Recent findings show that treatment with a specific alpha blocker helps reduce symptoms and improve quality of life for men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).  This alpha-blocker, called silodosin, works by selectively relaxing the muscles in the neck of the urinary bladder and prostate.  It has been approved in Canada, the United States, the EU and Japan to treat symptoms of another prostate gland condition, benign prostatic hyperplasia, which is commonly referred to as an enlarged prostate.

Although CP/CPPS is the most common form of prostatitis, it is the most misunderstood and difficult to treat because the symptoms are very similar to other conditions and requires a significant amount of testing and screening to identify.

Curtis Nickel, a professor in the Department of Urology, practicing urologist at Kingston General Hospital and Canada Research Chair in Urologic Pain and Inflammation, emphasized that antibiotics are commonly used as a treatment, but they are not typically effective.  This could be because CP/CPPS does not seem to be caused by a bacterial infection.

CP/CPPS is a debilitating condition; patients with this condition suffer from discomfort in the lower pelvic area including the bladder area, testicles, and penis.  Symptoms may be severe and can include painful and frequent urination and difficult or painful ejaculation.  The cause of CP/CPPS is not known.

In Dr. Nickel’s study, about 60 percent of men reported feeling better after treatment with silodosin as opposed to 30 percent of participants who were given a placebo.  These results for patients feeling better is higher than a similar study he conducted several years ago that tested the effects of a different alpha blocker.

Nearly 25 percent of men diagnosed with chronic pelvic pain fail to find relief. Chronic pelvic pain is a poorly understood, yet debilitating syndrome. Generally, three treatments for the condition exist: antibiotics, anti-inflammatories, and alpha-blockers or nerve inhibitors. So far, these treatments are the only mainstream treatments found to be effective in curing or reducing symptoms of chronic pelvic pain.

The Journal of the American Medical Association published a new review in the January 5 issue that notes about 9 percent of men in the United States suffer from different types of inflammation of the prostate gland. Symptoms include pain in the pelvis, urethra or penis, back pain, trouble urinating and frequent urination.

Up to 95 percent of these cases are caused by chronic pelvic pain syndrome triggered by chronic prostatitis, which is an inflammation of the prostate gland that surrounds the male urethra. Usually, this condition is caused by a chronic bacterial infection and is most likely to affect men between the ages of 35 and 45.
“This is a very ambitious study, and it appears to shed some light on a very challenging condition,” said Dr. Paul C. Cook on the most recent study. Cook is a urologist at the Hermann Memorial Medical Center in Houston and is not connected to the study. “The fact that they distilled it down to only 23 studies in all the literature that met their criteria exemplifies that there [are so few] really good controlled studies out there.”
Researchers found that the most effective treatment for chronic pelvic pain syndrome was a combination of antibiotics and alpha-blockers. This combination helped the most to alleviate the main symptom of pain during urination; however, anti-inflammatory medications are also helpful for those patients who seek help for pain.

The role of antibiotics remains unclear to the researchers, as infection has to be ruled out before a man is diagnosed with chronic pelvic pain syndrome. The speculation is that the antibiotics might work against unrecognized germs, and the researchers noted that antibiotics such as quinolones also have anti-inflammatory properties.

Alpha-blockers are used to block the nerves going into the muscles of the prostate and are often prescribed along with antibiotics for the condition. If that combination doesn’t work, then a new antibiotic is tried. But constantly switching from one antibiotic to another is discouraged.

“If the patient comes back and the treatment isn’t working, it’s time to rethink the diagnosis,” Cook said. “It’s time to start thinking outside the box.”

“It’s very important that the patient be a partner with their physician,” explains Cook. “I always encourage patients to do independent research on their condition.” This helps the patients work together with their physician to pinpoint the problem.

Several factors predispose men to pelvic pain syndrome and include infection, hormone imbalance, allergic and immune system triggers, and psychological and hereditary traits, said the researchers. Dr. Samadi, chief of robotics and minimally invasive surgery at Mount Sinai, even notes that men who are not sexually active for a long time may be a bit more prone to the syndrome.

