Chronic Nonbacterial Prostatitis/chronic Pelvic Pain Syndrome
It has been widely reported that more than 90 percent of men with prostatitis meet the criteria for chronic nonbacterial prostatitis/chronic pelvic pain syndrome .10 However, these estimates come from urologic referral centers and are likely to over-represent more complex cases and under-represent more straightforward cases of acute and chronic bacterial prostatitis. Because of these referral biases, the true incidence and prevalence of these syndromes are unknown.
This syndrome can be differentiated from other types of prostatitis by using the Stamey-Meares localization method. No bacteria will grow on any culture, but leukocytosis may be found in the prostatic secretions. When the PPMT is used, all cultures are negative. The premassage urine has fewer than 10 white blood cells per high-power field, and the postmassage urine contains more than 10 to 20 white blood cells per high-power field . The possibility of bladder cancer, which can also cause irritative symptoms, bears consideration.
The treatment of this condition is challenging, and there is limited evidence to support any particular therapy. Given the high rate of occult prostatic infection, an antibiotic trial is reasonable, to see if the patient responds clinically. Because Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis have been identified as potential pathogens, treatment should cover these organisms.
Treatments That A Specialist May Suggest
Various treatments have been tried for chronic prostatitis. They may benefit some people but so far there are few research studies to confirm whether they help in most cases. They are not ‘standard’ or routine treatments but a specialist may advise that you try one.
For chronic bacterial prostatitis, possible treatments may include the following:
- A longer course of antibiotics. If the specialist suspects that you have chronic bacterial prostatitis and your symptoms have not cleared after a four-week course of antibiotics, they may suggest a longer course. Sometimes a course of up to three months is used.
- Removal of the prostate may be considered if you have small stones in the prostate. It is not clear how much this may help but it has been suggested that these small stones may be a reason why some people have recurrent infections in chronic bacterial prostatitis. However, this is not commonly carried out and is not suitable in everyone. Your specialist will advise.
For chronic prostatitis/CPPS, possible treatments may include the following:
What Research Is Being Done
Researchers are trying to find out more about prostatitis so that they can develop better treatments.
Theyre looking into the causes of CPPS and why it affects men differently. This includes looking at the genes involved. A better understanding of the causes will mean that, in the future, treatments can be tailored to suit each man.
Theyre also looking into different treatments. These include a number of medicines, botox, surgery, and using small electrical currents to reduce pain.
Another area of research is looking at ways to help men live with CPPS, such as cognitive behavioural therapy , and ways men can take more control themselves such as with diet and supplements.
At the moment, most of the research is happening in other countries, but if youre interested in taking part in a clinical trial, mention this to your doctor. There might be trials you can join in the future.
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Treating Prostatitis Not Caused By Infection
Chronic non-bacterial prostatitis, also known as chronic pelvic pain syndrome , is inflammation of the prostate without any detectable infection. The cause is unknown, making it difficult to treat.
Even though no bacteria are implicated in this kind of prostatitis, a physician will sometimes prescribe antibiotics in case there is a hidden infection. Most often, however, therapy involves treating the symptoms. Options include:
- Over-the-counter pain medications like ibuprofen or naproxen
- Soaking in a hot bath
- Medications such as phenazopyridine , oxybutynin, or tolterodine to help with frequent, urgent, or painful urination
- Psychological counseling to help with the ongoing pain
The Upoint Clinical Phenotyping System For Cpps
The most widely adopted questionnaire for clinical evaluation of CPPS is the National Institutes of Health Chronic Prostatitis Symptom Index .16 This tool, validated in 1999, is composed of nine different questions investigating pain, urinary symptoms, and QoL related to CPPS. In 2009, Shoskes et al17 proposed a dedicated clinical classification of CPPS, to separately identify the different possible reported symptoms. It considers: Urinary symptoms Psychosocial dysfunction Organ-specific findings Infection Neurological/systemic and Tenderness of muscles .
The understanding of this clinical phenotyping system for CP/CPPS can explain why this disease has a wide multifactorial genesis, potentially different in each patient, therefore generating an individual multifaceted complex of symptoms for every patient diagnosed with CP/CPPS. A review by Magistro et al23 analyzed 28 randomized controlled trials evaluating various treatments for CP/CPPS, and underlined that monotherapy is never enough to achieve symptom relief and that the therapeutic approach should focus on the different symptomatic pattern presented by the patient in a multimodal setting.
