Nonbacterial Prostatitis 

Updated: Nov 25, 2019
Author: Sunil K Ahuja, MD; Chief Editor: Edward David Kim, MD, FACS 

Overview

Practice Essentials

Nonbacterial prostatitis refers to a condition that affects patients who present with symptoms of prostatitis but without a positive result on culture of urine or expressed prostate secretions (EPS). Bacterial causes and their presentations can be reviewed in Acute Bacterial Prostatitis and Prostatic Abscess, Chronic Bacterial Prostatitis, and Bacterial Prostatitis.

Prior to 1995, the diagnosis of prostatitis was based on the classification of Meares and Stamey, which classified prostatitis into the following four categories:

  • Acute bacterial prostatitis
  • Chronic bacterial prostatitis
  • Nonbacterial prostatitis
  • Prostatodynia.

In 1995, the US National Institutes of Health (NIH) convened a workshop on prostatitis and developed a new classification scheme.[1, 2]  The first two categories—acute and chronic bacterial prostatitis—remained the same. Nonbacterial prostatitis and prostatodynia were combined as category III (ie, chronic abacterial prostatitis/chronic pelvic pain syndrome [CPPS]). Category III was further subdivided into IIIa, inflammatory CPPS, and IIIb, noninflammatory CPPS. Category IV encompasses asymptomatic inflammatory prostatitis. See the image below for a comparison of the old and new categories of prostatitis.

Nonbacterial prostatitis. Comparison of new and ol Nonbacterial prostatitis. Comparison of new and old prostatitis classifications.

Prostate specimens often reveal evidence of category IV prostatitis after a biopsy. However, patients with category IV prostatitis have no symptoms. Though not recommended, some physicians treat these patients with antibiotics in an effort to lower their prostate-specific antigen (PSA) level.[3, 4]

The rationale for the new diagnostic classification was to promote additional research to find effective forms of treatment for a symptom complex that cannot always be attributed to a bacterial infection.

Traditional treatment of chronic nonbacterial prostatitis (IIIa and IIIb) was with antibitotics for 4-6 weeks. However, a large percentage of patients do not show infection of their prostate secretions and the long-term use of quinolone antibiotics put these patients at increased risk of tendon rupture. Increasing rates of antibiotic resistance also make this approach less favorable. By dividing chronic prostatitis into two categories, IIIa (inflammatory) and IIIb (noninflammatory), the IIIa patients with inflammatory cells on expressed prostatic secretion can receive a short course of antibiotics (2 wk), while the IIIb patients without inflammatory cells can receive other, nonantimicroial therapy.[5]

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

Pathophysiology

Of all men evaluated for prostatitis, only 5-10% actually have a true bacteriologic condition as evidenced by a positive urine culture. However, approximately 50% of these men nevertheless receive antibiotics for treatment of the prostatitis symptom complex.

Evidence suggests that despite negative culture findings, some patients with nonbacterial prostatitis in the traditional sense may have a bacterial infection. Studies have found bacterial ribosomal ribonucleic acid (rRNA) by reverse transcriptase-polymerase chain reaction (RT-PCR) in the prostatic fluid of patients with prostatitis symptoms.

In addition, some fastidious organisms that do not grow in standard culture media may be the cause of the symptom complex. Some of these organisms are Chlamydia trachomatis, Ureaplasma urealyticum, and Neisseria gonorrhoeae. Despite having nonbacterial prostatitis by the classic definition, these patients improve with an appropriate, short course of antibiotics.

The pathophysiology of chronic abacterial prostatitis has not been fully elucidated, emphasizing the lack of understanding of this disease complex. However, chronic abacterial prostatitis may involve an etiology similar to that of chronic bacterial prostatitis. The peripheral zone of the prostate is composed of a system of ducts, which possess a poor drainage system that prevents the dependent drainage of secretions. As the prostate enlarges with increasing age, patients develop obstructive symptoms and urine refluxes into the prostatic ducts.

Urine reflux may also occur in patients with urethral stricture disease, voiding dysfunction, or benign prostatic hyperplasia. Refluxing urine, even when it is sterile, may lead to chemical irritation and inflammation. Tubule fibrosis is initiated, and prostatic stones form and lead to intraductal obstruction and stagnation of intraductal secretions. This obstruction initiates an inflammatory response, and prostatitis symptoms develop.

