Dr. Clemens said that his typical approach with CP/CPPS patients is to start with alpha blockers and physical therapy if pelvic floor muscle tenderness is present. "There is no good evidence to suggest that alpha blockers work better than placebo, but I still use them," he said. "There is some effect and they are relatively benign, especially compared with gabapentin and pregabalin."
Amitriptyline (Elavil) can be useful, as is pregabalin, if burning pain is present. For particularly difficult-to-treat cases, Dr. Clemens recommends referral to a pain specialist, but he said that narcotics should be used as a last resort because of long-term use issues.
Other Prostatitis Types
Other forms of prostatitis that should be distinguished from CP/CPPS include type I (acute bacterial prostatitis). Symptoms include fever, chills, irritation when voiding, a tender and warm prostate, and a positive urinalysis and culture. Hospital admission may be required, as a prostate abscess can form, but symptoms typically resolve with a 14- to 30-day course of antibiotics.
Type II (chronic bacterial prostatitis) is often discussed but is actually very rare, Dr. Clemens said. The hallmark of type II prostatitis is recurrent urinary tract infection spread out over time, often with the same organism. Patients are typically asymptomatic between episodes, although they may have smoldering chronic pain symptoms. Diagnosis is made by urine cultures taken before and after massaging the prostate, and treatment includes antibiotics.
Type IV (asymptomatic inflammatory prostatitis) is typically picked up as an incidental finding in semen or prostate cancer specimens or in prostate fluid. No treatment is needed unless white blood cells are present in the semen, in which case antibiotics can improve semen parameters, Dr. Clemens noted. If inflammation is suspected as a cause of an elevated prostate-specific antigen level, antibiotics may be of some use.
Dr. Clemens disclosed an investment interest in Merck & Co. and consulting for Pfizer Inc., Medtronic Inc., Eli Lilly & Co., and Afferent Pharmaceuticals Inc.