Chronic prostatitis

Brian Le; Dr Anthony J Schaeffer

. 2011 Jul 12;2011:1802.

Chronic prostatitis

Brian Le ^1,^#, Anthony J Schaeffer ^2,^#

PMCID: PMC3275320 PMID: 21736764

Abstract

Introduction

Chronic prostatitis can cause pain and urinary symptoms, and usually occurs without positive bacterial cultures from prostatic secretions (known as chronic abacterial prostatitis or chronic pelvic pain syndrome [CP/CPPS]). Bacterial infection can result from urinary tract instrumentation, but the cause and natural history of CP/CPPS are unknown.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for chronic bacterial prostatitis? What are the effects of treatments for chronic abacterial prostatitis/chronic pelvic pain syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 33 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: 5 alpha-reductase inhibitors, allopurinol, alpha-blockers, biofeedback, local injections of antimicrobial drugs, mepartricin, non-steroidal anti-inflammatory drugs (NSAIDs), oral antimicrobial drugs, pentosan polysulfate, prostatic massage, quercetin, radical prostatectomy, sitz baths, transurethral microwave thermotherapy, and transurethral resection.

Key Points

Bacterial infection can result from urinary tract instrumentation, but the cause and natural history of CP/CPPS are unknown.

Chronic bacterial prostatitis has identifiable virulent micro-organisms in prostatic secretions.

Oral antimicrobial drugs are likely to be beneficial, although trials comparing them with placebo or no treatment have not been found.
Clinical success rates with oral antimicrobials have reached about 70% to 90% at 6 months in studies comparing different regimens.
Trimethoprim–sulfamethoxazole (co-trimoxazole) and quinolones are most commonly used and seem the most beneficial.
Alpha-blockers may reduce symptoms and reduce recurrence of chronic prostatitis if added to antimicrobial treatment.
We don't know whether local injections of antimicrobial drugs, NSAIDs, transurethral resection, or radical prostatectomy improve symptoms compared with no treatment.

Effective treatment regimens for CP/CPPS remain to be defined, and strategies are based on symptomatic control and anxiety relief.

We don't know how effective alpha-blockers are in people with abacterial prostatitis.
Oral antimicrobial drugs have not been shown to improve symptoms.
We don't know whether 5 alpha-reductase inhibitors, NSAIDs, pentosan polysulfate, allopurinol, transurethral microwave thermotherapy, prostatic massage, sitz baths, biofeedback, mepartricin, or quercetin reduce symptoms in men with CP/CPPS.

About this condition

Definition

Chronic bacterial prostatitis is characterised by a positive culture of expressed prostatic secretions. It may cause symptoms such as suprapubic, lower back, or perineal pain, with or without mild urgency and increased frequency of urination, and dysuria, and may be associated with recurrent UTI. However, it may also be asymptomatic between acute episodes/exacerbations. Chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterised by pelvic or perineal pain in the absence of pathogenic bacteria in expressed prostatic secretions. It is often associated with irritative and obstructive voiding symptoms including urgency, frequency, hesitancy, and poor interrupted flow. Symptoms can also include: pain in the suprapubic region, lower back, penis, testes, or scrotum; and painful ejaculation. CP/CPPS may be inflammatory (white cells present in prostatic secretions) or non-inflammatory (white cells absent in prostatic secretions). A classification system for the prostatitis syndromes has been developed by the US National Institutes of Health (NIH).

Incidence/ Prevalence

One community-based study in the US (cohort of 2115 men aged 40–79 years) estimated that 9% of men have a diagnosis of prostatitis at any one time. Another observational study found that, in men presenting with genito-urinary symptoms, 8% of those presenting to urologists and 1% of those presenting to primary-care physicians were diagnosed as having chronic prostatitis. Most cases of chronic prostatitis are abacterial. Chronic bacterial prostatitis, although easy to diagnose, is rare.

Aetiology/ Risk factors

Organisms commonly implicated in bacterial prostatitis include Escherichia coli, other gram-negative enterobacteriaceae, occasionally Pseudomonas species, and, rarely, gram-positive enterococci. Risk factors for bacterial prostatitis include urethral catheterisation or instrumentation, condom drainage, dysfunctional voiding (high-pressure urination), and unprotected anal intercourse. The cause of CP/CPPS is unclear, although it has been suggested that it may be caused by undocumented infections with Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, and Trichomonas vaginalis. Viruses, Candida (in immunosuppressed people), and parasites have also rarely been implicated. Non-infectious factors might also be involved, including inflammation, autoimmunity, hormonal imbalances, pelvic floor tension myalgia, intraprostatic urinary reflux, and psychological disturbances. In one case-control study (463 men with CP/CPPS; 121 asymptomatic age-matched controls), when compared with controls, men with CP/CPPS reported a significantly higher lifetime prevalence of non-specific urethritis; CVD; neurological disease; psychiatric conditions; and haematopoietic, lymphatic, or infectious disease (non-specific urethritis: 12% with CP/CPPS v 4% with no CP/CPPS; P = 0.008; CVD: 11% with CP/CPPS v 2% with no CP/CPPS; P = 0.004; neurological disease: 41% with CP/CPPS v 14% with no CP/CPPS; P <0.001; psychiatric conditions: 29% with CP/CPPS v 11% with no CP/CPPS; P <0.001; haematopoietic, lymphatic, or infectious disease: 41% with CP/CPPS v 20% with no CP/CPPS; P <0.001). Further studies are necessary to determine whether these factors play a role in the pathogenesis of CP/CPPS.

Prognosis

The natural history of untreated chronic bacterial and abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) remains ill-defined. Chronic bacterial prostatitis may cause recurrent UTI in men, whereas CP/CPPS does not. Several investigators have reported an association between chronic bacterial prostatitis, CP/CPPS, and infertility. One study found that CP/CPPS had an impact on quality of life similar to that of angina, Crohn's disease, or a previous MI.

Aims of intervention

To relieve symptoms and eliminate infection where present, with minimum adverse effects.

Outcomes

Symptom improvement (includes rates of clinical cure/clinical success, symptom scores, bother scores, and urodynamics; does not include bacteriological cure rate); quality of life; bacteriological cure rate (bacterial prostatitis; clearance of previously documented organisms from prostatic secretions in question on chronic bacterial prostatitis); recurrence rate; adverse effects of treatment.

Methods

Clinical Evidence search August 2010. The following databases were used to identify studies for this systematic review: Medline 1966 to September 2010, Embase 1980 to September 2010, and The Cochrane Database of Systematic Reviews Issue 8 (August 2010 [online]) (1966 to date of issue). An additional search within The Cochrane Library was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language, at least single blinded, and containing >20 individuals of whom >80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded unless blinding was impossible. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied, applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table.

GRADE Evaluation of interventions for Chronic prostatitis.