A fastidious organism may cause an infection by ascending up the urethra or through reflux of infected urine into the prostatic ducts. Additionally, many men with prostatitis are also more prone to having allergies. Thus, these men may also have autoimmune-mediated inflammation caused by a preceding true infection.

Etiology

Nonbacterial prostatitis may be caused by fastidious organisms that cannot be cultured routinely from a urinary specimen. A negative result after routine urine culture is the reason the syndrome is referred to as nonbacterial prostatitis. These fastidious organisms include C trachomatis, U urealyticum, Trichomonas vaginalis, N gonorrhoeae, viruses, fungi, and anaerobic bacteria. Noninfectious causes of prostatitis have not been definitively proven, but allergies and autoimmune diseases (eg, reactive arthritis), are hypothesized causes.

Other purported etiologies are bladder neck or urethral spasm, a male variant of interstitial cystitis, and pelvic floor tension myalgia.[6] See Interstitial Cystitis for more information.

Pelvic floor tension myalgia is also known as levator ani syndrome. This syndrome often is diagnosed based solely on symptoms of a vague dull ache in the rectal area that often worsens when sitting or lying down. Symptoms can last for hours or days. Pelvic floor tension myalgia may result from overly contracted pelvic floor muscles due to psychological stress, tension, and anxiety.

The prevalence rate is approximately 6.6% in the general population and is higher in women. It is observed in persons aged 30-60 years, but incidence decreases in those older than 45 years.

Carcinoma in situ of the bladder, which can present with irritative urinary symptoms, must be considered and excluded.

Epidemiology

Approximately half of all men develop symptoms consistent with prostatitis at some time in their lives. Prostatitis symptoms are very common in men aged 35-50 years. These symptoms are the most common urologic problem in men younger than 50 years and the third most common urologic problem in older men; these symptoms account for 25% of men evaluated for a urologic problem and 8% of all visits to urologists.[7, 8]

Studies using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI; see image below) found the prevalence of prostatitis symptoms to be approximately 10% in a population of men aged 20-74 years. The most common form of prostatitis (90%) is category III, ie, chronic abacterial prostatitis and CPPS.

Nonbacterial prostatitis. National Institutes of H Nonbacterial prostatitis. National Institutes of Health Chronic Prostatitis Symptom Index.

No racial predilection is found. The common age range for presentation of prostatitis symptoms is 36-74 years.

Patient Education

Patients should be instructed to try to limit stress in their lives, which may exacerbate symptoms. Some urologists, the author included, also recommend frequent ejaculation to prevent a buildup or stasis of secretions within the prostate, thus avoiding inflammation and prostatitis symptoms.

Patients should be told that certain foods (see Dietary Considerations) may cause more irritation; and, with a little experimenting, they can determine which foods to avoid or limit.

For patient education information, see Prostatitis.

 

Presentation

History

Patients with abacterial prostatitis/chronic pelvic pain syndrome (CPPS; category III in the 1995 National Institutes of Health prostatitis classification system) have the same symptom complex as those with chronic bacterial prostatitis. The chief symptom reported by patients with abacterial prostatitis/CPPS is pain. Genitourinary symptoms include perineal, penile tip, testicular, rectal, lower abdominal, or back pain.

Patients can also have irritative or obstructive urologic symptoms such as frequency, urgency, dysuria, decreased force of the urinary stream, nocturia, and incontinence. Other symptoms are a clear urethral discharge, ejaculatory pain, hematospermia, and sexual dysfunction.

Many patients with abacterial prostatitis have emotional strife and some psychological difficulties (ie, socially, sexually, or both). Patients should be questioned with regard to their overall social adjustment. Stress level is important because stress is responsible for increased tension of the pelvic floor and the internal urinary sphincter, resulting in the symptoms of prostatitis.

Physical Examination

In most cases, physical examination findings are nonspecific. Many patients have normal findings, others may have an exquisitely sensitive prostate or other pelvic trigger points on internal and external perianal examination, and still others may have an enlarged, boggy prostate.

 

DDx

Diagnostic Considerations

Carcinoma in situ of the bladder can present with irritative urinary symptoms and should be excluded as a cause of irritative voiding symptoms. Failure to consider this possibility is a serious pitfall because bladder cancer can be cured if diagnosed in the early stages; a delay in diagnosis can result in the development of metastatic disease.

