Treatments For Chronic Prostatitis or CPPS

Drs Potts and Payne in the Cleveland Clinic Journal of Medicine states that:

"Indeed, chronic abacterial prostatitis (also known as chronic pelvic pain syndrome) is both the most prevalent form and also the least understood and the most challenging to evaluate and treat. This form of prostatitis may respond to non-prostate-centered treatment strategies such as physical therapy, myofascial trigger point release, and relaxation techniques."

CP/CPPS, which makes up the majority of men diagnosed with "prostatitis", a treatment called the "Wise-Anderson Protocol" (aka the "Stanford Protocol"), has recently been published. This is a combination of:

• medication using tricyclic antidepressants and benzodiazepines
• psychological therapy which uses paradoxical relaxation, an advancement and adaptation, specifically for pelvic pain, of a type of progressive relaxation technique developed by Edmund Jacobson during the early 20th century, and
  
• physical therapy - trigger point release therapy on pelvic floor and abdominal muscles, and also yoga-type exercises with the aim of relaxing pelvic floor and abdominal muscles.

While these studies are encouraging, definitive proof of efficacy would require a randomized, sham controlled study, which is not as easy to do with physical therapy as with drug therapy.

Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress. Biofeedback physical therapy to relearn how to control pelvic floor muscles may be useful.

Aerobic exercise can help those sufferers who are not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms are not exacerbated by exercise. Acupuncture has reportedly benefited some patients.

Pharmacological treatment

There is a substantial list of medications used to treat this disorder.

• The effectiveness of alpha blockers (tamsulosin, alfuzosin) is questionable in men with CPPS. A 2006 meta analysis found that they are moderately beneficial when the duration of therapy was at least 3 months. However a 2004 trial found no benefit from alfuzosin during 6 weeks of treatment and a 2008 clinical trial of alfuzosin found it was no better than placebo for treating CPPS in treatment naive recently diagnosed men.
• Quercetin has shown effective in a randomized, placebo-controlled trial in chronic prostatitis using 500 mg twice a day for 4 weeks. Subsequent studies showed that quercetin, a mast cell inhibitor, reduces inflammation and oxidative stress in the prostate.
• Pollen extract (Cernilton) has also been shown effective in randomized placebo controlled trials.
  
• Commonly used therapies that have not been properly evaluated in clinical trials are dietary modification, gabapentin, and amitriptyline.
• Therapies shown to be ineffective by randomized placebo/sham controlled trials: levaquin (antibiotics), alpha blockers for 6 weeks or less, transurethral needle ablation of the prostate (TUNA).
• At least one study suggests that multi-modal therapy (aimed at different pathways such as inflammation and neuromuscular dysfunction simultaneously) is better long term than monotherapy.
• Antibiotics are generally not recommended. Any improvement on antibiotics is likely to be evanescent, and due to the anti-inflammatory effects of the antibiotic.
  

Surgery

Surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.

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What Are The Diagnosis Of Chronic Prostatitis or CPPS?

There are no definitive diagnostic tests for CP/CPPS. This is a poorly understood disorder, even though it accounts for 90%-95% of prostatitis diagnoses. It is found in men of any age, with the peak onset in the early 30s.

CP/CPPS is subcategorized as:

• Category IIIa or inflammatory - urine, semen, and other fluids from the prostate contain pus cells (dead white blood cells or WBCs)
• Category IIIb or non-inflammatory - no pus cells are present

Based on levels of pus cells in expressed prostatic secretions, these subcategories are of limited use clinically.

Recent studies have questioned the distinction between categories IIIa and IIIb, since both categories show evidence of inflammation if pus cells are ignored and other more subtle signs of inflammation, like cytokines, are measured.

In 2006, Chinese researchers found that men with categories IIIa and IIIb both had significantly and similarly raised levels of anti-inflammatory cytokine TGFβ1 and pro-inflammatory cytokine IFN-γ in their expressed prostatic secretions when compared with controls; therefore measurement of these cytokines could be used to diagnose category III prostatitis.

For CP/CPPS patients, analysis of urine and expressed prostatic secretions for leukocytes is debatable, especially due to the fact that the differentiation between patients with inflammatory and non-inflammatory subgroups of CP/CPPS may not be useful. Serum PSA tests, routine imaging of the prostate, and tests for Chlamydia trachomatis and Ureaplasma are not really proven to provide benefit for the patient.

Extraprostatic abdominal/pelvic tenderness is present in half of the patients with chronic pelvic pain syndrome but only 7% of controls.

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What Are Signs And symptoms Of Chronic Prostatitis?

The third category of prostatitis is Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS). It is a pelvic pain condition in men, and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis.

Signs and Symptoms

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterised by pelvic or perineal pain without evidence of urinary tract infection, lasting longer than 3 months, as the key symptom.

Symptoms may wax and wane. Pain can range from mild discomfort to debilitating. Pain may radiate to back and rectum, making sitting difficult. Dysuria, arthralgia, myalgia, unexplained fatigue, abdominal pain, constant burning pain in the penis, and frequency may all be present. Frequent urination and increased urgency may suggest interstitial cystitis (inflammation centred in bladder rather than prostate). Ejaculation may be painful, as the prostate contracts during emission of semen, although nerve- and muscle-mediated post-ejaculatory pain is more common, and a classic sign of CP/CPPS. Some patients report low libido, sexual dysfunction and erectile difficulties. Pain after ejaculation is a very specific complaint that distinguishes CP/CPPS from men with BPH or normal men.

In 2008, a literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine, finding that the symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

Theories behind the disease include stress-driven hypothalamic-pituitary-adrenal axis dysfunction and adrenocortical hormone (endocrine) abnormalities, neurogenic inflammation, and myofascial pain syndrome. In the latter two categories, dysregulation of the local nervous system due to past trauma, infection or an anxious disposition and chronic albeit unconscious pelvic tensing lead to inflammation that is mediated by substances released by nerve cells (such as substance P). The prostate (and other areas of the genitourinary tract: bladder, urethra, testicles) can become inflamed by the action of the chronically activated pelvic nerves on the mast cells at the end of the nerve pathways.

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