Editing Chronic Pelvic Pain Syndrome & Prostatitis (section)

==== Chronic Pelvic Pain Syndrome (CPPS) ====
* Medical therapies that have been properly evaluated in RCTs in CPPS: antibiotics, α-adrenergic blockers, anti-inflammatory agents, hormonal therapies, phytotherapies, and pregabalin
* Minimally invasive therapies that have been properly evaluated in RCTs in CPPS: extracorporeal shockwave therapy (ESWT), transurethral microwave therapy (TUMT), and neuromodulation (electrostimulation, botulinum toxin).
* '''<span style="color:#ff0000">Therapies that have shown benefits in placebo sham-controlled studies in CPPS:</span>'''
** '''<span style="color:#ff0000">Marked benefit—none</span>'''
** '''<span style="color:#ff0000">Moderate benefit in some selected trials (2):</span>'''
**# '''<span style="color:#ff0000">α-adrenergic blockers</span>'''
**# '''<span style="color:#ff0000">Pregabalin</span>'''
** '''<span style="color:#ff0000">Modest benefit</span>'''
**# '''<span style="color:#ff0000">Anti-inflammatory agents</span>'''
**# '''<span style="color:#ff0000">Phytotherapies</span>'''
**# '''<span style="color:#ff0000">ESWT</span>'''
**# '''<span style="color:#ff0000">TUMT</span>'''
**# '''<span style="color:#ff0000">Selected neurostimulation</span>'''
* '''<span style="color:#ff0000">Recommended</span>'''
*# '''<span style="color:#ff0000">α-Blocker therapy as part of a multimodal treatment strategy for newly diagnosed, α blocker–naive patients who have voiding symptoms.</span>'''
*# '''<span style="color:#ff0000">Antibiotic trial for selected newly diagnosed, antibiotic-naive patients</span>'''
*# '''<span style="color:#ff0000">Selected phytotherapies: Cernilton and Quercetin</span>'''
*# '''<span style="color:#ff0000">Multimodal therapy directed at individual UPOINT phenotypes may result in better management outcomes</span>'''
*# '''<span style="color:#ff0000">Directed physiotherapy</span>'''
* '''<span style="color:#ff0000">Not recommended</span>'''
*# '''<span style="color:#ff0000">α-Blocker monotherapy,</span> particularly in patients previously treated with α-blockers.'''
*# '''<span style="color:#ff0000">Anti-inflammatory monotherapy</span>'''
*# '''Antibiotics as primary therapy, particularly for patients in whom treatment with antibiotics has previously failed'''
*# '''5α-Reductase inhibitor monotherapy;''' can be considered in older patients with coexisting benign prostatic hyperplasia
*# '''Most minimally invasive therapies''' such as transurethral needle ablation (TUNA), laser therapies
*# '''Invasive surgical therapies''' such as transurethral resection of the prostate (TURP) and radical prostatectomy
* Requiring further evaluation
*# Low-intensity shock wave treatment.
*# Acupuncture.
*# Biofeedback.
*# Invasive neuromodulation (e.g., pudendal nerve modulation).
*# Electromagnetic stimulation.
*# Botulinum toxin A injection.
*# Medical therapies including mepartricin, muscle relaxants, neuromodulators, immunomodulators.

* '''<span style="color:#ff0000">Antibiotics</span>'''
** Although bacteria are cultured in only 5-10% of cases of prostatitis, bacteria may be the cause of CP symptoms in a significant percentage of patients with this syndrome
** '''<span style="color:#ff0000">Antibiotic therapy may benefit CP/CPPS patients by 3 different mechanisms:</span>'''
**# '''<span style="color:#ff0000">Strong placebo effect</span>'''
**# '''<span style="color:#ff0000">Eradication or suppression of non-cultured microorganisms</span>'''
**# '''<span style="color:#ff0000">Anti-inflammatory effect of some antibiotics</span>'''
*** '''<span style="color:#ff0000">For CP caused by E. coli, 1 month of fluoroquinolones is recommended; antibiotics should be continued only for 4-6 weeks if pre-treatment cultures are positive and/or the patient has reported positive effects from treatment</span>'''
**** The fluoroquinolones have demonstrated improved therapeutic results, especially in prostatitis caused by E. coli and other members of the Enterobacteriaceae but not necessarily in prostatitis caused by P. aeruginosa or enterococci.
**** '''TMP/SMX is less effective both in bacterial eradication and cost-effectiveness when compared with the newer fluoroquinolones'''
**** Other than fluoroquinolones, most antibiotics (including minocycline, cephalexin, and carbenicillin) do not demonstrate significant clinical efficacy in clinical studies in which patients were observed for sufficient time
**** No significant differences in microbiologic and clinical efficacy or in adverse effect rates among the oral fluoroquinolones ciprofloxacin, levofloxacin, lomefloxacin, ofloxacin, and prulifloxacin.