Different phenotypes of chronic prostatitis/chronic pelvic pain syndrome according to the UPOINT classification system,17,20 with the most relevant research work cited in the text.
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Treating Bacterial Prostatitis By Type
Bacterial infection can cause two types of prostatitisacute and chronic .
Acute Bacterial Prostatitis
The main treatment for acute bacterial prostatitis is the use of antibiotics to kill the bacteria. Depending on the antibiotic and the type of bacteria, this treatment can last anywhere from several weeks to a few months. Escherichia coli infections are one of the most common causes, with this species of bacteria found in 65 to 80 percent of cases.
Severe infections may require hospitalization for monitoring and additional antibiotics. In addition, the infection can cause the prostate to grow bigger and block the urethra, the tube that removes urine from the body. Such blockages are especially important to treat so as to prevent urine from backing up in the urinary tract and damaging the kidneys.
Chronic Bacterial Prostatitis
With chronic bacterial prostatitis, bacteria can linger in the prostate even after treatment about 5 percent of men with acute bacterial prostatitis end up with the chronic type. E. coli has been implicated in chronic prostatitis, too, as has a species of Corynebacterium. When these bacteria hang around, they can also cause occasional urinary tract infections.
Understanding Drug Pharmacokinetics And Pharmacodynamics Is Essential When Determining The Most Effective Antibiotic Therapy For Utis In Dogs And Cats
Dr. Foster is an internist and Director of the Extracorporeal Therapies Service at Friendship Hospital for Animals in Washington, D.C. He has lectured around the world on various renal and urinary diseases and authored numerous manuscripts and book chapters on these topics. He is the current president of the American Society of Veterinary Nephrology and Urology.
Urinary tract infections are common in small animal practice it has been reported that up to 27% of dogs will develop infection at some time in their lives.1
Most UTIs are successfully treated with commonly used drugs, dosages, and administration intervals. However, infections can be challenging to effectively treat when they involve the kidneys and prostate . In addition, it can be difficult to create an appropriate antibiotic prescription in patients with kidney disease due to reduced drug clearance.
Understanding drug pharmacokinetics and pharmacodynamics is essential when determining the most effective antibiotic therapy. In addition, successful antimicrobial therapy requires appropriate choice of antibiotic, including dose, frequency, and duration .
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Overview Of Existing Data
A number of pharmacologic and nonpharmacologic therapies for CP/CPPS have been studied in clinical trials. Most of these correspond to particular etiologic hypotheses ,18,19 and many have shown at least some degree of utility in treatment. However, these therapies are all classified as Grade I evidence, according to the US Preventive Services Task Force system, which is defined as âcurrent evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determinedâ.18
Surgery And Minimally Invasive Therapy
Unless a specific indication is encountered during a work-up of patients with CP/CPPS, surgery does not have an important role in its treatment. In the 1980s, it was popular to try a radical TURP with mixed results and it is no longer advocated for patients with CP/CPPS. With the introduction of minimally invasive therapy, a surgical option was again explored. Transurethral needle ablation of the prostate was shown to be of benefit in men with CP/CPPS in open-label studies . However, a sham controlled study could not demonstrate any efficacy of TUNA in men with CP/CPPS . Another minimally invasive approach is transurethral microwave therapy . It has been studied in men with CP/CPPS, and found to be effective in non-controlled studies . The main issue is whether the high temperatures used in BPH therapy are necessary for CP/CPPS and whether prostatic necrosis may lead to an increase in the inflammatory component of the condition. Sham controlled studies are required before these therapies can be recommended for routine use.
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What Is The Outlook
It is difficult to give an outlook . Your symptoms may last a long time, although they may ‘come and go’ or vary in severity. Painkillers can keep discomfort to a minimum.
Most men diagnosed with chronic prostatitis/CPPS tend to have an improvement in their symptoms over the following six months. In one study, about a third of men had no further symptoms one year later. In another large study, one third of men showed moderate to marked improvement over two years.