Important outcomes	Bacteriological cure rate, Quality of life, Recurrence rate, Symptom improvement
Studies (Participants)	Outcome	Comparison	Type of evidence	Quality	Consistency	Directness	Effect size	GRADE	Comment
What are the effects of treatments for chronic bacterial prostatitis?
4 (602)	Symptom improvement	Oral antimicrobial drugs versus each other	4	0	0	–1	0	Moderate	Directness point deducted for narrow range of comparators
4 (595)	Bacteriological cure rate	Oral antimicrobial drugs versus each other	4	0	0	–1	0	Moderate	Directness point deducted for narrow range of comparators
1 (64)	Symptom improvement	Alpha-blockers plus antimicrobial drugs versus antimicrobial drugs alone	4	–2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (64)	Recurrence rate	Alpha-blockers plus antimicrobial drugs versus antimicrobial drugs alone	4	–2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (50)	Symptom improvement	Local injection of antimicrobial drugs versus each other	4	–1	0	–1	0	Low	Quality point deducted for sparse data. Directness point deducted for restricted population
1 (50)	Bacteriological cure rate	Local injection of antimicrobial drugs versus each other	4	–1	0	–1	0	Low	Quality point deducted for sparse data. Directness point deducted for restricted population
What are the effects of treatments for chronic abacterial prostatitis/chronic pelvic pain syndrome?
9 (at least 626)	Symptom improvement	Alpha-blockers versus placebo	4	–1	0	0	0	Moderate	Quality point deducted for weak methods in many of the RCTs identified
4 (358)	Quality of life	Alpha-blockers versus placebo	4	–1	0	0	0	Moderate	Quality point deducted for weak methods
2 (105)	Symptom improvement	5 alpha-reductase inhibitors versus placebo	4	–2	0	0	0	Low	Quality points deducted for sparse data and incomplete reporting of results
1 (54)	Symptom improvement	Allopurinol versus placebo	4	–3	0	0	0	Very low	Quality points deducted for sparse data, poor follow-up, and incomplete definition of reported outcome
1 (26)	Symptom improvement	Mepartricin versus placebo	4	–1	–1	0	0	Low	Quality point deducted for sparse data. Consistency point deducted for different results for different outcomes
1 (26)	Quality of life	Mepartricin versus placebo	4	–1	–1	0	0	Low	Quality point deducted for sparse data. Consistency point deducted for different results for different outcomes
1 (64)	Symptom improvement	NSAIDs versus placebo	4	–2	0	–1	0	Very low	Quality points deducted for sparse data and incomplete recording of results. Directness point deducted for data on only one NSAID
2 (124)	Symptom improvement	Pentosan polysulfate versus placebo	4	–3	0	0	0	Very low	Quality points deducted for sparse data, no intention-to-treat analysis, and for subjective assessment of outcome
1 (100)	Quality of life	Pentosan polysulfate versus placebo	4	–1	0	0	0	Moderate	Quality point deducted for sparse data
1 (33)	Symptom improvement	Quercetin versus placebo	4	–2	–1	0	0	Very low	Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for different results for different outcomes
1 (20)	Symptom improvement	Transurethral microwave thermotherapy versus sham treatment	4	–3	0	0	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and for subjective outcome measurement
1 (20)	Quality of life	Transurethral microwave thermotherapy versus sham treatment	4	–3	0	0	0	Very low	Quality points deducted for sparse data, incomplete reporting of results, and for subjective outcome measurement
2 (276)	Symptom improvement	Oral antimicrobial drugs versus placebo/no treatment	4	0	0	–2	0	Low	Directness points deducted for too few comparators and for uncertainty about generalisability of results
1 (81)	Symptom improvement	Prostatic massage plus antimicrobial drugs versus antimicrobial drugs alone	4	–1	0	0	0	Moderate	Quality point deducted for sparse data

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We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.

Glossary

International Prostate Symptom Score (IPSS): A patient questionnaire that is essentially the same as the American Urological Association Symptom Index (AUA-SI) questionnaire.
Low-quality evidence: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Meares–Stamey: The Meares–Stamey test involves collection of 4 sequential urine samples. Two are taken before prostatic massage; the first from the initial 10 mL and the second from the mid-stream urine. After prostatic massage, the expressed prostatic secretions are collected, as is the initial 10 mL of urine passed after massage. When bacteria, inflammatory cells, or both are significantly higher in the two samples after prostatic massage, the pathology is considered to be specific to the prostate.
Moderate-quality evidence: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
NIH classification system: Category I: acute bacterial prostatitis is an acute infection of the prostate. Category II: chronic bacterial prostatitis is a recurrent infection of the prostate. Category III: chronic non-bacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) is where there is no demonstrable infection. Subgroups of this class are: (A) inflammatory CPPS (leukocytes seen in semen, prostatic fluid, or urine after prostatic massage); and (B) non-inflammatory CPPS (no leukocytes seen). Category IV: asymptomatic inflammatory prostatitis, no subjective symptoms but leukocytes found in prostate/prostatic secretions during work-up for other disorders (e.g., on prostate biopsy for prostate cancer).
National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI): Includes 9 items across 3 domains: pain (4 items; 0–21), urinary symptoms (2 items; 0–10), and quality of life impact (3 items; 0–12). In all domains, higher scores indicate worse outcomes.
Prostatic massage: Digital pressure applied to the prostate through the rectum.
Sitz bath: A warm water bath taken in the sitting position. The water covers only the hips and buttocks.
Very low-quality evidence: Any estimate of effect is very uncertain.

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Contributor Information

Brian Le, Department of Urology, Northwestern University Medical Centre, Chicago, USA.

Dr Anthony J Schaeffer, Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, USA.

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63.Nickel JC, Downey J, Clark J, et al. Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial. Urology 2003;62:614–617. [DOI] [PubMed] [Google Scholar]
64.Ateya A, Fayez A, Hani R, et al. Evaluation of prostatic massage in treatment of chronic prostatitis. Urology 2006;67:674–678. [DOI] [PubMed] [Google Scholar]

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Antimicrobial drugs (oral) for chronic bacterial prostatitis

Summary

Oral antimicrobial drugs are likely to be beneficial, although studies comparing them with placebo or no treatment have not been found.

Clinical success rates with oral antimicrobials have reached about 70% to 90% at 6 months in studies comparing different regimens.

Trimethoprim–sulfamethoxazole (co-trimoxazole) and quinolones are most commonly used and seem the most beneficial.

Benefits and harms

Oral antimicrobial drugs versus placebo or no antimicrobial drugs:

We found no systematic review or RCTs.

Oral antimicrobial drugs versus each other:

We found no systematic review but found 4 RCTs.

