eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Chronic Pelvic Pain Syndrome and Prostatodynia: Treatment & Medication

Author: Richard A Watson, MD, Chief of Ambulatory Urology, HUMC Department of Urology, Professor of Surgery (Urology), Department of Surgery, Division of Urology, UMDNJ New Jersey Medical School, Hackensack University Medical Center
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Jul 17, 2009

Treatment

Medical Care

• Initial points to address
  • CPPS is a well-established condition notorious for the pain and disability it causes.
  • CPPS is a condition, not a disease or syndrome. It is similar to other chronic conditions, such as arthritis, that, while treatable, are not curable. No known cure exists for CPPS, but treatments based on the cooperation of patient and physician make this condition more bearable. Over time, this condition may improve or stabilize on its own.
  • Because CPPS is a diagnosis of exclusion, review the patient's records and perform a thorough physical examination to eliminate the possibility that another, more treatable disease is causing these symptoms. Assure the patient that only diagnostic tests that hold a reasonable chance of producing a significant result will be recommended. The patient should not rule out the possibility that these examinations may reveal an alternate diagnosis, but he should also know that he will not be burdened by excessive testing.
  • Many medications and other forms of treatment can help alleviate the symptoms of CPPS. However, being patient is important; try only 1 or 2 new treatments at a time, giving each enough time to take effect. Do not overwhelm the patient with an unreasonable number of simultaneous treatments, which causes only excessive inconvenience and expense. Simultaneous treatments might actually work against one another, and the adverse effects of these treatments might cause more, rather than fewer, problems for the patient.
  • Reassure the patient that CPPS is a real physical condition; the problem is not imagined. However, this devastating problem causes many psychological stresses for the patient; therefore, suggest medications to help calm the patient and offer consultation with a psychiatrist or psychologist. A mental health care professional who has a special interest in this area may prove beneficial.
  • Reassure the patient that CPPS is a legitimate condition, and, more importantly, it is not cancer. This is not a life-threatening condition, it is not a venereal disease, and it is not contagious. Explain that the patient did not acquire this condition from someone else, nor will he pass it on to anyone.
  • Remind the patient that he is not alone. Many men experience this problem. Local and national support groups recommended by the physician can provide additional information and encouragement.
  • Agree on a schedule of planned follow-up visits performed regularly as frequently as appropriate management of symptoms dictates. These scheduled appointments minimize the need for emergency visits and telephone calls while providing comfort and creating trust between doctor and patient.
  • The urologist institutes treatment through, and in close communication with, the patient's primary care physician, who remains the mainstay of care.
  • Remind the patient that he is free to seek the advice of other physicians and health care providers while he is under a urologist's care. However, the patient must keep the urologist informed of all other treatments and medications tried, including alternative medicines and home remedies.
  • Remind the patient that his problem is taken very seriously and that every effort will be made, with the patient's cooperation, to minimize the problems that this condition causes. The patient-physician relationship should be a partnership formed to gain control of this condition and allow the patient to more fully enjoy life.
• Prostatic massage (therapeutic)
  • The physician places a finger rectally over the back of the prostate gland (as is performed during a routine prostate examination) and presses firmly and methodically down upon the entire surface gland, working from the lateral edge centrally, with the goal of breaking open prostatic ducts that have become plugged with inspissated material and expressing the released secretions into the urethra.
  • The role of prostate massage in providing symptomatic relief is controversial.
  • With little evidence-based medicine to recommend it, regularly repeated prostatic massages have been recommended in the past, particularly for patients with a large, congested gland.
  • Some patients find that massage provides temporary relief worth the awkwardness and discomfort of the maneuver itself.
  • In 1969, Winter recommended prostatic massage 1-3 times weekly for 3-4 weeks for chronic infection of the prostate.
  • Although this maneuver has largely fallen out of favor with many contemporary urologists, some still revert to it, albeit on a less frequent schedule, to provide supplementary symptomatic relief for select patients.
• Therapeutic ejaculation
  • The role of frequent ejaculation in either producing or reducing CPPS symptoms remains controversial.
  • Patients with enlarged, symptomatically congested glands are often advised that regular sexual intercourse may alleviate their symptoms.
  • While little objective evidence substantiates this claim, most patients find this recommendation more attractive than serial prostate massages by their local urologist.
  • Whether frequent sexual intercourse relieves or actually exacerbates the condition seems to vary idiosyncratically from patient to patient.
  • Many patients enjoy informing their partners that the doctor prescribed frequent sex as therapy, which is notable because opportunities for amusement are few when dealing with this issue.
  • The primary author's anecdotal observation is that patients tend to be most adversely affected by sudden, dramatic changes in the frequency of intercourse, either increase or decrease. For example, a patient who remains sexually chaste while on prolonged business trips is apt to experience a flare-up both when he leaves home and again when he returns.
  • Whether masturbation produces an effect comparable to that of intercourse remains as unproven as it is widely advised. Ironically, similar prostatic maladies were attributed in 19th-century medicine to an excess of masturbation; what was condemned as a cause of prostatitis in the 1800s is being promoted as a cure in the 20th century. Before recommending masturbation, bear in mind sensitively that this activity is objectionable to some patients' moral and religious standards.