Treating Prostatitis Effectively: A Challenge For Clinicians
Nhuan Nguyen, PharmD, MBA, CHEClinical PharmacistGR Health, Georgia Regents Medical CenterAugusta, GeorgiaCharlie Norwood VA Medical CenterAugusta, GeorgiaUniversity of Georgia College of PharmacyAthens, Georgia
US Pharm. 2014 39:35-40.
ABSTRACT: Prostatitis, which affects 5% to 9% of males and occurs mostly in middle age, is classified based on signs and symptoms, with urinary urgency, frequency, and pain typical in nearly all categories. Most physicians are not familiar with prostatitis, particularly chronic prostatitis associated with chronic pelvic pain syndrome . Accordingly, patients are often misdiagnosed and receive ineffective treatment, resulting in poor quality of life. CP/CPPS is challenging to treat, as its causes are not clearly defined and the antibiotics used for therapy have low effective rates. Clinical pharmacists can contribute significantly to patient care by advising physicians and other medical professionals regarding drug efficacy, adverse drug reactions, and drug interactions, and by assisting in the selection of optimal antibiotics and/or treatment regimens for prostatitis.
Prostatitis , which occurs in 5% to 9% of males aged 18 years and older, most often develops in middle age.1 In the early 1990s, prostatitis accounted for about 1% and 8% of office visits to family practitioners and urologists, respectively.1
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Alternative Medicine Treatment For Chronic Prostatits
Alternative therapies that have shown potential in decreasing prostatitis symptoms include:
8. Biofeedback: The signals from monitoring equipment are used by a biofeedback specialist to teach you how to manage particular body functions and responses, such as relaxing your muscles.9. Acupuncture: This entails putting very small needles to varying depths through your skin at various locations on your body.10. Supplements and herbal cures: The intake of herbal supplements can boost your immune system naturally without side effects and help fight against Chronic prostatitis. Ryegrass , a substance found in green tea, onions, and other plants , and saw palmetto extract are among natural therapies for prostatitis.
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Questions to ask your doctor about prostatitis include:
- What is the most likely source of my symptoms?
- What other ailments could possibly be causing my discomfort?
- What sort of testing will I require?*
- What treatment would you suggest?
- Are there any other choices for treatment?
- Do you have any brochures or other printed materials that I might have? What are some of your favorite websites?
Can Prostatitis Make Your Body Ache
There may be difficulties as well as severe pain when urinating. Other symptoms, such as fever, chills, lower back pain, pain in the genital area, frequent urination, burning during urination, or urinary urgency at night, may be present. aches and pains all over your body are possible.
Prostatitis: A Common, But Often Debilitating Condition
Prostatitis, a common, often debilitating condition, affects a wide range of body parts. The symptoms may be more severe in some cases if they are accompanied by other symptoms in addition to the prostate gland symptoms. Pain is one of the most common symptoms of prostatitis. It may cause extreme pain and be localized to the prostate gland, but it may also cause other body symptoms. If you have frequent urination but do not urinate frequently , have trouble starting or stopping your urination, or feel like you have to pee immediately, you may have blood in your urine however, this is rarely the cause of the problem. A painful poo can also indicate prostatitis, and there can be problems with starting or stopping, not having an erection, and feeling heaviness in the lower abdomen or lower back. If you have any of these symptoms, you should consult a doctor. There is no cure for prostatitis, but it can often be treated. Antibiotics, pain medication, and/or physical therapy are among the treatments available depending on the severity of the symptoms.
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Hypothetical Heterogeneous Clinical Phenotypes In Chronic Prostatitis Syndromes
Patients with acute bacterial prostatitis are similar in both presentation of symptoms and response to therapy. In contrast, a single treatment fitting all patients diagnosed with CP does not succeed in clinical practice. It has become increasingly clear that patients with CBP and CPPS are not a homogeneous group with identical etiologic mechanisms, but rather are a heterogeneous group of individual patients with widely differing clinical symptoms including genitourinary pain, voiding symptoms, or psychosexual problems. Therefore, a single panacea to this challenging clinical entity will likely not be found soon. Rather, the challenge is to identify which subgroup of patients will respond best to a particular therapy. A clinically practical phenotyping classification system for patients diagnosed with urologic chronic pelvic pain syndromes has recently been proposed . UPOINT is a six-point clinical classification system that categorizes the phenotype of patients with UCPPS into one or more of six clinically identifiable domains as follows: urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness . A physician can easily and quickly categorize patients into one or more UPOINT domains and propose an individually designed therapeutic plan that specifically addresses the clinical phenotypes identified. Most patients will be categorized with more than one UPOINT domain and will require multimodal therapy. This concept is outlined in Table 1.