Symptom improvement

Oral antimicrobial drugs compared with each other Lomefloxacin or levofloxacin seem as effective as ciprofloxacin at achieving clinical success rates (defined as complete resolution of symptoms, improvement in symptoms, or clear improvement without need for additional antimicrobial drugs) at 6 months (moderate-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Clinical success
RCT	182 men with chronic bacterial prostatitis	Clinical success 6 months 61/93 (67%) with lomefloxacin 400 mg daily for 4 weeks 64/89 (72%) with ciprofloxacin 500 mg twice daily for 4 weeks	Difference –5% 95% CI –23.6% to +6.0% P = 0.16		Not significant
RCT	377 men with chronic bacterial prostatitis	Clinical success 6 months 102/136 (75%) with levofloxacin 500 mg daily for 28 days 91/125 (73%) with ciprofloxacin 500 mg twice daily for 28 days	Difference –2.2% 95% CI –13.3% to +8.9%		Not significant
RCT	96 men with chronic bacterial prostatitis	Mean decrease in National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score 6 months after treatment completion 10.75 with prulifloxacin 600 mg daily for 4 weeks 10.73 with levofloxacin 500 mg daily for 4 weeks	P = 0.98		Not significant
RCT	63 men with prostate infection caused by Ureaplasma urealyticum	Clinical cure 4 to 6 weeks after treatment completion 22/32 (69%) with azithromycin 500 mg 3 times a week for 3 weeks 21/31 (68%) with doxycycline 100 mg twice daily for 21 days	P = 1.00		Not significant

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Bacteriological cure rate

Oral antimicrobial drugs compared with each other Lomefloxacin or levofloxacin seem as effective as ciprofloxacin at increasing bacteriological cure rates at 6 months, and prulifloxacin and levofloxacin seem equally effective at increasing microbiological eradication rates at 6 months in men with chronic bacterial prostatitis (moderate-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Bacteriological cure
RCT	182 men with chronic bacterial prostatitis	Bacteriological cure 6 months 49/93 (53%) with lomefloxacin 400 mg daily for 4 weeks 54/89 (61%) with ciprofloxacin 500 mg twice daily for 4 weeks	Difference –8% 95% CI –26.0% to +6.0% P = 0.62		Not significant
RCT	377 men with chronic bacterial prostatitis	Bacteriological cure 6 months 102/136 (75%) with levofloxacin 500 mg daily for 28 days 96/125 (77%) with ciprofloxacin 500 mg twice daily for 28 days	Difference –1.8% 95% CI –9.0% to +12.6%		Not significant
RCT	96 men with chronic bacterial prostatitis	Microbiological eradication rates (as determined by follow-up Meares–Stamey tests) 6 months after treatment completion 32/44 (73%) with prulifloxacin 600 mg daily for 4 weeks 32/45 (71%) with levofloxacin 500 mg daily for 4 weeks	P = 0.86		Not significant
RCT	63 men with prostate infection caused by Ureaplasma urealyticum	Bacteriological cure 4 to 6 weeks after treatment completion 25/32 (78%) with azithromycin 500 mg 3 times a week for 3 weeks 23/31 (74%) with doxycycline 100 mg twice daily for 3 weeks	P = 0.77		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	182 men with chronic bacterial prostatitis	Gastrointestinal disorders 5/93 (5%) with lomefloxacin 400 mg daily for 4 weeks 8/89 (9%) with ciprofloxacin 500 mg twice daily for 4 weeks	Significance not assessed
RCT	182 men with chronic bacterial prostatitis	Premature withdrawal from the study because of adverse effects 5/93 (5%) with lomefloxacin 400 mg daily for 4 weeks 4/89 (4%) with ciprofloxacin 500 mg twice daily for 4 weeks	Significance not assessed
RCT	377 men with chronic bacterial prostatitis	At least 1 treatment-related adverse effect 87/197 (44%) with levofloxacin 500 mg daily for 28 days 67/180 (37%) with ciprofloxacin 500 mg twice daily for 28 days	Significance not assessed
RCT	377 men with chronic bacterial prostatitis	Gastrointestinal disturbances 19% with levofloxacin 500 mg daily for 28 days 17% with ciprofloxacin 500 mg twice daily for 28 days Absolute numbers not reported	Significance not assessed
RCT	96 men with chronic bacterial prostatitis	Adverse effects 6 months after treatment completion 8/44 (18%) with prulifloxacin 600 mg daily for 4 weeks 10/45 (22%) with levofloxacin 500 mg daily for 4 weeks	P = 0.79		Not significant
RCT	63 men with prostate infection caused by Ureaplasma urealyticum	Nausea 5/32 (15%) with doxycycline 100 mg twice daily for 3 weeks no data reported with placebo

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Further information on studies

In this RCT, people receiving azithromycin took a total dose of 4.5 g over 3 weeks (500 mg was taken on each of 3 consecutive days a week). The authors report that the "rare occurrence of side effects in patients with the rather high total dosage of azithromycin is attributed to the intermittent administration of azithromycin".

Comment

We found data from retrospective case series about the bacteriological cure rates of different antimicrobials. These data do not compare antimicrobial drugs versus placebo, no treatment, or other treatments.

Trimethoprim–sulfamethoxazole (co-trimoxazole):

One non-systematic review identified 8 retrospective case series in 1140 men with bacteriologically confirmed prostatitis treated with trimethoprim–sulfamethoxazole (trimethoprim 160 mg plus sulfamethoxazole 800 mg twice daily for 10–140 days). The studies reported cure rates of 0% to 71%. Over 30% of men were cured when treated for at least 90 days. The review did not report on adverse effects.

Quinolones:

One non-systematic review summarised three retrospective case series in 106 men treated with norfloxacin (400 mg twice daily for 10, 28, and 174 days). The studies reported cure rates of 64% to 88%.

Amoxicillin–clavulanic acid (co-amoxiclav) and clindamycin:

One case series included 50 men resistant to empirical treatment with quinolones. The expressed prostatic secretions from 24 of these men exhibited high colony counts of gram-positive and gram-negative anaerobic bacteria, either alone (18 men) or in combination with aerobic bacteria (6 men). After treatment with either amoxicillin–clavulanic acid or clindamycin for 3 to 6 weeks, all men had a decrease or total elimination of symptoms, and no anaerobic bacteria were detected in prostatic secretions. Higher cure rates with quinolones may be explained by greater penetration into the prostate. We reviewed only studies that used standard methods to localise infection to the prostate.

Clinical guide:

Most clinicians agree that antimicrobial drugs are the preferred treatment for chronic bacterial prostatitis. However, if symptoms do not improve after eradication of bacteria, alternative treatments should be investigated.

Substantive changes

Antimicrobial drugs (oral) for chronic bacterial prostatitis New evidence added. Categorisation unchanged (Likely to be beneficial).

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Alpha-blockers for chronic bacterial prostatitis

Summary

Alpha-blockers may reduce symptoms and reduce recurrence of chronic prostatitis if added to antimicrobial treatment, but we found no direct evidence about whether alpha-blockers are better than no active treatment in men with chronic bacterial prostatitis.

Benefits and harms

Alpha-blockers versus placebo:

We found no systematic review or RCTs.

Alpha-blockers plus antimicrobial drugs versus antimicrobial drugs alone:

We found one RCT comparing alpha-blockers (terazosin 1–2 mg/day, terazosin 2.5 mg/day, or alfuzosin 2.5 mg once or twice daily) plus antimicrobial drugs versus antimicrobial drugs alone.

Symptom improvement

Compared with antimicrobial drugs alone Alpha-blockers (terazosin, alfuzosin) plus antimicrobial drugs may be more effective at improving symptoms (defined as clinical improvement) in men with chronic bacterial prostatitis (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	64 men with bacterial prostatitis (mean age 48 years)	Clinical improvement (assessed using International Prostate Symptom Score Questionnaire) with alpha-blockers (terazosin 1–2 mg/day, terazosin 2.5 mg/day, or alfuzosin 2.5 mg once or twice daily) plus antimicrobial drugs with antimicrobial drugs alone Absolute results not reported	P = 0.002	Effect size not calculated	alpha-blockers plus antimicrobial drugs

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Bacteriological cure rate

No data from the following reference on this outcome.