Surgical Care

Severely disabling CPPS has been teated with transurethral resection of the prostate (TURP) and even radical prostatectomy.

• Transurethral resection of the prostate
  • A widely held opinion among urologists is that TURP should be reserved for patients who have experienced extreme, persistent symptoms over a protracted period, with no relief from nonoperative interventions.
  • Reserve TURP as a rarely used approach of last resort, offered only by experienced resectionists and, even then, with the clear understanding that symptomatic relief is not guaranteed.
  • Indeed, symptoms might even worsen and might be compounded by the added burdens of erectile dysfunction and urinary incontinence.
  • When TURP is undertaken, completing a thorough resection of all tissues, down to the capsule, is essential. The concern is that residual tissue, partially coagulated, with obstruction of the ductal drainage from prostatic acini might exacerbate the patient's symptoms.¹⁴
• Radical prostatectomy
  • This is an extreme measure.
  • Consider this treatment only in the most desperate of cases, if at all.¹⁵

Consultations

• Pain management specialist
• Anesthesiologists and other experts in pain management may be able to assist with providing significant symptomatic relief.
• No analgesics are specifically appropriate in the treatment of prostatitis. Standard mild analgesics such as acetaminophen (Tylenol), aspirin, and ibuprofen are well within the purview of the urologist's (and indeed the primary care physician's) domain of management. Keep in mind that the patient's analgesic needs are likely to fluctuate. Often, encouraging the patient to maintain a long-term, low-level intake of a minor analgesic such as acetylsalicylic acid or acetaminophen 3 times a day diminishes his need for more potent analgesics.
• Both patient and physician fear of analgesic abuse or addiction often lead to undermedication, causing unnecessary pain and suffering.
• Be quick to invite consultation from specialists at an established pain management center. Clinicians at WashingtonUniversity have documented the beneficial impact that a coordinated, multidisciplinary approach between the urologist and the pain management team can have on improving the quality of life for many of these patients. These patients are often dismissed too easily, and their complaints are trivialized. Symptomatic patients can be encumbered by pain as devastating as that caused by cancer, neurologic diseases, and other conditions that merit a vigorous approach to effective pain management.
• Psychiatrist
• Frequently, if only anecdotally, patients with CPPS have been categorized as being tense, high-strung, hypochondriacal, and even neurotic.
• Experiencing the daily torment of uncontrolled pelvic pain, urinary dysfunction, and social embarrassment can understandably lead to profound psychological sequelae.
• Many patients encounter frustrated, dismissive, and unhelpful physicians in the course of treatment, compounding their frustration, depression, and despair.
• A sympathetic constructive attitude by the physician can do much to alleviate this strain (see Medical Care).
• Moreover, a mild relaxant such as diazepam (Valium), prescribed judiciously, may help the patient adjust to his condition and, at the same time, relax the spasm of the pelvic floor muscles, providing objective relief.
• Prescribe psychiatric medications with caution and rarely without consultation with a psychiatrist.
• A psychiatrist who is particularly interested in helping these patients can be a valuable member of the treatment team that includes the primary care physician, the urologist, and the pain management experts.
• Avoiding a misunderstanding when recommending psychiatric counseling is important because the patient may perceive that his physician thinks that he is insane, hysterical, or delusional.