How Is Chronic Pelvic Pain Syndrome Managed Or Treated
Prostatitis treatments vary depending on the cause and type. Asymptomatic inflammatory prostatitis doesnt require treatment.
For chronic pelvic pain syndrome , your healthcare provider may use a system called UPOINT to classify symptoms into six categories. Your provider uses multiple treatments at the same time to treat only the symptoms youre experiencing.
Approximately 80% of men with CPPS improve with the UPOINT system. The system focuses on these symptoms and treatments:
- Urinary: Medications, such as tamsulosin and alfuzosin , relax muscles around the prostate and bladder to improve urine flow.
- Psychosocial: Stress management can help. Some men benefit from counseling or medications for anxiety, depression and catastrophizing .
- Organ: Quercetin and bee pollen supplements may relieve a swollen, inflamed prostate gland.
- Infection:Antibiotics kill infection-causing bacteria.
- Neurologic: Prescription pain medicines, such as amitriptyline and gabapentin , relieve neurogenic pain. This pain can include fibromyalgia or pain that extends into the legs, arms or back.
- Tenderness: Pelvic floor physical therapy may include myofascial release . This therapy can reduce or eliminate muscle spasms.
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Other Drugs And Therapies
Many other pharmacologic interventions have been studied in patients with CP/CPPS, with variable results.29 Pentosan polysulfate is commonly used to treat patients with painful bladder syndrome/interstitial cystitis to replenish the glycosaminoglycan layer of the bladder. PBS/IC and CP/CPPS are thought to be related conditions, and pentosan polysulfate has been tested in an RCT for CP/CPPS.33 The results showed some clinical benefit in the treatment arm, but the change in total NIH-CPSI score was not statistically significant.
Several natural therapies have also been used for CP/CPPS, including saw palmetto and its extract, bee pollen extract and quercetin. A review of trials using these products suggests potential for each of them to have a therapeutic role,34 and a recent multicenter RCT has demonstrated statistically significant symptomatic improvement in patients receiving bee pollen extract.35
A number of other procedures have been employed to treat men with CP/CPPS, including transurethral microwave thermotherapy, transurethral needle ablation, spinal cord stimulation, pudendal nerve block or decompression, transurethral prostate resection, electromagnetic therapy and acupuncture. Assessment of each of these options is beyond the scope of this Review, but the data on transurethral microwave thermotherapy in particular is encouraging.1,46,47
Modulation Of Inflammatory Process
Since the early 2000s, the immunological mechanisms responsible for chronic inflammation in CP/CPPS have been exhaustively explored. Not surprisingly, many different factors seem to be involved. In vivo and in vitro CP/CPPS studies24,25 showed a sort of autoimmunity against prostate cells inducted by the inflammation, with the recruiting leukocytes including Th1 cells and mast cells, which enhance and trigger the development of CPPS,26 in a similar way to that described for rheumatoid arthritis, multiple sclerosis, and inflammatory bowel diseases.27,28
Thus, medications able to interrupt this molecular mechanism can have a primary therapeutic role.
An RCT by Zhao et al29 demonstrated the efficacy of celecoxib over placebo for pain modulation however, symptoms suddenly re-presented after treatment discontinuation. Another trial failed to demonstrate a benefit from oral prednisolone administration over 4 weeks.30 Similarly, studies involving monoclonal antibodies did not show significant clinical CPPS improvement.31 Common anti-inflammatory drugs seem to give rapid relief of symptoms but only for a short period . This limits the application of these drugs to acute phases of the disease, without the possibility for long-term administration. Moreover, their well-known side effects further limit their applicability for pain reduction in CP/CPPS.
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