Recurrence rate

Compared with antimicrobial drugs alone Alpha-blockers (terazosin, alfuzosin) plus antimicrobial drugs may be more effective at reducing recurrence rates (assessed by culture or expressed prostatic secretion) in men with chronic bacterial prostatitis (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Recurrence rate
RCT	64 men with bacterial prostatitis (mean age 48 years)	Recurrence rates (assessed by culture of expressed prostatic secretion) with alpha-blockers (terazosin 1–2 mg/day, terazosin 2.5 mg/day, or alfuzosin 2.5 mg once or twice daily) plus antimicrobial drugs with antimicrobial drugs alone Absolute results not reported	P = 0.02	Effect size not calculated	alpha-blockers plus antimicrobial drugs

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Quality of life

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

Since the last update of this review, a drug safety alert has been issued on risk of intra-operative floppy iris syndrome during cataract surgery with tamsulosin (http://www.mhra.gov.uk/home/groups/is-insp/documents/websiteresources/con2031031.pdf).

Clinical guide:

Some physicians think that treatment of chronic bacterial prostatitis with oral antimicrobial drugs (typically given as a first-line treatment) can be supplemented with alpha-blockers, especially in cases where symptoms persist despite eradication of bacteria from prostatic secretions.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Antimicrobial drugs (locally injected) for chronic bacterial prostatitis

Summary

We don't know whether local injections of antimicrobial drugs improve symptoms compared with no treatment as we found no direct information from RCTs.

Benefits and harms

Local injection of antimicrobial drugs versus placebo or no antimicrobial drugs:

We found no systematic review or RCTs comparing local injection of antimicrobial drugs versus placebo or no treatment.

Local injection of antimicrobial drugs versus each other:

We found one small RCT comparing anal submucosal injection of amikacin versus intramuscular amikacin.

Symptom improvement

Locally injected antimicrobial drugs compared with each other Anal submucosal injection of amikacin may be more effective at 3 months than intramuscular injection of amikacin at improving symptoms (measured by National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score) in men with chronic bacterial prostatitis whose prostatic secretions are sensitive to amikacin (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
NIH-CPSI score
RCT	50 men with prostatic secretions sensitive to amikacin	NIH-CPSI score 3 months 9.0 with anal submucosal injection of amikacin 400 mg daily for 10 days 22.5 with intramuscular amikacin 400 mg daily for 10 days	P <0.05	Effect size not calculated	anal submucosal injection of amikacin

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Bacteriological cure rate

Locally injected antimicrobial drugs compared with each other Anal submucosal injection of amikacin may be more effective at 3 months than intramuscular injection of amikacin at improving cure rate (measured by negative bacterial culture) in men with chronic bacterial prostatitis whose prostatic secretions are sensitive to amikacin (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Bacteriological cure rates
RCT	50 men with prostatic secretions sensitive to amikacin	Negative bacterial culture 3 months 28/30 (93%) with anal submucosal injection of amikacin 400 mg daily for 10 days 7/20 (35%) with intramuscular amikacin 400 mg daily for 10 days	P <0.05	Effect size not calculated	anal submucosal injection of amikacin

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	50 men with prostatic secretions sensitive to amikacin	Adverse effects with anal submucosal injection of amikacin 400 mg daily for 10 days with intramuscular amikacin 400 mg daily for 10 days

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Further information on studies

None.

Comment

One small cohort study (24 men with refractory chronic bacterial prostatitis) found that eradication of infection was eventually achieved, after an unstated period, in 15 men, with gentamicin 160 mg plus cefazolin 3 g injected directly into the prostate through the perineum.

Clinical guide:

There is limited evidence that local injection of antimicrobial drugs improves bacterial eradication rates compared with the standard treatment of oral antimicrobial drugs, and treatments of this type remain experimental.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

NSAIDs for chronic bacterial prostatitis

Summary

We found no direct information from RCTs about NSAIDs in the treatment of men with chronic bacterial prostatitis.

Benefits and harms

NSAIDs:

We found no systematic review or RCTs on the effects of NSAIDs in men with chronic bacterial prostatitis.

Further information on studies

None.

Comment

Clinical guide:

There is no evidence of benefit for NSAIDs in treating chronic bacterial prostatitis. Their use in combination with antimicrobial drugs has not been evaluated, but RCTs would be feasible.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Radical prostatectomy for chronic bacterial prostatitis

Summary

We found no direct information from RCTs about radical prostatectomy in the treatment of men with chronic bacterial prostatitis.

Benefits and harms

Radical prostatectomy:

We found no systematic review or RCTs on the effects of radical prostatectomy in men with chronic bacterial prostatitis.

Further information on studies

None.

Comment

Case series have found that radical prostatectomy can cause impotence (9% to 75% depending on age) and varying degrees of urinary stress incontinence. Other potential harms include those associated with any open surgery.

We found one report of radical prostatectomy in two young men whose refractory bacterial prostatitis caused relapsing haemolytic crises.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

TURP for chronic bacterial prostatitis

Summary

We found no direct information from RCTs about tranurethral resection of the prostate (TURP) in the treatment of men with chronic bacterial prostatitis.

Benefits and harms

Tranurethral resection of the prostate (TURP):

We found no systematic review or RCTs on the effects of TURP in men with chronic bacterial prostatitis.

Further information on studies

None.

Comment

One RCT in men with benign prostatic hypertrophy found no significant difference in the incidence of impotence or urinary incontinence between TURP and watchful waiting.

One retrospective study reported 40% to 50% cure rates in 50 men with chronic prostatitis treated with TURP. However, proof of bacterial prostatitis was not obtained in many of the men.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Alpha-blockers for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

The effectiveness of alpha-blockers in people with abacterial prostatitis is inconclusive; the data fluctuate between effective and ineffective, most probably because of the heterogeneity of participants in the RCTs we identified.

Benefits and harms

Alpha-blockers versus placebo:

We found two systematic reviews (search date 1999, 2 RCTs, 50 men; search date not reported, 6 RCTs, no RCTs included in the previous review, 386 men). Neither review performed a meta-analysis. The second systematic review searched from 1999, as 1999 was the year the National Institutes of Health-Chronic Prostatitis Symptom Index [NIH-CPSI] was first available for use. The review reported that meta-analysis of the data was unable to be performed owing to differences in data reporting and outcome interpretation, despite all studies having used the NIH-CPSI to monitor response. Two RCTs identified by this review were published as abstracts and are therefore not reported here; we report the results of 6 RCTs identified by the reviews that met Clinical Evidence inclusion criteria. We also found one additional RCT, one subsequent quasi-randomised trial, and one large subsequent multicentre RCT.

