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Chronic Pelvic Pain in Men Medication

  • Author: Richard A Watson, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jan 16, 2015
 

Medication Summary

By definition and exclusion, nonbacterial prostatitis, or chronic pelvic pain syndrome (CPPS), is without a documented bacterial origin. Antibiotics should have a very limited role in therapy for this condition. However, in desperation to do something for the patient, physicians frequently prescribe multiple courses of antibiotics, often for extraordinarily protracted periods.

Keep in mind that no antibiotic regimen has been proven to be efficacious in the treatment of chronic nonbacterial prostatitis. According to Meares, "Antibacterial agents are neither effective nor indicated in the treatment of nonbacterial prostatitis."[34, 35, 36] If Ureaplasma urealyticum or Chlamydia trachomatis infection is suggested, however, a trial treatment of antibiotics may be considered.

In bacterial prostatitis, antibiotic therapy may be guided by culture findings from the prostatic secretions, from the ejaculate, from a urethral swab, or from the spun sediment of a VB3. Even in this scenario, choosing the antibiotic is confounded by the fact that the organisms cultured from these sources may reflect urethral contaminants rather than a true pathogen.

In an aggressive attempt to clarify the presence of bacteria in the uncontaminated prostate tissue of men with CPPS, researchers in Seattle concluded that, while bacterial colonization within the prostate is not uncommon, particularly in older men, prostatic bacteria are probably not etiologically involved in the symptoms of most men with CPPS. The investigators performed digitally guided transperineal prostate biopsies in 118 subjects with CPPS and in 59 control subjects. They found no significant difference in the rates of positive cultures (38% vs 36%).[37]

Some patients with CPPS are maintained on long-term, low-dose regimens, such as one tablet of trimethoprim-sulfamethoxazole (Septra DS) daily. In some cases, patients experience symptomatic relief while on these regimens. Whether this is a reflection of the strong placebo effect associated with treatment of this condition or the result of suppression of an undetected pathogen is purely a matter of speculation. Studies suggest that, beyond the placebo effect, certain antibiotics may actually be providing an objective anti-inflammatory and/or analgesic benefit to these patients.

In screening for a bacterial etiology, the finding of gram-positive organisms has often been dismissed as a contaminant. However, small studies have found evidence to suggest that anaerobes and gram-positive aerobes, even coagulase-negative staphylococci, may in fact be pathogens, and appropriate antibiotic therapy has proven effective in select cases.[38]

In approaching the antibiotic option, remember that no antibiotic is free of complications. Regarding a blinded trial of antibiotics for CPPS, many have commented that the antibiotics cannot hurt. As a grim reminder of the rare, but devastating, consequences attendant to the casual use of such antibiotics, the primary author consulted on the treatment of a patient who experienced life-threatening complications following liver/kidney transplantation that was necessitated by his extremely adverse reaction to a course of trimethoprim-sulfamethoxazole. Tragically, the symptoms of chronic prostatitis (CP), for which this antibiotic was prescribed, were later proven to be manifestations not of prostatitis, but of a bladder neck contracture.

It should also be kept in mind that the expense of antibiotics is not negligible, particularly when multiple prescriptions are provided for the newest, most expensive wide-spectrum antibiotics.

The Urologic Diseases in America Project, reviewing Veterans Health Administration datasets, found that men with CP/CPPS were seven times more likely to have received a fluoroquinolone than were men without this condition. An increased use of other antibiotics was also observed. Despite the evidence that antibiotics are not effective in most men with CP/CPPS, they were prescribed in 69% of men with this diagnosis, suggesting that strategies to reduce unnecessary antibiotic use in these patients are warranted.[39]

In an editorial published in the Journal of Urology, Professor Richard Berger speculated that while considerable evidence suggests that antibiotics are no more effective than placebo in the treatment of CP/CPPS, this finding may be contrary to common experience, as the success rate associated with placebo has been approximately 50%. Thus, half of these men fare better whenever they are given something. It would not be surprising if the most common cause of inappropriate antibiotic prescriptions by urologists were for CP/CPPS type III, and if it were a major contributor to fluoroquinolone antibiotic resistance.[40]

Berger observes, "Because of our inappropriate nomenclature of 'prostatitis,' (when it is neither an infection nor an inflammation) and the message given by our antibiotic treatment, many men end up thinking they have an incurable but unknown infection. Old habits are hard to change, but need to be replaced by patient education, and perhaps by physical education and pain-directed drug therapy."[41]

