small randomized study.

Prostate massage:

Prostate massage may drain clogged channels of the prostate, improves circulation and may improve the access of antibiotics to the prostate. Randomized studies could not prove efficiency of prostate massage, although it is often recommended: prostate massage 2–3 times/week together with antibiotic treatment. Frequent ejaculations may also be helpful.

Polysulfates pentosan (PPS):

Polysulfates pentosan is an oral medication used to treat interstitial cystitis. It showed partial treatment response in randomized studies.

Physical therapy for chronic pelvic pain syndrome:

Following physical therapies could prove their effectiveness in prospective or randomized trials: aerobic exercise therapy, acupuncture, biofeedback or relaxation therapy of the pelvic floor (neuromuscular reeducation), pelvic floor electromagnetic therapy, trigger point therapy, heat therapy. The following therapies are used, but are not evaluated in prospective studies: massage, stretching, intramuscular injections of local anesthetics, yoga and hypnosis.

Intraprostatic injections:

Due to the poor penetration of many antibiotics into the prostatic tissue, direct injection of antibiotics into the prostate is used. There are only few controlled studies.

Botulinum toxin injections:

The injection of botulinum toxin A demonstrated in prospective studies significant treatment effects.

Transurethral microwave therapy (TUMT):

TUMT shows in randomized studies response rates between 50–75% vs. 10–50% in the placebo control. TUMT is the first choice between invasive treatment options for CPPS.

Surgical treatment for CPPS:

Treatment options are TURP or prostatectomy, but convincing long-term results from controlled studies are not available. Uncontrolled short-term studies have demonstrated some efficiency in selected patients.

Prognosis of chronic prostatitis and CPPS

Prognosis after initial presentation:

60% are free of symptoms within 6 months, 20% show a variable course and 20% will suffer continuously. Poor prognostic factors are recurrent or severe symptoms and pain during or after ejaculation.







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References

Fall, M.; Baranowski, A. P.; Elneil, S.; Engeler, D.; Hughes, J.; Messelink, E. J.; Oberpenning, F.; de C Williams, A. C. u.a.
EAU guidelines on chronic pelvic pain.
Eur Urol, 2010, 57, 35-48


Nickel 2003 NICKEL, J. C.:
Recommendations for the evaluation of patients with prostatitis.
In: World J Urol
21 (2003), Nr. 2, S. 75–81

Schaeffer u.a. 2002 SCHAEFFER, A. J. ; DATTA, N. S. ; FOWLER, Jr. ; KRIEGER, J. N. ; LITWIN, M. S. ; NADLER, R. B. ; NICKEL, J. C. ; PONTARI, M. A. ; SHOSKES, D. A. ; ZEITLIN, S. I. ; HART, C.:
Overview summary statement. Diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
In: Urology
60 (2002), Nr. 6 Suppl, S. 1–4


  Deutsche Version: Therapie der chronischen Prostatitis