A study led by Michel A. Pontari, MD, from the Temple University School of Medicine in Philadelphia, Pennsylvania, and colleagues from the Chronic Prostatitis Collaborative Research Network 2 has revealed that pregabalin therapy for 6 weeks is not more effective than placebos.

Pregabalin is an anticonvulsant drug often used for neuropathic pain, particularly chronic pain.  The drug has been approved to treat disorders such as fibromyalgia and spinal cord injury.  Because current evidence suggests that chronic prostatitis and chronic pelvic pain syndrome may be neurogenic pain syndromes, with urogenital pain as a defining symptom, it has previously been suggested that pregabalin could be used to treat the disorders.  Pontari’s new findings suggest the drug may be ineffective.

In Dr. Pontari and his colleagues’ randomized trial, the effects of pregabalin were compared with placebos in 324 men who have had pelvic pain for at least three of the last six months.  The men were taken from 10 tertiary care centers and were randomly assigned in a 2:1 ratio to receive pregabalin or placebo for six weeks.  By the end of the fourth week, the dosage of pregabalin was increased from 150 to 600 mg/day.  After six weeks, the study showed a higher percentage of the patients who received pregabalin were classified as responders because they reported at least a 6-point decrease in the primary endpoint when compared with the subjects who were taking a placebo (47.2% vs. 35.8%); however, the difference is not statistically significant.

On the other hand, the researchers did find greater reductions in the mean NIH-CPSI total score and sub-scores for those patients who received pregabalin when compared to the patients who received the placebo.  And these men also had a much higher Global Response Assessment response rate (31.2% vs. 18.9%).  The Global Response Assessment is a 7-question patient self-reported assessment measuring perception of change in symptoms.

Yet the Medical Outcomes Study 12-Item Short Form Health Survey, Sexual Health Inventory for Men, and Hospital Anxiety and Depression Scale scores were all similar between the two groups.

“A 6-week course of pregabalin compared with placebo did not result in a statistically significant reduction in the NIH-CPSI total score by at least 6 points, the primary outcome, an amount of change previously shown to be clinically perceptible to participants,” concluded the authors.

Although the results were published in Archives of Internal Medicine, Dr. Pontari and the researchers explain that one limitation of the trial is that participants had symptoms for a long time.  Patients who have experienced the symptoms of CP/CPPS for shorter periods of time may have responded differently to pregabalin.  In addition, the pregabalin therapy was only administered for 6 weeks in the study.  “It may take a longer period of treatment before a beneficial effect is seen,” suggest Pontari and his team.

Chronic prostatitis, also known as chronic pelvic pain syndrome (CPPS), is a persistent lower pelvic pain or discomfort. To be diagnosed, the pain should be present for at least three months in the past half year.

Who is at risk?

Chronic prostatitis is a common disorder, and as many as 9 in 10 men will have chronic prostatitis during their lifetime.

Symptoms

Symptoms of chronic prostatitis include:

-          Pain and discomfort around base of the penis, around the anus, and above the pubic bone/lower back. The pain may vary in severity on a daily basis.

-          Pain when passing stools and urine

-          Abnormally frequent or urgent urge to urinate, mild pain with urination, or a poor urinary stream.

-          Impotence (difficulty getting or maintaining an erection), painful ejaculation, or pain after sex.

-          General aches, pains, and lethargy (feeling tired).

If you are experiencing fever or symptoms that occur suddenly and intensely, you may have acute prostatitis.

Treatment

With treatment, most men with chronic prostatitis will see an improvement in their symptoms within six months. One study showed that 35% of men experienced no symptoms one year after treatment.

If you are diagnosed with chronic prostatitis/CPPS, your doctor may prescribe:

-          Antibiotics to be absolutely certain that there is no urinary tract or other infection present.

-          Alpha-blockers to relax the muscle tissue of the prostate and bladder.

-          Bioflavonoids such as quercetin and finasteride, which are thought to “shrink” the prostate and relieve symptoms.

-          Stress management and other pain-relieving techniques

-           Pain relievers