• Reassure the patient that his condition is real and that his suffering is not imaginary.
• Psychological support is appropriate in helping the patient cope more effectively with his serious, real-life problem.
• Andrology specialist
• An andrology specialist should be consulted for management of erectile dysfunction, if present.
• Specialists at Stanford University found that 92% of men with refractory CPPS reported related erectile dysfunction, including problems with decreased libido (66%), pain upon ejaculation (56%), and ejaculatory dysfunction (31%).¹⁶
• While erectile dysfunction and its remedies are discussed in detail in Erectile Dysfunction, remember that managing this potentially devastating effect of CPPS can greatly improve the patient's attitude and quality of life. An excellent review of this topic by Sadeghi-Nejad and Seftel brings attention to reports that link CPPS to sexual dysfunction.¹⁷
• Many remedies and treatments are available, including sildenafil, vacuum devices, injection and intraurethral therapies, and penile implants; a physician would be profoundly remiss to not broach the topic and its treatment possibilities.
• The patient's partner should be strongly encouraged to be involved early in counseling and treatment process.
• Physical medicine therapist and physiotherapist
• Lately, authorities have appreciated that, in many cases, the symptoms formerly attributed to prostatodynia may actually reflect pelvic floor spasm and chronic pelvic pain that is not prostatic in origin. In light of this, physiotherapists may provide an important role in helping to diagnostically distinguish and to therapeutically ameliorate neuromuscularly based symptomatologies. For example, patients with palpable myofascial tenderness in the rectal area often chronically unable to relax their pelvic floor musculature. This dysfunction of the pelvic floor muscles (ie, levator syndrome) is objectively documentable. Moreover, significant symptomatic relief has been achieved through modulation-based therapies such as biofeedback, alpha-blockers, and sacral nerve stimulation.
• Clinical researchers at Columbia University have found that an important subset of patients who had been treated unsuccessfully for symptoms of chronic abacterial prostatitis for 1.5 years to more than 10 years and who were unresponsive to long-term antibiotic and alpha-blocker therapies were actually experiencing pseudodyssynergia (a contraction of the external sphincter during voiding). This condition was documented based on electromyography and fluoroscopy findings. Patients thus identified responded to treatment with biofeedback and behavior modification in 83% of cases.¹⁸
• More recently, men with refractory CPPS were treated at StanfordUniversity with one month or more of trigger point release/paradoxical relaxation training, in order to release trigger points in their pelvic floor musculature. Clinical success – markedly or moderately improved symptoms – was achieved in 70% of the patients.¹⁶
• The presence of documented inflammation of the prostate and urethra does not exclude the presence of neuromuscular spasm of the pelvic floor. Whether the spasm comes first, resulting from dysfunctional voiding in subsequent urinary infections, or the infection comes first, triggering a chronic cycle of pain and pelvic spasm, is a "chicken-or-egg" conundrum (ie, deciding which came first is virtually impossible). In either case, both the infection and the spasm must be treated concurrently to achieve long-term relief in these difficult cases.
• While the urologist is best suited to address the prostatic inflammation, coordination of care with an interested physiotherapist for the management of biofeedback and nerve-root stimulation may prove worthwhile.