Other conditions to consider are pelvic floor tension myalgia, dysfunctional voiding, and benign prostatic hyperplasia

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

Differential Diagnoses

 

Workup

Approach Considerations

A patient with abacterial prostatitis can be evaluated in 2 ways. The first approach is to adhere strictly to the fact that these patients do not have an infection by performing an exhaustive search to exclude an infectious source. This often involves repetitive culturing of expressed prostate secretions (EPS) or prostate biopsy specimens using nonstandard culture media for Chlamydia, Ureaplasma, gonorrheal organisms, or anaerobes. Sophisticated research methods using real time polymerase chain reaction (RT-PCR) techniques can also be employed.

This first approach is very time-consuming and likely only of value in the research setting.

A second method involves examination of expressed prostatic secretions. If inflammatory cells are seen (IIIa), then a short course of antibiotics (2 wk) can be given. A longer course can be given if there is symptomatic improvement, as long as the patient is counseled on increased risks of tendon rupture and the development of antibiotic-resistant bacteria. These patients would likely also benefit from additional other treatment, including alpha-blockers. If no inflammatory cells are seen (IIIb), then other treatments should be tried.

This second method is often the one most commonly used and is used first to treat patients with nonbacterial prostatitis. It succeeds approximately 50% of the time when used over a course of 4 weeks. It should be noted that antibiotics have been shown to have analgesic, antipyretic, and antiinflmmatory effects as well, and this may account for symptom improvement in some patients.[9]

If the patient does not improve with antibiotics, then another cause of symptoms must be sought and different treatment regimens must be initiated until symptoms are controlled. If the symptoms are mostly irritative (eg, dysuria with urinary urgency and frequency), then carcinoma in situ of the bladder must be excluded using urine cytology studies and cystoscopy.

Category III prostatitis is divided into IIIa and IIIb based on whether greater or fewer than 10 WBCs are seen on microscopic examination of the EPS, respectively. However, the management approaches for these two categories do not differ, so they can be grouped together.

Other causes can also be sought, and they are evaluated in no particular order. Further workup is based on the clinical suspicion of the urologist. In addition, some patients may complain of symptoms that are not life-limiting, whereas others are completely limited in their activities of daily life. The search for a cause to these symptoms may be based on each individual, and the appropriate health care consultant should be used for the more esoteric diagnoses.

Category III prostatitis can be further categorized by using the UPOINT system, which divides a patient’s symptoms into 6 different categories (urinary, psychologic, organ specific, infection, neurologic/systemic, and tenderness of skeletal muscles). By subcategorizing, treatment may be better tailored to each patient’s specific needs.[10]  Multiple clinical trials have externally validated the UPOINT system, and it is gaining increasing widespread use.[11]

Interstitial cystitis requires a more complex workup. See the main article on Interstitial Cystitis for more information.

Urologic Studies

Voiding cystourethrography findings can aid in the diagnosis of bladder neck dysfunction by demonstrating intraprostatic and ejaculatory duct urinary reflux.

Retrograde urethrography findings may demonstrate a urethral stricture. This test is indicated if the patient demonstrates decreased peak urinary flow on uroflowmetry findings.

Prostatic enlargement can be investigated using uroflowmetry or a pressure flow study and the International Prostate Symptom Score.

Problems such as pelvic floor tension are more difficult to diagnose, but videourodynamic findings may be helpful in diagnosis. Patient symptoms of a dull ache or pressure in the rectal area may also suggest this diagnosis. A consultation with physical medicine and rehabilitation (PM&R) specialist may be beneficial for these patients.

 

Treatment

Approach Considerations

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.

Treatment algorithm for nonbacterial prostatitis. Treatment algorithm for nonbacterial prostatitis.

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.

Nonbacterial prostatitis. National Institutes of H Nonbacterial prostatitis. National Institutes of Health Chronic Prostatitis Symptom Index.

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.[12]

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.

Pharmacologic Treatment

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. Tamsulosin  (0.4-0.8 mg) and silodosin (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.[13]

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.[14]

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.[15]

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). Pain mangement of nonbacterial chronic prostatitis/chronic pelvic pain syndrome with intraprostatic injections of onabotulinumtoxinA (onaBoNT-A) has been reported however initial improvements gradually diminished at 9-12 months.[16]

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.

Invasive Treatment

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.[17] 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.