Symptom improvement

Compared with placebo Alpha-blockers seem no more effective at improving measured NIH-CPSI scores with a similar response rate in both groups at 12 weeks (moderate-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	20 people with chronic abacterial prostatitis In review	Maximal flow time (change from baseline) from 15.4 mL/second to 20.3 mL/second with alfuzosin 2.5 mg three times daily from 13.9 mL/second to 15.6 mL/second with placebo	P = 0.01	Effect size not calculated	alfuzosin
RCT	30 people with chronic abacterial prostatitis In review	Proportion of people with no or reduced pain after prostatic massage 6 weeks 6/12 (50%) with phenoxybenzamine 10 mg twice daily 2/17 (12%) with placebo	P <0.05	Effect size not calculated	phenoxybenzamine
RCT 3-armed trial	70 men with chronic abacterial prostatitis In review	Change in total National Institutes of Health-Chronic Prostatitis Symptom Index [NIH-CPSI] score from baseline 6 months –9.9 with alfuzosin 5 mg twice daily for 6 months –3.8 with placebo	Significance not assessed
RCT 3-armed trial	70 men with chronic abacterial prostatitis In review	Change in NIH-CPSI pain score from baseline 6 months –5.1 with alfuzosin 5 mg twice daily for 6 months –1.1 with placebo	Significance not assessed
RCT 3-armed trial	70 men with chronic abacterial prostatitis In review	Change in total NIH-CPSI score from baseline 12 months –3.5 with alfuzosin 5 mg twice daily for 6 months –0.1 with placebo	Significance not assessed
RCT	86 men with chronic abacterial prostatitis In review	Reduction in NIH-CPSI pain score >50% (from baseline) 14 weeks 26/43 (60%) with terazosin with dose escalation from 1–5 mg daily (for 14 weeks) 16/43 (37%) with placebo	P = 0.03	Effect size not calculated	terazosin
RCT	86 men with chronic abacterial prostatitis In review	Change in peak urinary flow rate 14 weeks from 15.4 mL/second to 18.7 mL/second with terazosin with dose escalation from 1–5 mg daily (for 14 weeks) from 18.1 mL/second to 19.7 mL/second with placebo	Reported as not significant P value not reported		Not significant
RCT	86 men with chronic abacterial prostatitis In review	Change in postvoid residual volume 14 weeks from 24.8 mL to 17.1 mL with terazosin with dose escalation from 1–5 mg daily (for 14 weeks) from 20.6 mL to 16.0 mL with placebo	Reported as not significant P value not reported		Not significant
RCT	58 men aged under 55 years with chronic abacterial prostatitis In review	Change in NIH-CPSI scores from baseline 45 days with tamsulosin with placebo Absolute results not reported	Difference between groups –3.6 95% CI –7.0 to –0.3 P = 0.04	Effect size not calculated	tamsulosin
RCT 4-armed trial	196 men with chronic abacterial prostatitis	NIH-CPSI scores (a negative change indicates improvement) after 6 weeks of treatment –4.3 with tamsulosin –4.7 with no tamsulosin	P >0.2 Longitudinal regression analysis		Not significant
RCT	60 men with chronic abacterial prostatitis	Change in mean International Prostate Symptom Score (IPSS) measured on a scale of 0 to 35 (change from baseline) 3 months after cessation of treatment from 9.8 to 5.9 with doxazosin from 9.3 to 8.8 with placebo	P = 0.001	Effect size not calculated	doxazosin
Pseudo-randomised trial 3-armed trial	90 men with chronic abacterial prostatitis	Mean NIH-CPSI score (change in score from baseline) 6 months from 23.1 to 10.7 with doxazosin 4 mg daily from 22.9 to 21.9 with placebo	P <0.001	Effect size not calculated	doxazosin
Pseudo-randomised trial 3-armed trial	90 men with chronic abacterial prostatitis	Mean NIH-CPSI score (change in score from baseline) 12 months from 23.1 to 12.5 with doxazosin 4 mg daily from 22.9 to 22.2 with placebo	P <0.001	Effect size not calculated	doxazosin
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Reduction of total NIH-CPSI score by at least 4 points 12 weeks 68/134 (49%) with alfuzosin 66/134 (49%) with placebo	P = 0.99		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Proportion of people with marked or moderate global response assessed on a scale from 0 to 7 12 weeks 48/138 (35%) with alfuzosin 45/134 (34%) with placebo	P = 0.90		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Mean change in total McGill Pain Questionnaire score (range 0–45 points, higher scores indicate more pain) 12 weeks –3.4 with alfuzosin 10 mg –3.1 with placebo	P = 0.45		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

Terazosin compared with placebo Terazosin seems no more effective at 14 weeks at improving quality of life in men with CP/CPPS (moderate-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Quality of life
RCT	86 men with chronic abacterial prostatitis In review	NIH-CPSI quality-of-life score of 0 to 2 14 weeks 24/43 (56%) with terazosin with dose escalation from 1–5 mg daily 14/43 (33%) with placebo	P = 0.03	Effect size not calculated	terazosin
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Mean change in quality-of-life score (range 0–12 points) 12 weeks –1.2 with alfuzosin 10 mg –1.2 with placebo	P = 0.99		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Mean change in score on short form (SF)-12 physical component summary (range 0–100 points, higher scores indicate better function) 12 weeks +3.0 with alfuzosin 10 mg +3.5 with placebo	P = 0.60		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Mean change in score on SF-12 mental component summary (range 0–100 points, higher scores indicate better function) 12 weeks +4.0 with alfuzosin 10 mg +1.9 with placebo	P = 0.16		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Mean change in score on International Index of Erectile Function (range 0–75 points, higher scores indicate better sexual function) 12 weeks +0.5 with alfuzosin 10 mg –0.2 with placebo	P = 0.94		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Mean change in score on Male Sexual Health Questionnaire (higher scores indicate better sexual function) 12 weeks +1.7 with alfuzosin 10 mg +0.6 with placebo	P = 0.06		Not significant

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No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	20 people with chronic abacterial prostatitis In review	Adverse effects with alfuzosin 2.5 mg three times daily with placebo
RCT 3-armed trial	70 men with chronic abacterial prostatitis In review	Adverse effects with alfuzosin 5 mg twice daily for 6 months with placebo
RCT	86 men with chronic abacterial prostatitis In review	Treatment-related adverse effects 14 weeks 18/43 (42%) with terazosin 9/43 (21%) with placebo	P = 0.04	Effect size not calculated	placebo
RCT	86 men with chronic abacterial prostatitis In review	Dizziness 14 weeks 7/43 (16%) with terazosin 2/43 (5%) with placebo	Significance not assessed
RCT	86 men with chronic abacterial prostatitis In review	Asthenia 14 weeks 7/43 (16%) with terazosin 3/43 (7%) with placebo	Significance not assessed
3-armed trial	90 men with chronic abacterial prostatitis	Adverse effects 12/30 (40%) with doxazosin 4 mg daily 7/30 (23%) with placebo	Significance not assessed
3-armed trial	90 men with chronic abacterial prostatitis	Dizziness 3/30 (10%) with doxazosin 4 mg daily 2/30 (7%) with placebo	Significance not assessed
3-armed trial	90 men with chronic abacterial prostatitis	Postural hypotension 3/30 (10%) with doxazosin 4 mg daily 1/30 (3%) with placebo	Significance not assessed
3-armed trial	90 men with chronic abacterial prostatitis	Gastrointestinal complaints 2/30 (7%) with doxazosin 4 mg daily 2/30 (7%) with placebo	Significance not assessed
RCT 4-armed trial	196 men with chronic abacterial prostatitis	Adverse effects with tamsulosin with no tamsulosin Absolute results not reported	P >0.2		Not significant
RCT	272 men with prostatitis for at least 2 years, and with no previous treatment with an alpha-blocker	Adverse effects 38/138 (28%) with alfuzosin 39/134 (29%) with placebo	P = 0.79		Not significant

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No data from the following reference on this outcome.

