CHICAGO – Prostatitis is used to describe almost all pelvic complaints in men, making it the most common urologic diagnosis in men younger than age 50 and the third most common in those older than 50.
"Frankly, it’s a garbage term," said Dr. J. Quentin Clemens, one of the nation’s leading experts on the subject of male pelvic pain.
Although prostatitis can cover everything from an uncomplicated urinary tract infection and boggy prostate to urethral discharge and hematospermia, the National Institutes of Health identify just four types of prostatitis in their classification system.
The most troublesome to treat is type III or chronic prostatitis/chronic pelvic pain syndrome. CP/CPPS is characterized by dysuria, painful ejaculation, or pain in the perineum, testicles, tip of the penis, or suprapubic region without an identifiable etiology. Men with isolated scrotal pain are excluded.
Some men will have white blood cells in fluid taken from the tip of the penis, but no markers have been identified that can be used to direct therapy outside of the research setting, said Dr. Clemens, director of the division of neurourology and pelvic reconstructive surgery at the University of Michigan Medical Center in Ann Arbor. The duration of pain has traditionally been 6 months for a CP/CPPS diagnosis, but has more recently dropped to as brief as 6 weeks for trial entry.
About 5%-9% of men report CP/CPPS symptoms, and "this is probably just as common as female pelvic pain," said Dr. Clemens at the annual meeting of the International Pelvic Pain Society.
Although CP/CPPS has been the subject of intensive study by the NIH over the past 15 years, little is known about short-term fluctuations in symptoms. Pain can range from mild to debilitating. There are few studies on the natural history of the syndrome, and no clear predictive factors, although it is thought that symptoms are moderately or markedly improved in 30% of patients at 2 years. The mean age at onset is 43 years, but a study by Dr. Clemens and his colleagues suggested that the prevalence increases with age, peaking between at age 71-75 years (J. Urol. 2007;178:1333-37).
Health care costs related to CP/CPPS are similar to those for other chronic pain conditions such as rheumatoid arthritis (RA), fibromyalgia, and lower back pain, but the condition is often particularly costly for patients.
"The quality of life impact is severe, similar to RA," Dr. Clemens said.
Evaluation and Treatment
An initial evaluation should include a careful history to characterize the symptoms and to identify complicating factors. "Look for things that may be atypical, like voiding symptoms that are much more severe than pain symptoms," Dr. Clemens recommended. The physical exam should include a digital rectal exam to assess pelvic floor muscle tenderness. Urinalysis and urine cultures are typically obtained, but Dr. Clemens pointed out that a negative urinalysis does not rule out CP/CPPS.
Other possible diagnostic studies include a urethral swab, the NIH Chronic Prostatitis Symptom Index (NIH-CPSI), urine cytology in smokers or those with hematuria, and pelvic imaging, although this has a low yield. Urologic-specific tests include postvoid residual urine volume measurement, urine culture after prostate massage, urinary flow rate, urodynamic testing, and cystoscopy, but Dr. Clemens admits that he doesn’t perform these tests for most cases of suspected CP/CPPS.
Common treatments for CP/CPPS include antibiotics, NSAIDs, alpha blockers, antidepressants, pelvic floor physical therapy, neurologic agents like gabapentin (Neurontin) and pregabalin (Lyrica), and narcotics. When Dr. Clemens’ talk proceeded to "proven effective treatments," a blank slide appeared before the audience.
"The problem is, we’re lumping together a heterogeneous population and it’s hard to tease out who will respond," he said.
Dr. Clemens highlighted several recent negative NIH studies, including one reporting that 6 weeks of tamsulosin (Flomax) or ciprofloxacin (Cipro) did no better than placebo in men with CP/CPPS. He pointed out that the study has been criticized for the short length of treatment; in addition, the population was heavily pretreated (Ann. Intern. Med. 2004;141:581-9). A second "fantastically negative" trial produced results identical to placebo, this time using alfuzosin (Uroxatral) for 12 weeks in men with new-onset symptoms (N. Engl. J. Med. 2008;359:2663-73).
A recent randomized, double-blind trial was slightly more encouraging, with 47% of men reporting at least a 6-point decrease in their NIH-CPSI total score after 6 weeks of pregabalin, compared with 36% of those given placebo. Although this primary end point did not reach statistical significance, secondary outcomes including NIH-CPSI subscores, as well as response rates and pain scores, were significantly improved in the pregabalin arm (Arch. Intern. Med. 2010;170:1586-93).