In a controlled, randomized investigation by the Chronic Prostatitis Collaborative Research Network-2, pregabalin (Lyrica) failed to show an advantage in relieving discomfort, as measured by the NIH Chronic Prostatitis Symptom Index. The problem was that while 47.2% of the men experienced significant (>6-point) relief when taking pregabalin, 35.8% of the men who were taking a placebo also experienced relief. Patients taking pregabalin fared better on the McGill Pain Questionnaire. Despite these findings, clinicians still hold that pregabalin may have a role in pain relief for select CP/CPPS patients. It is important to bear in mind that use of pregabalin is not US Food and Drug Administration approved for the treatment of CP/CPPS pain.[42]

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Antibiotics

Class Summary

Chronic pelvic pain syndrome (CPPS) in men should, by definition, exclude men with a proven bacteriologic etiology. Therefore, antibiotics should not be deemed appropriate for the treatment of this condition. However, most practitioners are inclined to attempt at least 1 trial of long-term antibiosis.

Clinical evidence upon reviewing the results of all available clinical trials indicates limited validation for the use of antibacterials, even in the face of chronic bacterial prostatitis. The cure rates for sterilization of prostatitic secretions, even for this more specific indication, ranged from 0-90% and correlated poorly with symptomatic responses. Limited evidence from retrospective studies suggests that quinolones (eg, ciprofloxacin [Cipro], levofloxacin [Levaquin]) may be more effective than trimethoprim-sulfamethoxazole (Bactrim, Septra).

Minocycline (Dynacin, Minocin)

 

Minocycline helps to treat infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible chlamydial, rickettsial, and mycoplasmal organisms.

Erythromycin (E.E.S., E-Mycin, Ery-Tab)

 

Erythromycin is a macrolide antibiotic with the theoretical advantage of penetrating the blood-prostate barrier, but it carries an increased incidence of gastrointestinal (GI) intolerance.

Ciprofloxacin (Cipro)

 

Ciprofloxacin is a fluoroquinolone with activity against Pseudomonas species, streptococci, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. It inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 days (7-14 d typical) after signs and symptoms have disappeared.

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Muscle Relaxants

Class Summary

Tension myalgia of the pelvic floor muscles, combined with overall stress-related tension, can be partially relieved with muscle relaxants.[34, 35, 36]

Diazepam (Valium, Diastat)

 

Diazepam is a benzodiazepine derivative indicated for short-term relief of anxiety and adjunctive relief of skeletal muscle spasm. It depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of gamma-aminobutyric acid (GABA). Individualize the dosage and increase it cautiously to avoid adverse effects.

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Alpha-Adrenergic Blockers

Class Summary

These agents have become a mainstay in the symptomatic treatment of chronic pelvic pain syndrome (CPPS) in men.[34, 35, 36] These agents, by relieving the secondary smooth muscle spasm within the bladder neck and prostatic urethra, afford the patient greater comfort in voiding. The dosage should be titrated progressively and administered at night to minimize the main adverse effect of orthostatic hypotension. The final dose must be individualized to meet the patient's needs.

While the antihypertensive agent has been administered to patients already taking other blood pressure medications, coordinating the addition of this medication with the primary care physician or cardiologist who is prescribing the patient's other antihypertensive medications is wise.

Again, as with other medications, such as antibiotics, remember that the use of alpha-adrenergic blockade is not approved by the US Food and Drug Administration (FDA) for the treatment of prostatodynia. One study suggested an advantage to the use of alpha blockers in combination with antibiotics over antibiotic therapy alone in the treatment of chronic bacterial prostatitis.[40]

Doxazosin (Cardura)

 

Quinazoline compounds counteract alpha1-induced adrenergic contractions of the bladder neck, facilitating urinary flow in the presence of benign prostatic hyperplasia (BPH).

Terazosin (Hytrin)

 

Terazosin is a quinazoline compound that counteracts alpha1-induced adrenergic contractions of the bladder neck, facilitating urinary flow in presence of BPH. Reporting at the annual convention of the American Urological Association, researchers confirmed a significant, albeit limited, value for alpha1-blockers in the management of CPPS. Patients with CPPS treated with terazosin showed a 56% improvement in their NIH-CPSI scores; however, placebo controls showed a 36% response rate.

In a parallel report from Finland, using the selective alpha-blocker alfuzosin, modest improvement again occurred. After 6 months, 19 patients on alfuzosin showed significant reduction in pain scores but not in voiding or quality-of-life scores. This finding seems counterintuitive in that one would expect an alpha blocker to have its most dramatic effect on voiding performance. Moreover, unlike BPH treatment, in which a response to alpha blockers is prompt, the symptomatic response in patients with CPPS can take 6 months or longer to mature.

These studies raise the question of whether the expense and nuisance of these long-term medications are warranted for this modest response, which is in close competition with the placebo effect.