Alpha-blockers versus each other:

We found no systematic review or RCTs of sufficient quality (see comment).

Alpha-blockers versus antimicrobials:

We found no systematic review or RCTs of sufficient quality (see comment).

Further information on studies

The RCT identified by the first systematic review found no significant difference in outcomes other than maximal flow time from baseline (insufficient information was presented to assess comparative effects on symptom scores).

Comment

Alpha-blockers versus placebo:

The largest randomised, multicentre, double-blind, placebo-controlled trial to date showed no overall difference between placebo and alpha-blocker therapy (alfuzosin 10 mg/day). Both groups showed a similar response rate, defined as a decrease of 4 or more points on the NIH-CPSI of 49.3% at 12 weeks. Other trials looked at response periods greater than 3 months; thus, it is difficult to generalise the results to longer periods of treatment. Additionally, people with a lower urinary tract symptoms (LUTS) component may be a subgroup that would benefit, although the literature does not currently support this premise.

Alpha-blockers versus each other or versus antimicrobials:

We found one 5-armed open-label RCT that did not meet the inclusion criteria for Clinical Evidence. The RCT divided participants into groups depending on prostatitis type (3A or 3B), and randomly allocated them to treatment with either tamsulosin, treatment with a combination of tamsulosin plus levofloxacin, or, for only the people with type 3A disease, levofloxacin alone. All groups had a decrease in symptom scores, but improvements in symptom scores in the combined treatment group were superior to those in the single treatment groups. Combination therapy improved pain, urinary symptoms, and quality-of-life scores compared with levofloxacin alone (P <0.05). The authors conclude that tamsulosin and levofloxacin are both effective in the treatment of, and may have an additional effect in, the treatment of non-bacterial prostatitis.

Drug safety alert:

A drug safety alert has been issued on risk of intraoperative floppy iris syndrome during cataract surgery with tamsulosin (http://www.mhra.gov.uk/home/groups/is-insp/documents/websiteresources/con2031031.pdf).

Clinical guide:

Most clinicians believe that alpha-blockers are the appropriate first-line treatment for CP/CPPS, despite the lack of strong RCT evidence. However, if alpha-blockers fail to improve symptoms, as determined by the NIH-CPSI, alternative treatments should be investigated.

Substantive changes

Alpha-blockers for chronic abacterial prostatitis/chronic pelvic pain syndrome New evidence added. Categorisation changed from Likely to be beneficial to Unknown effectiveness (as a new large RCT found no significant difference between alfuzosin and placebo, by contrast with previous, smaller trials).

BMJ Clin Evid. 2011 Jul 12;2011:1802.

5 alpha-reductase inhibitors for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether 5 alpha-reductase inhibitors reduce symptoms in men with CP/CPPS.

Benefits and harms

5 alpha-reductase inhibitors versus placebo:

We found one systematic review (search date 1999, 1 RCT) and one subsequent RCT comparing finasteride versus placebo.

Symptom improvement

Compared with placebo We don't know whether 5 alpha-reductase inhibitors are more effective at improving symptoms in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	41 men In review	Symptom scores 1 year with finasteride with placebo Absolute results reported graphically	Reported as significant P value not reported The RCT was small and had low power (3:1 randomisation)	Effect size not calculated	finasteride
RCT	41 men In review	Pain 1 year with finasteride with placebo Absolute results not reported	Reported as not significant P value not reported The RCT was small and had low power (3:1 randomisation)		Not significant
RCT	64 men	Treatment response (defined as >25% improvement in National Institutes of Health-Chronic Prostatitis Symptom Index scores) 6 months 33% with finasteride 16% with placebo Absolute numbers not reported	P >0.05		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	41 men In review	Partial impotence 3/31 (10%) with finasteride 0/10 (0%) with placebo	Significance not assessed The RCT was small and had low power (3:1 randomisation)
RCT	64 men	Adverse effects 5/33 (15%) with finasteride 7/31 (23%) with placebo	Significance not assessed

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Further information on studies

None.

Comment

Finasteride is known to decrease prostate volume (as it did in the study included in the review; P <0.03), but it is unclear how this relates to symptoms of prostatitis.

Clinical guide:

If alpha-blockers fail to provide symptom relief, 5 alpha-reductase inhibitors can be considered as a second-line treatment for men with CP/CPPS.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Allopurinol for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether allopurinol reduces symptoms in men with CP/CPPS.

Benefits and harms

Allopurinol versus placebo:

We found one systematic review (search date 2000, 1 RCT).

Symptom improvement

Compared with placebo Allopurinol may be more effective at reducing symptoms (measured by an unvalidated "degree of discomfort" score) in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (very low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Degree of discomfort
RCT	54 men In review	Degree of discomfort score 240 days –1.1 with allopurinol 300 and 600 mg combined +0.2 with placebo	P = 0.02	Effect size not calculated	allopurinol

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	54 men In review	Adverse effects with allopurinol 300 and 600 mg combined with placebo

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Further information on studies

In the RCT, 34 men (63%) completed the study; 55% of people on placebo and 68% of people on allopurinol completed the trial.

Comment

Clinical guide:

If alpha-blockers fail to provide symptom relief, some physicians believe that allopurinol can be considered as a second-line treatment for men with CP/CPPS.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Biofeedback for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We found no direct information from RCTs about biofeedback in the treatment of men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS).

Benefits and harms

Biofeedback:

We found no systematic review or RCTs on the effects of biofeedback in men with CP/CPPS.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Mepartricin for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether mepartricin reduces symptoms in men with CP/CPPS.

Benefits and harms

Mepartricin versus placebo:

We found one RCT comparing oral mepartricin versus placebo in the treatment of CP/CPPS.

Symptom improvement

Compared with placebo We don't know whether oral mepartricin is more effective at improving symptoms in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	26 men	Median score improvement in the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) for pain –7 with mepartricin 40 mg daily –2 with placebo	P = 0.009	Effect size not calculated	mepartricin
RCT	26 men	Median score improvement in the total NIH-CPSI score –15 with mepartricin 40 mg daily –5 with placebo	P = 0.0018	Effect size not calculated	mepartricin
RCT	26 men	Median score improvement in the NIH-CPSI for urinary dysfunction –5 with mepartricin 40 mg daily –4 with placebo	P = 0.2891		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

Compared with placebo Oral mepartricin may be more effective at improving quality of life (measured by NIH-CPSI) in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Quality of life
RCT	26 men	Median score improvement in the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) for quality of life –5 with mepartricin 40 mg daily –1 with placebo	P = 0.0046	Effect size not calculated	mepartricin

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Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	26 men	Adverse effects with mepartricin 40 mg daily with placebo

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Further information on studies

None.

Comment

Mepartricin has been shown to form a complex with oestrogen when taken orally, leading to faecal oestrogen excretion and lower plasma oestrogen levels.