Diet

• The influence of diet on this condition varies.
• Traditionally, these patients have been warned to avoid excessive intake of prostate irritants, such as tobacco (smoking), coffee, tea, soda (cola drinks and diet drinks may be especially irritating), caffeine, spicy foods, and alcohol.
  • Inform the patient that none of these items is known to cause actual physical damage or to worsen the long-term prognosis.
  • Nevertheless, responsible limitation of these items may help to control the day-to-day symptoms.
  • A glass or two of wine or sherry may lessen nocturia symptoms.
• Alkalinization of the urine seems to help some patients. A teaspoonful of baking soda (sodium bicarbonate) in a tall glass of warm water taken at bedtime may help reduce nighttime symptoms. However, caution patients regarding the risk of an excessive sodium load with higher oral intakes, especially in those receiving treatment for hypertension, fluid retention, or congestive heart failure. A potassium-based alkalinizer, such as potassium citrate (Urocit K), may prove more efficacious under these circumstances. Conversely, Stephen W. Leslie, MD, has found that some of his patients have very alkaline urine, which can also be irritating and result in discomfort and dysuria.

Activity

• Sitz baths may provide partial relief from acute exacerbations.
• Rather than a shallow perineal dip, a deep tub bath in water as hot as can be comfortably tolerated seems to provide better overall temporary relief and relaxation.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Keep in mind that no antibiotic regimen has been proven efficacious in the treatment of chronic nonbacterial prostatitis. According to E.M. Meares, "Antibacterial agents are neither effective nor indicated in the treatment of nonbacterial prostatitis."^19,20,21 If U urealyticum or C trachomatis infection is suggested, a trial treatment of antibiotics may be considered.

In bacterial prostatitis, antibiotic therapy might 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 a recent aggressive attempt to clarify the presence of bacteria in the uncontaminated prostate tissue of men with chronic pelvic pain syndrome (CPPS), researchers in Seattle performed digitally guided transperineal prostate biopsies in 118 subjects with CPPS and in 59 control subjects. They found no difference in the rates of positive cultures (38% vs 36%) and concluded that, while the prostatic colonization of bacteria within the prostate is not uncommon, particularly in older men, prostatic bacteria are probably not etiologically involved in the symptoms in most men with CPPS.²²

Abacterial prostatitis or prostatodynia is, by definition and by exclusion, 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, multiple courses of antibiotics are frequently prescribed, often for extraordinarily protracted periods.

Some patients are maintained on long-term, low-dose regimens, such as 1 capsule of trimethoprim-sulfamethoxazole (Septra DS) daily, and some 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. Recent 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.²³

In approaching the antibiotic option, remember that no antibiotic is free of complications. Regarding a blinded trial of antibiotics for prostatodynia, many comment 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 is currently consulting on the treatment of a patient who is experiencing 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 of a bladder neck contracture rather than prostatitis.

The expense of these medications 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 7 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.²⁴

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 should not be surprising to find that the most common cause of inappropriate antibiotic prescriptions by urologists is CP/CPPS type III, potentially constituting a major contribution to fluoroquinolone antibiotic resistance nationwide.

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."²⁵

Antibiotics

Prostatodynia (CPPS in men), by definition, should 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 one 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)

Helps 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)

Macrolide antibiotic with theoretical advantage of penetrating blood-prostate barrier, but carries increased incidence of GI intolerance.

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against Pseudomonas species, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Trovafloxacin (Trovan) overcomes many of these limitations. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.

Muscle relaxants

Tension myalgia of the pelvic floor muscles, combined with overall stress-related tension, can be partially relieved with muscle relaxants.^19,20,21

Diazepam (Valium)

Benzodiazepine derivative indicated for short-term relief of anxiety and adjunctive relief of skeletal muscle spasm. Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Individualize dosage and increase cautiously to avoid adverse effects.

Alpha-adrenergic blockers

These agents have become a mainstay in the symptomatic treatment of this condition.^19,20,21 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 for the treatment of prostatodynia. One study has suggested an advantage for alpha-blockers in combination with antibiotics over antibiotic therapy alone in the treatment of chronic bacterial prostatitis.²⁶

Doxazosin (Cardura)

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

Terazosin (Hytrin)

Quinazoline compound that counteracts alpha1-induced adrenergic contractions of bladder neck, facilitating urinary flow in presence of BPH.
Reporting at the annual convention of the American Urological Association, researchers have confirmed a significant, albeit limited, value for alpha1-blockers in the management of this condition. 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 mo, 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 could take 6 mo 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 (Schaeffer, 2003).

Tamsulosin (Flomax)

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

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