Tamsulosin (Flomax)

 

Tamsulosin is an alpha-adrenergic blocker that specifically targets A1 receptors. It has the advantage of causing relatively less orthostatic hypotension and requires no gradual up-titration from the initial introductory dosage. On the other hand, the rate of ejaculatory dysfunction is higher with this medication (8.4-18.1%).

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Contributor Information and Disclosures
Author

Richard A Watson, MD Professor of Surgery (Urology), Department of Surgery, Division of Urology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Hackensack University Medical Center

Richard A Watson, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Urological Association, Association of Military Surgeons of the US, Society of University Urologists

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Robert J Irwin, Jr, MD Chair, Harris L Willits Professor, Department of Surgery, Division of Urology, University Hospital, University of Medicine and Dentistry of New Jersey

Robert J Irwin, Jr, MD is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Pontari MA, Ruggieri MR. Mechanisms in prostatitis/chronic pelvic pain syndrome. J Urol. 2004 Sep. 172(3):839-45. [Medline].

  2. Krieger JN, Riley DE. Chronic prostatitis: Charlottesville to Seattle. J Urol. 2004 Dec. 172(6 Pt 2):2557-60. [Medline].

  3. Cohen RJ, Shannon BA, McNeal JE, Shannon T, Garrett KL. Propionibacterium acnes associated with inflammation in radical prostatectomy specimens: a possible link to cancer evolution?. J Urol. 2005 Jun. 173(6):1969-74. [Medline].

  4. Rudick CN, Berry RE, Johnson JR, et al. Uropathogenic Escherichia coli induces chronic pelvic pain. Infect Immun. 2011 Feb. 79(2):628-35. [Medline]. [Full Text].

  5. Soto SM, Smithson A, Martinez JA, Horcajada JP, Mensa J, Vila J. Biofilm formation in uropathogenic Escherichia coli strains: relationship with prostatitis, urovirulence factors and antimicrobial resistance. J Urol. 2007 Jan. 177(1):365-8. [Medline].

  6. Zermann DH, Ishigooka M, Doggweiler R. Chronic Prostatitis: a myofascial syndrome?. Infect Urol. 1999. 12:82-92.

  7. Penna G, Fibbi B, Maggi M, Adorini L. Prostate autoimmunity: from experimental models to clinical counterparts. Expert Rev Clin Immunol. 2009 Sep. 5(5):577-86. [Medline].

  8. Davis SN, Maykut CA, Binik YM, Amsel R, Carrier S. Tenderness as measured by pressure pain thresholds extends beyond the pelvis in chronic pelvic pain syndrome in men. J Sex Med. 2011 Jan. 8(1):232-9. [Medline].

  9. Miller JL, Rothman I, Bavendam TG, Berger RE. Prostatodynia and interstitial cystitis: one and the same?. Urology. 1995 Apr. 45(4):587-90. [Medline].

  10. Parsons CL, Albo M. Intravesical potassium sensitivity in patients with prostatitis. J Urol. 2002 Sep. 168(3):1054-7. [Medline].

  11. Forrest JB, Schmidt S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity. J Urol. 2004 Dec. 172(6 Pt 2):2561-2. [Medline].

  12. MacLennan GT, Eisenberg R, Fleshman RL, Taylor JM, Fu P, Resnick MI, et al. The influence of chronic inflammation in prostatic carcinogenesis: a 5-year followup study. J Urol. 2006 Sep. 176(3):1012-6. [Medline].

  13. Schaeffer A, Stern J. Chronic prostatitis. Clin Evid. 2002 Jun. (7):788-95. [Medline].

  14. Nickel JC. Practical approach to the management of prostatitis. Tech Urol. 1995 Fall. 1(3):162-7. [Medline].

  15. Pansadoro V, Emiliozzi P, Defidio L, Scarpone P, Sabatini G, Brisciani A, et al. Prostate-specific antigen and prostatitis in men under fifty. Eur Urol. 1996. 30(1):24-7. [Medline].

  16. Theodorou C, Konidaris D, Moutzouris G, Becopoulos T. The urodynamic profile of prostatodynia. BJU Int. 1999 Sep. 84(4):461-3. [Medline].

  17. Davis BE, Weigel JW. Adenocarcinoma of the prostate discovered in 2 young patients following total prostatovesiculectomy for refractory prostatitis. J Urol. 1990 Sep. 144(3):744-5. [Medline].

  18. Chung SD, Huang CC, Lin HC. Chronic prostatitis and depressive disorder: a three year population-based study. J Affect Disord. 2011 Nov. 134(1-3):404-9. [Medline].

