Nonbacterial Prostatitis Treatment & Management

The goal of the National Institutes of Health (NIH) classification system was to try to classify prostatitis into distinct categories to help stimulate research on the causes of this enigmatic disease. Research into the causes of prostatitis in its myriad forms is still at an early stage, and new discoveries of the etiologies of the symptom complex will no doubt lead to more successful treatments.

See image below for a treatment algorithm.

Nonbacterial prostatitis can be a very time-consuming and difficult disease to treat. A typical patient the author sees presents with a constellation of symptoms consistent with prostatitis. In the initial office setting, the patient is given a copy of the NIH Chronic Prostatitis Symptom Index (NIH-CPSI; see image below) to complete.

If the patient has normal findings after urinalysis, a rectal examination with prostatic massage and evaluation of the expressed prostate secretions (EPS) is performed. If evidence of inflammation is present (≥10 WBCs per high-power field), a trial of antibiotics is administered, along with alpha-blockers and instructions to ejaculate every 3 days. A postmassage urine culture may be sent for analysis.

If the EPS culture results are negative, then the same treatment is applied minus the antibiotics. A prostate-specific antigen (PSA) blood test is not sent at this time because the massage may skew the results.

Patients are usually seen again after 1 month, symptoms are reevaluated, and another NIH-CPSI form is completed. If symptoms have resolved, antibiotics are stopped. Alpha-blockers may be continued at the discretion of the treating physician. Patients with continued symptoms undergo a second prostate massage and EPS evaluation. If inflammation is still present, another short course of antibiotics is prescribed.

Upon reevaluation at 2 months, symptoms are reviewed again. For patients with continued inflammation and symptoms, other causes are sought such as reflux of urine into the prostate, which may be indicative of a urethral stricture or enlargement of the prostate. If either process is suggested, a uroflow examination and/or retrograde urethrogram is performed.

If the findings from these are normal, the patient may have increased pelvic floor tension and a trial of diazepam (Valium) or baclofen may be initiated. If these agents are unsuccessful, referral to a physical medicine and rehabilitation specialist or treatment with transurethral microwave thermotherapy may be effective. Recent studies have shown success with the use of a self-treatment wand to access internal pelvic trigger points to relieve pelvic floor muscle pain. Use of the wand does require initial patient instruction from a qualified physical therapist.^[11]

Other medications that may be effective at this point are nonsteroidal anti-inflammatory drugs (NSAIDs), pollen extract (Cernilton, PollenAid), and quercetin. If urinary urgency and frequency are a problem, anticholinergic medicines may be prescribed. Also, do not forget to order a cytology examination to help exclude bladder cancer. If pain with urination is a problem, consider interstitial cystitis. Pelvic pain symptoms can also be treated with gabapentin or amitriptyline.

The stress level of the individual should also be evaluated. Patients who appear to be under significant job or family stress may benefit from consultation with a mental health provider.

Go to the overview topic Prostatitis for complete information on this subject.

Nonbacterial prostatitis may be bacterial, originating from infection with a fastidious organism. Therefore, a 2-week trial of an antibiotic such as trimethoprim-sulfamethoxazole (160 mg/800 mg), levofloxacin (250 mg qd), or ciprofloxacin (500 mg) twice daily for 2 weeks may support the diagnosis. If the patient improves, continue therapy with a full 4-week course of treatment.

Bladder neck dysfunction may be treated with alpha-blockers such as terazosin (2-15 mg) or doxazosin (2-8 mg) given in a dose titration. Flomax (0.4-0.8 mg) and Rapaflo (8 mg), more selective alpha-blockers with fewer adverse effects, may also be tried. Alpha-blocker therapy should be continued for a minimum of 6 months or symptoms may recur.^[12]

Saw palmetto, an herbal supplement for benign prostatic hyperplasia, has been used with some success. It is hypothesized to work similar to 5-alpha-reductase inhibitors.^[13]

Finasteride and dutaseride, 5-alpha-reductase inhibitors, have been shown to be effective in reducing symptoms by decreasing the hormonal response of macrophages and leukocytes and their migration to areas of inflammation. This decreases the subsequent release of tissue-damaging myeloperoxidase, platelet-derived growth factor, and transforming growth factor-beta.

Cernilton, a pollen extract product, is thought to have anti-inflammatory activity. Cernilton can be taken 3 times daily for 6 months for symptom improvement. Reports of successful treatment are anecdotal.^[14]

Quercetin, a flavonoid found in green tea, oranges, onions, and red wine, has also been shown to reduce symptoms. Its mechanism of action is hypothesized to be through its antioxidant and anti-inflammatory effects.