**** Macrolides appear to be superior to the fluoroquinolones for the treatment of proven chlamydial infection.
**** '''As many as 20% of patients in whom an initial treatment period fails could be rescued with a second cycle of treatment with another antibiotic'''
*** '''Antibiotics should not be prescribed for previously treated men with CP/CPPS of long duration.'''
** '''<span style="color:#ff0000">Antibiotic treatment may be considered for antibiotic-naive patients with a recent diagnosis of prostatitis, regardless of culture status.</span>'''
* '''Alpha-blockers'''
** '''Patients with CP/CPPS have significant lower urinary tract symptoms, which appear to be related to poor relaxation of the bladder neck during voiding;''' α-adrenergic blockade may improve outflow obstruction, improving urinary flow and perhaps diminishing intraprostatic ductal reflux.
** However, trials have not supported the use of α-adrenergic blockers in recently diagnosed α-adrenergic blocker–naive men with CP/CPPS.
* '''Anti-inflammatory agents and immune modulators'''
** '''NSAIDs, corticosteroids, and immunosuppressive drugs theoretically should improve the inflammatory parameters within the prostate and possibly result in a reduction of symptoms'''
*** At this time, high-dose, long duration monotherapy with cyclooxygenase-2 inhibitors is not recommended.
*** An RCT with '''pentosan polysulfate,''' 900 mg/day (three times the usual dose), demonstrated a '''modest benefit for some men with CPPS'''
**** '''Alopecia is associated with pentosan polysulfate'''.§
** The potential of various anti-inflammatory agents, immune modulators, and cytokine inhibitors makes these classes of drugs potentially useful as adjunctive therapy for the CP syndromes, but clinical trials suggest that they are '''not a useful monotherapy'''
* Muscle relaxants
** The role of muscle relaxants has yet to be determined
* '''Hormonal therapy'''
** '''Finasteride and dutasteride cannot be recommended as a monotherapy except in men with associated BPH'''
* Phythotherapeutic agents
** Phytotherapy for CP/CPPS may look promising, but further multicenter RCTs with well-characterized, standardized, and stable herbal components should be considered to assess their role in therapy.
* Neuromodulator therapy
** For neuromodulatory therapy to be effective, it will need to be targeted toward a specific patient phenotype; however, biomarkers, either clinically or laboratory derived, have yet to be confirmed
* Allopurinol
** Randomized clinical trial further showed no advantage of allopurinol compared with placebo
* '''Prostatic massage'''
** The primary form of therapy for prostatitis during most of the 20th century was repetitive prostate massage. Its benefits are believed to arise from draining theoretically occluded prostatic ducts and improving circulation and antibiotic penetration
** A subsequent systematic review of the literature concluded that evidence for a role of repetitive prostatic massage as an adjunct in the management of CP is at most “soft” but that the practice '''could be considered as part of multimodal therapy in selected patients; frequent ejaculation may achieve the same function as prostatic''' '''massage'''
* '''Pelvic Floor Physiotherapy''' (including directed perineal and/or pelvic floor massage and myofascial trigger point release)
** Although level 1 evidence is not available, evidence from multiple weak trials and vast clinical experience strongly suggests benefit for selected patients.
** Most clinicians with experience in the field believe that variations of pelvic floor physiotherapy can be extremely helpful in patients with demonstrable pelvic floor pathology that was found to be refractory to other therapies
* Acupuncture
** Reasonable choice of therapy for selected men with CP/CPPS.
* Pudendal Nerve Entrapment Therapy
* Biofeedback
* Psychological support
* '''Lifestyle modification and other conservative therapies'''
** Conservative therapy should always be considered the primary therapy for CP/CPPS, despite the lack of evidence.
** Education (sometimes the only therapy required); avoidance of food, drink, and/or activities that exacerbate the symptoms; lowimpact exercise (walking, elliptical machine, swimming, yoga, stretching); local heat therapy (hot water bottle, heating pad, hot tub or bath); and positive attitude and development of personal coping skills provide the basis on which all the other therapies rest.
* Minimally invasive techniques
** Some minimally invasive surgical procedures (electrical neuromodulation, extracorporeal shock wave therapy, electroacupuncture, and perhaps transurethral microwave thermotherapy (TUMT) and botulinum toxin injection may be beneficial for treatment for CP/CPPS in selected patients; however, large, well-designed sham-controlled trials are required before these therapies can be considered recommended.
* '''<span style="color:#ff0000">Traditional surgery</span>'''
** '''Surgery does not have an important role in the treatment of most CP syndromes unless a specific indication is discovered during the evaluation of the patient'''
*** '''<span style="color:#ff0000">A developing prostate abscess that fails to respond quickly to antibiotics is optimally drained (transurethral or percutaneous; percutaneous drainage is the more effective and less morbid)</span>'''
*** '''<span style="color:#ff0000">Seminal vesicle abscesses can be managed with antibiotic therapy, transrectal aspiration, and, if necessary, an operation to remove the seminal vesicles</span>'''.
* '''<span style="color:#ff0000">Phenotype directed multimodal treatment</span>'''
** '''No one all-encompassing causative mechanism responsible for all cases of CP/CPPS.'''
** UPOINT is a clinical tool for urologists to use to direct individually based therapy; each of these domains has been associated with specific therapy based on best evidence and expert experience
* See CW11 Figure 13-9 for suggested diagnostic and therapeutic algorithm for the treatment of CPPS based on UPOINT
* See CW11 Table 13-4 for suggested doses of medical therapy for CPPS