Clinical guide:

Mepartricin remains an experimental drug, but some physicians believe that it should be considered as a second-line treatment if alpha-blockers fail to provide symptomatic relief.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

NSAIDs for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether NSAIDs are more effective than placebo in reducing symptoms in men with CP/CPPS.

Benefits and harms

NSAIDs versus placebo:

We found one RCT.

Symptom improvement

Compared with placebo We don't know whether NSAIDs are more effective at improving symptoms in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (very low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	64 men with NIH category 3A chronic pelvic pain syndrome	Proportion of men with decrease in National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) score of 25% or more 6 weeks 78% with celecoxib 31% with placebo Absolute numbers not reported	P <0.02	Effect size not calculated	celecoxib
RCT	64 men with NIH category 3A chronic pelvic pain syndrome	Proportion of men with decrease in NIH-CPSI score of 25% or more 8 weeks 31% with celecoxib 19% with placebo Absolute numbers not reported	Reported as significant P value not reported	Effect size not calculated	celecoxib
RCT	64 men with NIH category 3A chronic pelvic pain syndrome	Proportion of people with Subjective Global Assessment (SGA) improvement of 25% or more 6 weeks 56% with celecoxib 41% with placebo Absolute numbers not reported	Significance not assessed
RCT	64 men with NIH category 3A chronic pelvic pain syndrome	Proportion of people with SGA improvement of 25% or more 8 weeks 28% with celecoxib 22% with placebo Absolute numbers not reported	Significance not assessed
RCT	64 men with NIH category 3A chronic pelvic pain syndrome	Proportion of people with SGA improvement of 50% or more 6 weeks 38% with celecoxib 13% with placebo Absolute numbers not reported	Significance not assessed
RCT	64 men with NIH category 3A chronic pelvic pain syndrome	Proportion of people with SGA improvement of 50% or more 8 weeks 13% with celecoxib 6% with placebo Absolute numbers not reported	Significance not assessed

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Further information on studies

The RCT included men with NIH (National Institute of Health classification system) category 3A chronic pelvic pain syndrome. In category 3A chronic pelvic pain syndrome, leukocytes can be found in expressed prostatic secretion in the urine after prostatic massage and in semen. In category 3B disease no leukocytes are detectable.

Comment

We found one RCT of sufficient quality comparing rofecoxib (a COX-2 inhibitor) versus placebo in men with CP/CPPS. However, rofecoxib has now been withdrawn from clinical use.

Substantive changes

NSAIDs for chronic abacterial prostatitis/chronic pelvic pain syndrome New evidence added. Categorisation unchanged (Unknown effectiveness), as there remains insufficient evidence to judge this intervention.

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Pentosan polysulfate for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether pentosan polysulfate reduces symptoms in men with CP/CPPS.

Benefits and harms

Pentosan polysulfate versus placebo:

We found one systematic review (search date 1999, 1 RCT) and one subsequent RCT.

Symptom improvement

Compared with placebo We don't know whether pentosan polysulfate is more effective at improving symptom scores in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (very low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	30 men In review	Physician-rated improvement 3 months 7/10 (70%) with pentosan polysulfate sodium 200 mg twice daily 5/14 (36%) with placebo	RR 2.00 95% CI 0.87 to 4.40 The RCT may have been too small to detect important clinical differences between groups		Not significant
RCT	30 men In review	Proportion of people reporting improvement in symptom score 3 months 5/10 (50%) with pentosan polysulfate sodium 200 mg twice daily 6/14 (43%) with placebo	RR 1.2 95% CI 0.5 to 2.8		Not significant
RCT	100 men	Mean score improvement in the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) total score 16 weeks 5.9 with pentosan polysulfate 300 mg three times daily 3.2 with placebo	P = 0.081		Not significant
RCT	100 men	Mean score improvement in the NIH-CPSI score for urinary symptoms domain 16 weeks 1.2 with pentosan polysulfate 300 mg three times daily 0.5 with placebo	P = 0.374		Not significant
RCT	100 men	Mean score improvement in the NIH-CPSI score for pain domain 16 weeks 2.7 with pentosan polysulfate 300 mg three times daily 1.7 with placebo	P = 0.21		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

Compared with placebo Pentosan polysulfate seems more effective at improving quality of life (measured by NIH-CPSI life quality domain score) in men with CP/CPPS (moderate-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Quality of life
RCT	100 men	Mean score improvement in the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) score for life quality domain 16 weeks 2.0 with pentosan polysulfate 300 mg three times daily 1.0 with placebo	P = 0.037	Effect size not calculated	pentosan polysulfate

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No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	30 men In review	Adverse effects with pentosan polysulfate sodium 200 mg twice daily with placebo
RCT	100 men	Withdrawal because of adverse effects 16 weeks 11/51 (22%) with pentosan polysulfate 300 mg three times daily 4/49 (8%) with placebo	Significance not assessed
RCT	100 men	Diarrhoea 16 weeks with pentosan polysulfate 300 mg three times daily with placebo	P >0.2		Not significant
RCT	100 men	Nausea 16 weeks with pentosan polysulfate 300 mg three times daily with placebo	P >0.2		Not significant
RCT	100 men	Headache 16 weeks with pentosan polysulfate 300 mg three times daily with placebo	P >0.2		Not significant
RCT	100 men	Abdominal pain 16 weeks with pentosan polysulfate 300 mg three times daily with placebo	P >0.2		Not significant
RCT	100 men	Back pain 16 weeks with pentosan polysulfate 300 mg three times daily with placebo	P >0.2		Not significant
RCT	100 men	Proportion of people with no adverse effects after 16 weeks of treatment with pentosan polysulfate 300 mg three times daily with placebo Absolute results not reported	P = 1.0		Not significant

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Further information on studies

The RCT found no significant difference between pentosan polysulfate and placebo in other, more objective and standardised outcomes. The analysis in the RCT was not by intention to treat; 6 people were excluded from the analysis for non-compliance or because they had bacterial prostatitis.

Comment

Clinical guide:

If alpha-blockers fail to provide symptom relief, pentosan polysulfate can be considered as a second-line treatment for men with CP/CPPS.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Quercetin for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether quercetin reduces symptoms in men with CP/CPPS.

Benefits and harms

Quercetin versus placebo:

We found one RCT comparing oral quercetin versus placebo in the treatment of CP/CPPS.

Symptom improvement

Compared with placebo We don't know whether oral quercetin (a bioflavonoid) is more effective at improving symptoms in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (very low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	33 men	Mean improvement in total National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) scores 1 month from 21 to 13 with quercetin 500 mg twice daily for 1 month from 20.2 to 18.8 with placebo	P = 0.003	Effect size not calculated	quercetin
RCT	33 men	Clinically meaningful improvement (more than 25% improvement in NIH-CPSI scores) 1 month 67% with quercetin 500 mg twice daily for 1 month 20% with placebo Absolute numbers not reported	P = 0.001	Effect size not calculated	quercetin
RCT	33 men	Urinary dysfunction 1 month with quercetin 500 mg twice daily for 1 month with placebo Absolute results not reported	Reported as not significant P value not reported		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	33 men	Adverse effects with quercetin 500 mg twice daily for 1 month with placebo

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Further information on studies

None.

Comment

Quercetin is a non-prescription medication. Bioflavonoids have antioxidant properties.

