Prostatitis And Inflammatory Conditions Of The Prostate

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology
Article Date: 10 Aug 2008 - 0:00 PDT

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Objectives

* Provide an overview of the prostatitis syndromes
* Present a practical approach to diagnosis
* Summarize current treatment options

Materials and Methods

The recent literature on the prostatitis syndromes was reviewed with particular reference to randomized controlled clinical trials (RCTs). Published expert and consensus opinions were utilized together with the evidence-based findings from RCTs to arrive at a current consensus on diagnosis and treatment of the enigmatic prostatitis syndromes.

Findings

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a prevalent condition in urologic and primary care practices and it has been estimated that it represents the commonest office diagnosed and treated urologic condition in men younger than 50 years. CP/CPPS has a detrimental effect on quality of life (QOL) and it diagnosis and treatment represents a significant economic burden to the healthcare system. It is probable that as many as 10-16% of men carry a lifetime risk of being diagnosed with CP/CPPS.

The common symptoms of CP/CPPS are irritative voiding symptoms and pelvic/perineal/scrotal pain (symptoms reminiscent of Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) in women). This overlap and the similarity to symptoms of LUTS/BPH (lower urinary tract symptoms/benign prostatic hyperplasia) led to the 1999 NIH-NIDDK classification of the prostatitis syndromes and the validation of the patient self-administered NIH Chronic Prostatitis Symptom Index (CPSI). The latter has proven useful in day to day clinical practice (similar to the IPPS for LUTS/BPH) as well as in research studies.

The pillars for the diagnosis of CP/CPPS are a focused history and physical examination, search for an inflammatory/bacterial etiology and symptom evaluation using the NIH CPSI. This questionnaire has nine questions related to the domains of voiding, quality of life and pain.

The utility of Meares-Stamey and Nickel prostate localization tests (expressed prostatic secretions, post-massage voided urine) have been recently questioned as it is now known that prostatic inflammation poorly correlates with microscopic prostate inflammation, immune mediators, symptoms or response to treatment.

Only about 5% men with CP/CPPS have bacteriologically documented infection and these patients benefit from antibiotic treatment especially when newly-diagnosed. Men with culture-positive CP/CPPS who have Category 2 Chronic Bacterial Prostatitis may benefit from antibiotic treatment with one of the fluoroquinolones (that penetrate the prostate) especially if newly-diagnosed. Alpha-blockers are useful in men with Category 3 CP/CPPS with negative cultures. Like with antibiotics, newly-diagnosed, alpha-blocker naïve patients benefit most from long courses (3-6 months) of alpha-blocker therapy. Randomized controlled trials have not shown significant benefit for either alpha-blockers or antibiotics in chronic, pre-treated CP/CPPS patients.

Adjuvant therapy with a variety of oral drugs is frequently necessary. - including anti-inflammatory agents, phytotherapeutic drugs, Tricyclic anti-depressants, analgesics, muscle relaxants, pentosanpolysulfate, finasteride etc. Complimentary therapies such as acupuncture, psychological counseling, and pelvic floor physical therapy are commonly employed in combination with alpha-blockers/antibiotics as part of a multi-modality treatment paradigm.

Rarely used are the minimally invasive surgical treatments such as transurethral microware thermotherapy, transurethral needle ablation.

Summary

The last decade has witnessed a flourishing of research into the prostatitis syndromes that has resulted in the development of a validated patient self-administered questionnaire and a more scientific understanding of the etiology and pathophysiology of these male syndromes. Bacterial prostatitis is rare. However, the mainstays of treatment especially in newly-diagnosed, treatment-naïve patients are long courses of oral antibiotics and alpha-blockers.

References

1. McNaughton-Collins M, Stafford RS, O'Leary MP et al: How common is prostatitis? A national survey of physical visits. J Uro 1998: 159:1224-1228.
2. Krieger N, Nyberg L, Nickel J C: NIH consensus definition and classification of prostatitis. JAMA 1999; 282: 236-237.
3. Litwin MS, McNaughton-Collins M, Fowler F, et al: The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. J Urol 1999: 162(2): 369-375.
4. Nickel JC. The three A's of chronic prostatitis therapy: antibiotics, alpha-blockers and anti-inflammatory. What is the evidence?: BJU International 2004; 94(9): 1230-1233,
5. Nickel JC: Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A decade of change. AUA Update Series, Lesson 34. 25:309-316, 2006

Presented by: Grannum R. Sant, MD, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach, Bermuda

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