Nonpharmacologic Treatments

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.[18, 19]

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.[20, 21, 22]

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.[23]

New studies have shown self-treatment of myofascial pain with a self-treatment wand.[12]

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

Dietary Considerations

Some foods and beverages 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. Reduced water intake may also be a factor.[24]

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.

Activity

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.

Chen et al reported that sedentary lifestyle (along with consumption of caffeinated drinks and lower water intake) were associated with severe pain in patients with chronic prostatitis/chronic pelvic pain syndrome. They suggested that these factors are potential targets for treatment.[24]

Long-Term Monitoring

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.

 

Medication

Medication Summary

Medical therapy is important in the treatment of nonbacterial prostatitis to decrease the severity of symptoms and to allow patients to return to normal function. Because nonbacterial prostatitis may originate from infection with a fastidious organism, an empiric trial of antibiotic therapy may provide relief.

Antibiotics

Class Summary

These are often used on a trial basis despite a negative culture result to check for symptom improvement and to rule out infection with a fastidious organism.

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Trimethoprim blocks dihydrofolate reductase and sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid (PABA). These are 2 sequential steps in bacterial biosynthesis of nucleic acids and proteins. This agent is available in single- and double-strength form. In adults, it is most commonly taken in pill form, although a liquid suspension is available.

Levofloxacin (Levaquin)

A derivative of pyridine carboxylic acid with a broad-spectrum bactericidal effect, levofloxacin penetrates the prostate well and is effective against Neisseria gonorrhoeae and Chlamydia trachomatis.

Ciprofloxacin (Cipro)

Ciprofloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, methicillin-resistant Staphylococcus aureus (MRSA), S epidermidis, and most gram-negative organisms, but no activity against anaerobes. It inhibits bacterial DNA synthesis and, consequently, growth. It diffuses into prostatic fluid and is indicated for chronic prostatitis.

Alpha-Adrenergic Blocking Agents

Class Summary

Selective alpha-1 receptor blockers relax smooth muscle in the prostate and bladder neck. They have been found to improve symptoms of prostatic obstruction. They are the first choice in therapy for benign prostatic hyperplasia and can be very effective in patients with prostatitis symptoms by improving urine flow and decreasing irritative symptoms.

Doxazosin (Cardura, Cardura XL)

Doxazosin inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decrease in total peripheral resistance and blood pressure.

This agent has antihypertensive effects and is recommended to be given at bedtime to prevent patient injury if a syncopal episode occurs. If added to the regimen of antihypertensive medicines a patient is already taking, monitor patient's blood pressure while in titration phase. This agent is usually started as a titration up to the effective dose. It is available in a starter pack containing 1-, 2-, 4-, and 8-mg tablets. The usual effective dose is 4 or 8 mg.

Terazosin

Terazosin decreases arterial tone by allowing peripheral postsynaptic blockade. It has minimal alpha-2 effect. As it is an antihypertensive agent, dosing at bedtime is recommended to prevent patient injury if a syncopal episode occurs. If given to a patient already on antihypertensive agents, monitor blood pressure routinely while in titration phase.

Terazosin is usually titrated up to the effective dose. It is available as a starter pack that has doses of 1, 2, 5, and 10 mg.

This agent is sold in capsule form and cannot be broken in half easily; therefore, each specific dose must be prescribed.

Tamsulosin (Flomax)

Tamsulosin is an antagonist of the alpha-1a receptor found in smooth muscle of prostate and bladder neck. It is effective for relieving symptoms of prostatic enlargement. Because it is more selective than other alpha-blockers (ie, terazosin and doxazosin), it has minimal, if any, effect on blood pressure and does not require dose titration.

Silodosin (Rapaflo)

Silodosin is a selective antagonist of postsynaptic alpha-1-adrenoceptors. It helps relax the smooth muscle in the bladder neck and prostate, causing urine flow and benign prostatic hyperplasia symptoms to improve.

5-Alpha Reductase Inhibitors

Class Summary

These agents inhibit the conversion of testosterone to dihydrotestosterone (DHT).

Finasteride (Proscar)

Finasteride inhibits the steroid 5-alpha-reductase, which converts testosterone into 5-alpha-DHT, causing serum DHT levels to decrease.

