Few Good Treatments for Chronic Prostatitis/Chronic Pelvic Pain Syndrome

By Will Boggs MD

November 07, 2019

NEW YORK (Reuters Health) - Few individual therapies provide meaningful reduction of symptoms in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), according to a systematic review.

"Considering that we summarized the evidence of 99 unique studies, we found it surprising that few interventions may help men with chronic prostatitis," Dr. Juan V. A. Franco of the Argentine Cochrane Center, Instituto Universitario Hospital Italiano, in Buenos Aires, told Reuters Health by email.

The main clinical features of CP/CPPS are pelvic pain and lower-urinary-tract symptoms (LUTS), for which both pharmacological and nonpharmacological interventions have been tried.

Dr. Franco and colleagues assessed the effects of eight individual interventions for CP/CPPS in their review of 99 unique studies that enrolled more than 9,000 men with CP/CPPS.

They found low- to very-low-quality evidence that antibiotics, 5-alpha reductase inhibitors, anti-inflammatories, phytotherapy, intraprostatic botulinum toxin A injection and traditional Chinese medicine (TCM) might cause a reduction in prostatitis symptoms without an increased incidence of adverse events in the short term.

Very-low-quality evidence suggested that alpha-blockers might reduce prostatitis symptoms over the short and long term. Low-quality evidence suggested that alpha blockers may be associated with an increased incidence of such adverse events as dizziness and postural hypotension, the researchers report in the Cochrane Database of Systematic Reviews, online October 6.

Low-quality evidence suggested little or no difference in prostatitis symptoms and adverse events associated with allopurinol treatment.

There was little evidence of the effects of these drugs on sexual dysfunction, quality of life, or anxiety and depression.

Based on these findings, Dr. Franco suggested that clinicians "discuss the wide variety of pharmacological and nonpharmacological alternatives with patients and incorporate their values and preferences and expectations. Some men may prefer to avoid drugs and would like to try acupuncture or extracorporeal shockwave. Some men may prefer anti-inflammatories or a combination of drugs."

"It's important to warn them that the effects are small and combining therapies may not provide more relief and may be associated with adverse events due to interactions," he said. "Considering that we explored all interventions for which we found evidence, physicians may need to check the availability and costs of local alternatives."

Dr. Daniel Shoskes, director of The Center for Men's Health at Cleveland Clinic, in Ohio, recently reviewed the management of CP/CPPS. He told Reuters Health that the new review "does not help guide the clinician in managing men with CPPS. CPPS is a syndrome, not a disease. The best results, documented by numerous authors around the world, is multimodal therapy based on the clinical phenotype of the patient. Rehashing one-size-fits-all monotherapies because they happen to be placebo-controlled is not actionable evidence."

"Headache caused by migraine, brain tumor, or infected sinuses are treated with different things," he said. "If you treat them all with the same drug, your overall results will be poor. If you treat all men with CPPS with the same monotherapies, the treatments will fail in the majority."

"Because multimodal therapy is logistically extremely difficult to study in a large placebo/sham-controlled study, the methodology of reviews like this will exclude the best evidence we have for how to treat these men," Dr. Shoskes said.

Dr. Jeannette M. Potts of Vista Urology and Pelvic Pain Partners, in San Jose, California, echoed these criticisms. She told Reuters Health by email, "Respectfully, I cannot support or endorse this project as it serves to perpetuate the decades-long erroneous approach to the condition. This is not ‘chronic prostatitis,’ and such a review makes it even more difficult for the few of us in the trenches to correct the harms done to men with this condition through clinical ignorance and misappropriated funding for research."

SOURCE: https://bit.ly/2pzwGr8

Cochrane Database Syst Rev 2019.

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