Painful symptoms may be treated with ibuprofen (600-800 mg tid), amitriptyline (25-75 mg qhs), or gabapentin (100-300 mg tid).

Irritative voiding symptoms of urgency and frequency may be treated with anticholinergics such as oxybutynin (5 mg bid/tid) or tolterodine (1-2 mg bid). Dysuria may be treated short term with phenazopyridine (Pyridium) for 1-2 weeks (100-200 mg tid).

Patients with significant pelvic floor tension may benefit from diazepam (5 mg tid), methocarbamol (1500 mg tid) or cyclobenzaprine (10 mg tid).

In an effort to include all possible therapies, note that some evidence suggests that symptoms may improve with the use of allopurinol. Allopurinol reduces the level of urates of urine refluxing into the prostate. However, long-term data show that allopurinol is no better than placebo in improving symptoms.

Pentosan polysulfate has shown some benefit in placebo-controlled trials in reducing pelvic pain symptoms. This suggests a crossover in symptoms and diagnosis with interstitial cystitis.

Consider interstitial cystitis, which can be treated with a combination of anticholinergics and behavioral therapy, if a patient is refractory to other therapies. In addition, hydrodistention, dimethyl sulfoxide (DMSO) cocktail instillation (DMSO at 50 mL, heparin at 5000 U, Solu-Medrol at 40 mg, gentamicin at 80 mg) or initiation of pentosan polysulfate oral therapy may be required. Refer to Interstitial Cystitis for more information.

If urethral stricture is determined to be the cause, it can be treated either with an open surgical repair or via direct visual internal urethrotomy.

If no other cause for symptoms can be found, some patients have had improvement of prostatitis symptoms after transurethral microwave thermotherapy (TUMT). TUMT has been successful in 70% of patients in one study.^[15] Some possible reasons for its success are that it may speed up the body's response to inflammation in the gland and promote fibrosis or it may damage the afferent nerve fibers that transmit pain.

In addition, patients with tension floor myalgia have been shown to improve after rectal heat therapy. Therefore, the application of heat therapies to the prostate may transmit sufficient energy to also help treat pelvic floor tension.

Other ablative procedures that destroy or remove prostate tissue can accomplish the same results for prostatic sources of pain, but these have not been studied in controlled trials. These include interstitial laser, radiofrequency ablation, and transurethral resection of the prostate.

In addition to the other previously mentioned therapies, patients with suspected tension floor myalgia may benefit from biofeedback therapy to help relax the pelvic floor muscles.^{[16, 17]}

Acupuncture has been shown to improve pain, urinary symptoms, and quality of life in patients with conditions that are refractory to treatment with antibiotics, alpha-blockers, and anti-inflammatories.^[18]

Myofascial trigger point release (TPM), a manipulative therapy that uses pressure on joints and soft tissue as trigger points to relieve pelvic floor muscle dysfunction has been shown to improve symptoms in some patients.^[19]

New studies have shown self-treatment of myofascial pain with a self-treatment wand.^[11]

Sitz baths may be helpful. Manual self-massage of the perianal area may also provide some relief from pelvic floor tension.

Some foods thought to be irritants to the urinary tract include alcohol, cranberry juice/cranberries, lemon juice, carbonated drinks (especially colas), spicy foods (eg, hot chilies), coffee, acidic foods, and chocolate. Patients should be made aware of these potential irritants and told to limit them one at a time to see if their symptoms improve.

The reported success of this approach is anecdotal, and it will not work for all patients. After being instructed to take note of their reactions to certain foods, some patients can identify the foods that cause more irritation to their urinary system.

Avoiding specific activities will not improve symptoms. This author tells patients that relatively frequent ejaculation (ie, every 3 d) may help improve their symptoms. The rationale for this is that it allows for the natural drainage of secretions from the prostate. Some physicians have advocated frequent prostatic massage to promote prostatic drainage and improve symptoms. The rationale for this stems from studies that have revealed higher intraprostatic pressures in patients with prostatitis. Frequent ejaculation allows the same drainage without repeated invasive and uncomfortable prostatic massages.

Perianal self-massage may also offer some relief in conjunction with frequent ejaculation because this may relieve tension in the pelvic floor. The reported success is also anecdotal, but it is worth mentioning to patients with persistent symptoms.

If symptoms resolve, patients do not need routine reevaluation. If symptoms do not resolve, periodic reevaluation should be considered. If the patient is older than 50 years, he should have an annual examination, including a rectal examination and possibly a prostate-specific antigen test.