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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

Antibiotics:

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.

Phytotherapeutics:

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.

Analgetics:

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

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.

References

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

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