Clinical guide:

Quercetin remains an experimental intervention. However, if alpha-blockers fail to provide symptomatic relief, some physicians think that quercetin can be considered as a second-line treatment for CP/CPPS.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Sitz baths for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We found no direct information from RCTs about sitz baths in the treatment of men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS).

Benefits and harms

Sitz baths:

We found no systematic review or RCTs on the effects of sitz baths in men with CP/CPPS.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Transurethral microwave thermotherapy for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether transurethral microwave thermotherapy (TUMT) reduces symptoms in men with CP/CPPS.

Benefits and harms

Transurethral microwave thermotherapy versus sham treatment:

We found one systematic review (search date 1999, 1 double-blind RCT). The RCT included in the review compared transurethral microwave thermotherapy (TUMT) versus sham treatment.

Symptom improvement

Compared with sham treatment Transurethral microwave thermotherapy (TUMT) may be more effective at 21 months at increasing the proportion of men with an improvement of symptoms (measured by subjective global assessment) in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (very low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	20 men In review	Proportion of men with improvement of a subjective global assessment by more than 50% mean of 21 months 7/10 (70%) with transurethral microwave thermotherapy (TUMT) 1/10 (10%) with sham treatment	Reported as significant P value not reported	Effect size not calculated	thermotherapy

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

Compared with sham treatment Transurethral microwave thermotherapy may be more effective at 3 months at improving quality of life (measured on a 10-point scale) in men with CP/CPPS (very low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Quality of life
RCT	20 men In review	Improvement in quality of life on a scale of 1 to 10 (lower score favourable) 3 months from 4.4 to 3.0 with transurethral microwave thermotherapy (TUMT) from 5.2 to 5.2 with sham treatment	P <0.05	Effect size not calculated	thermotherapy

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Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT	20 men In review	Adverse effects with transurethral microwave thermotherapy (TUMT) with sham treatment

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Further information on studies

None.

Comment

TUMT caused persistent elevation of leukocytes in the prostatic fluid, which could indicate tissue damage.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Antimicrobial drugs (oral) for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

Oral antimicrobial drugs have not been shown to improve symptoms.

Antimicrobial agents have been evaluated in people with chronic abacterial prostatitis because of their known anti-inflammatory properties. However, there is consensus, based on clinical experience, that they are unlikely to be beneficial in this population.

Benefits and harms

Oral antimicrobial drugs versus placebo/no treatment:

We found two RCTs.

Symptom improvement

Oral antimicrobial drugs compared with placebo or no ciprofloxacin Oral ciprofloxacin and levofloxacin may be no more effective after 6 weeks at improving symptoms (measured by NIH-CPSI score) in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) and a mean symptom duration of 6.2 to 6.5 years (low-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT 4-armed trial	196 men	National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) scores after 6 weeks of treatment –5.2 with ciprofloxacin –3.9 with no ciprofloxacin	P = 0.15 Longitudinal regression analysis		Not significant
RCT	80 men	Mean improvement in NIH-CPSI score measured on scale from 0 to 43 6 weeks 5.4 with levofloxacin 2.9 with placebo	P = 0.2 The treatment group may have been too small for reliable conclusions to be drawn		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Adverse effects
RCT 4-armed trial	196 men	Adverse effects with ciprofloxacin with no ciprofloxacin Absolute results not reported	P >0.2		Not significant
RCT	80 men	Mild drug-related effects 6 weeks 9/45 (20%) with levofloxacin 6/35 (17%) with placebo	Reported as not significant P value not reported		Not significant

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Oral antimicrobial drugs versus each other:

We found no systematic review or RCTs.

Oral antimicrobial drugs versus alpha-blockers:

See option on alpha-blockers for chronic abacterial prostatitis.

Further information on studies

None.

Comment

The men included in the two RCTs had a mean symptom duration of 6.2 and 6.5 years. It is unclear whether the duration of symptoms before treatment affects treatment response, or whether response rates would have been different in treatment-naive men.

Substantive changes

No new evidence

BMJ Clin Evid. 2011 Jul 12;2011:1802.

Prostatic massage for chronic abacterial prostatitis/chronic pelvic pain syndrome

Summary

We don't know whether prostatic massage reduces symptoms in men with CP/CPPS.

Benefits and harms

Prostatic massage versus placebo:

We found no RCTs comparing prostatic massage versus placebo.

Prostatic massage plus antimicrobial drugs versus antimicrobial drugs alone:

We found one RCT comparing prostatic massage in combination with antimicrobial drugs versus antimicrobial drugs alone in men with CP/CPPS.

Symptom improvement

Compared with antimicrobial drugs alone Prostatic massage plus antimicrobial drugs and antimicrobial drugs alone are equally effective at 4 months at improving symptoms (measured by NIH-CPSI score) in men with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (moderate-quality evidence).

Ref (type)	Population	Outcome, Interventions	Results and statistical analysis	Effect size	Favours
Symptom improvement
RCT	81 men	Final mean National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) scores 4 months 11.3 with prostatic massage (3 times a week for 4 weeks) plus antimicrobial drug 12.4 with antimicrobial drugs alone	P >0.05		Not significant

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Recurrence rate

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Further information on studies

None.

Comment

None.

Substantive changes

No new evidence

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PERMALINK

Chronic prostatitis

Brian Le, M.D

Dr Anthony J Schaeffer, MD

Abstract

Introduction

Methods and outcomes

Results

Conclusions

Key Points

About this condition

Definition

Incidence/ Prevalence

Aetiology/ Risk factors

Prognosis

Aims of intervention

Outcomes

Methods

Table.

Glossary

Contributor Information

References

Antimicrobial drugs (oral) for chronic bacterial prostatitis

Summary

Benefits and harms

Oral antimicrobial drugs versus placebo or no antimicrobial drugs:

Oral antimicrobial drugs versus each other:

Symptom improvement

Bacteriological cure rate

Recurrence rate

Quality of life

Adverse effects

Further information on studies

Comment

Trimethoprim–sulfamethoxazole (co-trimoxazole):

Quinolones:

Amoxicillin–clavulanic acid (co-amoxiclav) and clindamycin:

Clinical guide:

Substantive changes

Alpha-blockers for chronic bacterial prostatitis

Summary

Benefits and harms

Alpha-blockers versus placebo:

Alpha-blockers plus antimicrobial drugs versus antimicrobial drugs alone:

Symptom improvement

Bacteriological cure rate

Recurrence rate

Quality of life

Adverse effects

Further information on studies

Comment

Clinical guide:

Substantive changes

Antimicrobial drugs (locally injected) for chronic bacterial prostatitis

Summary

Benefits and harms

Local injection of antimicrobial drugs versus placebo or no antimicrobial drugs:

Local injection of antimicrobial drugs versus each other:

Symptom improvement

Bacteriological cure rate

Recurrence rate

Quality of life

Adverse effects

Further information on studies

Comment

Clinical guide:

Substantive changes

NSAIDs for chronic bacterial prostatitis

Summary

Benefits and harms

NSAIDs:

Further information on studies

Comment

Clinical guide:

Substantive changes

Radical prostatectomy for chronic bacterial prostatitis

Summary

Benefits and harms

Radical prostatectomy:

Further information on studies