Dutasteride (Avodart)

Dutasteride is a selective inhibitor of the type 1 and type 2 isoforms of 5-alpha-reductase, which converts testosterone into 5-alpha-DHT, causing serum DHT levels to decrease.

Nonsteroidal Anti-Inflammatory Agents

Class Summary

These agents inhibit the action of cyclooxygenase, which results in decrease of prostaglandin synthesis.

Ibuprofen (Motrin, Advil, Caldolor)

Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It also has anti-inflammatory and antipyretic properties. Ibuprofen is available in 200-, 400-, 600-, and 800-mg doses.

Benzodiazepines

Class Summary

These agents are indicated for symptomatic relief of pain, burning, urgency, and frequency associated with prostatitis.

Diazepam (Valium, Diastat)

Diazepam depresses all levels of the CNS (eg, limbic, reticular formation), possibly by increasing activity of gamma-aminobutyric acid (GABA). It is available as 2-, 5-, and 10-mg doses.

Interstitial Cystitis Agents

Class Summary

For symptomatic relief of pain, burning, urgency, and frequency associated with prostatitis.

Pentosan polysulfate sodium (Elmiron)

A heparinlike derivative of macromolecular carbohydrate that resembles glycosaminoglycans, this agent has anticoagulant and fibrinolytic properties. Its mechanism of action is unknown but it may act to prevent irritative or noxious stimuli in the bladder by inhibiting mucosal cell wall permeability.

Dimethyl sulfoxide (Rimso-50)

This agent is converted to dimethyl sulfone and dimethyl sulfide in vivo. It is used intravesically to treat symptoms of interstitial cystitis. When administered intravesically, patients often report a garliclike taste.

Uricosurics

Class Summary

These agents reduce uric acid levels. They have no analgesic or anti-inflammatory activity.

Allopurinol (Zyloprim, Aloprim)

Allopurinol inhibits xanthine oxidase, the enzyme that synthesizes uric acid from hypoxanthine. It reduces synthesis of uric acid without disrupting biosynthesis of vital purines.

Flower Pollens

Class Summary

Pollen (male flower microspore) enables plant reproduction. Produced in anthers of the flower. May have effects on inflammatory response.

Cernitin pollen extract (Cernilton, Cervital, PollenAid)

This product may have anti-inflammatory activity.

Muscle relaxants

Class Summary

These agents are helpful in relieving discomfort associated with tonically contracted muscles.

Methocarbamol (Robaxin)

Methocarbamol reduces nerve impulse transmission from spinal cord to skeletal muscle

Cyclobenzaprine (Flexeril, Amrix, Fexmid)

Cyclobenzaprine is a skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. It is structurally related to tricyclic antidepressants and thus carries some similar liabilities.

Anticholinergic agents

Class Summary

These agents are used for treatment of overactive bladder to prevent associated symptoms of urinary frequency, urgency, and incontinence.

Tolterodine tartrate (Detrol, Detrol LA)

A competitive muscarinic receptor antagonist for overactive bladder, tolterodine differs from other anticholinergic types in that it has selectivity for urinary bladder over salivary glands. It exhibits high specificity for muscarinic receptors and has minimal activity or affinity for other neurotransmitter receptors and other potential targets, such as calcium channels.

Anticonvulsants, Other

Class Summary

Anticonvulsants used as neuropathic analgesics may be helpful, because myofascial pain may at its core be a spinal-mediated disorder affected by neuropathic dysfunction. Gabapentin has been shown to be effective in treating myofascial and neuropathic pain.

Gabapentin (Neurontin)

Gabapentin is a membrane stabilizer. It is a structural analogue of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), but, paradoxically, it is thought not to exert an effect on GABA receptors. Gabapentin appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels. It is used to manage pain and provide sedation in neuropathic pain.

Titration to effect occurs over several days (300 mg on day 1, 300 mg twice on day 2, and 300 mg 3 times on day 3).

Tricyclic Antidepressants

Class Summary

Tricyclic antidepressants are commonly used for chronic pain. They help to treat insomnia and reduce painful dysesthesia. These agents treat nociceptive and neuropathic pain syndromes.

Amitriptyline

Amitriptyline inhibits the reuptake of serotonin and/or norepinephrine at the presynaptic neuronal membrane, which increases their concentration in the central nervous system (CNS). Amitriptyline may increase or prolong neuronal activity, since the reuptake of these biogenic amines is important physiologically in terminating transmitting activity.