  19. Nickel JC, Shoskes DA. Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome. BJU Int. 2010 Nov. 106(9):1252-63. [Medline].

  20. Davis SN, Binik YM, Amsel R, Carrier S. Is a Sexual Dysfunction Domain Important for Quality of Life in Men with Urological Chronic Pelvic Pain Syndrome? Signs "UPOINT" to Yes. J Urol. 2013 Jan. 189(1):146-51. [Medline].

  21. Samplaski MK, Li J, Shoskes DA. Clustering of UPOINT domains and subdomains in men with chronic prostatitis/chronic pelvic pain syndrome and contribution to symptom severity. J Urol. 2012 Nov. 188(5):1788-93. [Medline].

  22. Nickel JC. Lower urinary tract symptoms associated with prostatitis. Can Urol Assoc J. 2012 Oct. 6(5 Suppl 2):S133-5. [Medline]. [Full Text].

  23. Smart CJ, Jenkins JD, Lloyd RS. The painful prostate. Br J Urol. 1975. 47(7):861-9. [Medline].

  24. Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005 Jul. 174(1):155-60. [Medline].

  25. FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2009 Aug. 182(2):570-80. [Medline].

  26. Wise D, Anderson RU. A Headache in The Pelvis: A New Understanding and Treatment. Occidental, CA: National Center for Pelvic Pain Research; 2003. [Full Text].

  27. Anderson RU, Wise D, Sawyer T, Chan CA. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol. 2006 Oct. 176(4 Pt 1):1534-8; discussion 1538-9. [Medline].

  28. Lee JH, Lee SW. Relationship between Premature Ejaculation and Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Sex Med. 2014 Dec 5. [Medline].

  29. Sadeghi-Nejad H, Seftel A. Sexual dysfunction and prostatitis. Curr Urol Rep. 2006 Nov. 7(6):479-84. [Medline].

  30. Kaplan SA, Santarosa RP, D'Alisera PM, Fay BJ, Ikeguchi EF, Hendricks J, et al. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. J Urol. 1997 Jun. 157(6):2234-7. [Medline].

  31. Lee SH, Lee BC. Electroacupuncture relieves pain in men with chronic prostatitis/chronic pelvic pain syndrome: three-arm randomized trial. Urology. 2009 May. 73(5):1036-41. [Medline].

  32. Küçük EV, Suçeken FY, Bindayi A, Boylu U, Onol FF, Gümüs E. Effectiveness of Acupuncture on Chronic Prostatitis-Chronic Pelvic Pain Syndrome Category IIIB Patients: A Prospective, Randomized, Nonblinded, Clinical Trial. Urology. 2015 Jan 9. [Medline].

  33. Anderson RU, Sawyer T, Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol. 2009 Dec. 182(6):2753-8. [Medline].

  34. Meares EM Jr. Prostatitis. Med Clin North Am. 1991 Mar. 75(2):405-24. [Medline].

  35. Meares EM Jr. Non-specific infections of the genitourinary tract. Tanagho EH, McAninch JW, eds. Smith's General Urology. 14th ed. Appleton & Lange: Norwalk, Conn; 1995. 231-4.

  36. Meares EM Jr. Prostatitis and related disorders. Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders; 1998. 285-6.

  37. Lee JC, Muller CH, Rothman I, Agnew KJ, Eschenbach D, Ciol MA, et al. Prostate biopsy culture findings of men with chronic pelvic pain syndrome do not differ from those of healthy controls. J Urol. 2003 Feb. 169(2):584-7; discussion 587-8. [Medline].

  38. Lowentritt JE, Kawahara K, Human LG, Hellstrom WJ, Domingue GJ. Bacterial infection in prostatodynia. J Urol. 1995 Oct. 154(4):1378-81. [Medline].

  39. Taylor BC, Noorbaloochi S, McNaughton-Collins M, Saigal CS, Sohn MW, Pontari MA. Excessive antibiotic use in men with prostatitis. Am J Med. 2008 May. 121(5):444-9. [Medline].

  40. Barbalias GA, Nikiforidis G, Liatsikos EN. Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. 1998 Mar. 159(3):883-7. [Medline].

  41. Berger R. Editorial comment: Urological survey--infection and inflammation in the genitourinary tract. J Urol. Jan 2009. 181:135.

  42. Pontari MA, Krieger JN, Litwin MS, et al. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: a randomized controlled trial. Arch Intern Med. 2010 Sep 27. 170(17):1586-93. [Medline].

  43. Schaeffer AJ. Editorial: Emerging concepts in the management of prostatitis/chronic pelvic pain syndrome. J Urol. 2003 Feb. 169(2):597-8. [Medline].

 
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