What are the treatment options for chronic prostatitis and chronic pelvic pain syndrome (CPPS)?

Updated: Nov 01, 2019
  • Author: Paul J Turek, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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A 4- to 6-week trial of antibiotic therapy is indicated in chronic bacterial prostatitis and chronic pelvic pain syndrome with inflammation, but no consensus exists regarding its use in chronic pelvic pain syndrome without inflammation and asymptomatic prostatitis. Recurrences of chronic bacterial prostatitis are common, possibly in part because few antibacterial agents distribute well into the prostatic tissue and achieve sufficient concentrations to eradicate infections. Preferred antimicrobial agents include fluoroquinolones, macrolides, tetracyclines, and trimethoprim. [26] Fluoroquinolones provide relief in about 50% of patients, and treatment is more effective if treatment starts earlier in the course of symptoms. The course of antibiotics can be repeated if the first course provides some relief. [27] A Cochrane review of 18 studies that compared the various fluoroquinolone antibiotics suggested that there were no differences in clinical efficacy or adverse events among them in treating chronic bacterial prostatitis. [26] Fosfomycin has been used to effectively treat multidrug-resistant gram-negative prostatitis. [28]

Supportive measures such as analgesics (particularly nonsteroidal anti-inflammatory drugs [NSAIDs]), alpha-blocking agents, hydration, stool softeners, and sitz baths are often used. Alpha-blockers reduce bladder outlet obstruction and thus improve voiding dysfunction that may be associated with prostatic swelling that is common with prostatitis. [29]

Some evidence suggests that pelvic floor training/biofeedback can be effective in controlling the symptoms of chronic prostatitis and chronic pelvic pain syndrome. [2]

In cases where infected prostatic calculi serve as a nidus, transurethral resection or total prostatectomy may result in a cure.

If a patient has received no relief from antibiotics, NSAIDs, and alpha blockade, ensure prompt referral to a urologist.

Carefully treat associated septicemia in acutely ill patients. Carefully monitor for bladder outlet obstruction and renal failure. If urination issues do not resolve and incomplete emptying of bladder urine is suspected, refer the patient to a urologist for an evaluation of urination with flow rate and postvoid assessment of residual urine.

Chronic prostatitis/chronic pelvis pain syndrome (NIH Category III prostatitis) appears to be a collection of clinical phenotypes that may manifest as urinary symptoms, pain, sexual symptoms, and/or psychiatric issues. As a result, it has been largely resistant to monotherapy. Recently, a tailored multimodal approach to this condition has been advocated with success. Based on clinical phenotype, patients are placed into the "UPOINT" system, which classifies symptoms into urinary, psychological, organ-specific, infection, neurologic/systemic, and tenderness domains. [30] Based on the patient-specific symptom domains, multimodality therapy that is tailored to each patient is prescribed.

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