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Treatment of Chronic Prostatitis and Chronic Pelvic Pain Syndrome
- Chronic prostatitis and CPPS: definition and etiology
- Chronic prostatitis and CPPS: signs and symptoms, diagnostic workup
- Chronic prostatitis and CPPS: Treatment
Therapy concepts for functional complaints:
The classification into UPOINT(S) domains enables a structured multimodal therapy, see table UPOINT(S) domains.
- Take complaints seriously and show empathy.
- Careful diagnostic workup without excessive use of technology.
- Explain chronic pain as a multifactorial disease without a one-sided emphasis on psychosocial or somatic factors.
- Formulate realistic therapy goals; do not promise a cure.
- Do not prescribe opiates for pain. Options include physical medicine, complementary medicine, and psychotherapy, supported by NSAIDs and psychotropic drugs.
- Strengthen self-care and self-efficacy, encourage physical activity, and avoid long-term disability certificates.
- Prescribe concomitant outpatient psychotherapy and inpatient treatment in severe cases.
Options of Physical Medicine:
Aerobic exercise therapy, pelvic floor biofeedback relaxation therapy, pelvic floor electromagnetic therapy, myofascial trigger point therapy, microwave heat therapy, massage, stretching, and yoga.
Options of Complementary Medicine:
Osteopathy, acupuncture, homeopathy, and hypnosis.
Medical Treatment of Chronic Pelvic Pain Syndrome
Despite the lack of evidence for a bacterial infection, randomized trials showed high response rates in the early stages of the disease; this justifies one therapeutic trial of long-term antibiotics for 4–6 weeks, e.g., fluoroquinolone antibiotics such as ciprofloxacin 500 mg 1-0-1 or levofloxacin 500 mg 1-0-0.
Alpha blockers improve subvesical obstruction; several randomized studies have demonstrated the effectiveness of alpha blockers for chronic pelvic pain syndrome in 40–60% of patients. Dosage: e.g., terazosine 2–10 mg/d, tamsulosin 0.4 mg/d. For pharmacology and side effects, see section alpha blockers.
5α-reductase inhibitors improve subvesical obstruction, and several randomized trials have shown a significant improvement in subjective symptoms after 6–12 months. They are a treatment option in older patients with an enlarged prostate.
Quercetin, a plant flavonoid with antioxidant activity, has shown effectiveness with a dosage of 500 mg 1-0-1. The pollen extract Pollstimol has demonstrated 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.
NSAIDs and COX-2 inhibitors are often used for symptomatic therapy of CPPS, but only half of the patients show a significant response. The side effects of continuous administration of NSAID are a major drawback. Do not prescribe opiates for pain in functional complaints like CPPS.
Treatment Options for Specific Domains
Therapy of bladder pain syndrome:
Pentosan polysulfate (PPS) and intravesical instillations, among others, are used, see section interstitial cystitis.
Therapy of pudendal pain syndrome:
Injections of local anesthetics and steroids at sites of the nerve passage constriction. If effective, surgical decompression via a transgluteal access is an option.
Therapy of testicular pain syndrome:
Infiltration of the spermatic cord with local anesthetics and steroids, if effective surgical denervation via an inguinal approach is an option. A vasovasostomy is an additional option for patients with post-vasectomy pain syndrome.
Invasive Treatment Options for CPPS
Botulinum toxin injections:
The injection of botulinum toxin A demonstrated in prospective studies a significant treatment effect but is not approved for CPPS.
Transcutaneous electrical nerve stimulation:
TENS is a low-invasive option with up to 50% response rate.
Transurethral microwave therapy:
Randomized trials found response rates of approximately 50–75% vs. 10–50% in the placebo group.
Surgical therapy of BPH (TURP, endoscopic or open surgical enucleation) is indicated only in patients with subvesical obstruction. No convincing long-term studies are available; only uncontrolled studies show improvement of the pain syndrome. Sacral nerve stimulation is a treatment option within trials.
Prognosis after initial manifestation: 60% will become symptom-free within six months, 20% will show a variable course, and 20% will develop continuous symptoms and chronicity. Factors for poor prognosis are marked (polysymptomatic) complaints, passive or overactive behavior, psychological comorbidity (depression, anxiety, addiction, posttraumatic, suicidality), social withdrawal, and disability.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
EAU guidelines: Chronic pelvic pain
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Deutsche Version: Therapie der chronischen Prostatitis