Dr. med. Dirk Manski

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Treatment of Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Therapy concepts for functional complaints:

The classification into UPOINT(S) domains enables a structured multimodal therapy, see table UPOINT(S) domains.

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:

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:

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:

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

Krieger u.a. 1999 KRIEGER, J. N. ; NYBERG, Jr. ; NICKEL, J. C.: NIH consensus definition and classification of prostatitis.
In: Jama
282 (1999), Nr. 3, S. 236–7

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