What is the treatment for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)?

Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

The most effective approach to treating CP/CPPS is a multimodal treatment strategy that addresses individual symptom patterns, with physical therapy being particularly beneficial for patients with pelvic floor tenderness. 1

Understanding CP/CPPS

CP/CPPS is characterized by:

• Pelvic pain (perineum, suprapubic region, testicles, penis tip)
• Pain often exacerbated by urination or ejaculation
• Voiding symptoms (frequency, incomplete emptying)
• Significant impact on quality of life

It's important to note that CP/CPPS shares many clinical characteristics with interstitial cystitis/bladder pain syndrome (IC/BPS), and some men may meet criteria for both conditions 1.

First-Line Treatments

1. Behavioral Modifications and Self-Care Practices

   • Identify and avoid behaviors that worsen symptoms
   • Modify fluid intake (restriction or hydration as needed)
   • Apply heat or cold over perineum
   • Avoid bladder irritants (coffee, citrus products)
   • Consider elimination diet to identify trigger foods
   • Implement stress management techniques
   • Avoid tight-fitting clothing and manage constipation 1

2. Physical Therapy

   • Manual physical therapy should be offered to patients with pelvic floor tenderness
   • Focus on resolving pelvic, abdominal, and hip muscular trigger points
   • Lengthening muscle contractures and releasing painful scars
   • Avoid pelvic floor strengthening exercises (Kegel exercises) as they may worsen symptoms 1
   • In randomized controlled trials, myofascial physical therapy showed 59% improvement compared to 26% with global therapeutic massage 1

Second-Line Pharmacological Treatments

Oral Medications:

1. Amitriptyline (Evidence Strength: Grade B)

   • Start at low doses (10 mg)
   • Gradually titrate to 75-100 mg if tolerated
   • Common side effects: sedation, drowsiness, nausea 1

2. Cimetidine (Evidence Strength: Grade B)

   • Shown to improve symptoms, pain, and nocturia
   • Minimal reported adverse events 1

3. Hydroxyzine (Evidence Strength: Grade C)

   • May be particularly effective in patients with systemic allergies
   • Side effects include sedation and weakness 1

4. Alpha-blockers

   • More effective in treatment-naïve or newly diagnosed patients
   • Longer courses (12 weeks to 6 months) appear superior to shorter courses
   • Less selective agents may be more effective than highly selective alpha-1 blockers 2
   • Mechanism: Promotes smooth muscle relaxation in bladder and prostate 3

5. Antibiotics

   • Often used as first-line treatment despite limited evidence
   • Fluoroquinolones (e.g., levofloxacin) for 4-6 weeks
   • Alternative: Trimethoprim/sulfamethoxazole 4

Third-Line Treatments

1. Pentosan Polysulfate (Evidence Strength: Grade B)

   • FDA-approved for IC/BPS but with mixed results
   • Important warning: Patients should be counseled about potential risk for macular damage and vision-related injuries
   • Requires ophthalmologic monitoring 1

2. Intravesical Treatments (if bladder symptoms predominate)

   • Consider if CP/CPPS overlaps with IC/BPS
   • Options include dimethyl sulfoxide, heparin, or lidocaine 1

Fourth-Line Treatments

Botulinum Toxin A

• Consider if other treatments have not provided adequate symptom control
• Patient must accept possibility of needing intermittent self-catheterization
• 100U dose appears as effective as 200U with fewer adverse events 1

Treatment Algorithm

1. Initial Assessment:

   • Evaluate predominant symptoms (pain, urinary symptoms, sexual dysfunction)
   • Check for pelvic floor tenderness
   • Rule out other conditions (urinary tract infection, prostate cancer)

2. First-Line Approach:

   • Start with behavioral modifications and stress management
   • If pelvic floor tenderness is present, refer for physical therapy
   • Consider over-the-counter supplements (quercetin, calcium glycerophosphates)

3. Second-Line Approach (if inadequate response after 4-6 weeks):

   • For predominant pain: Amitriptyline or anti-inflammatories
   • For predominant urinary symptoms: Alpha-blockers
   • For patients with allergic features: Hydroxyzine
   • For suspected infection: Trial of antibiotics (fluoroquinolone)

4. Third-Line Approach (if inadequate response after 12 weeks):

   • Combination therapy (e.g., alpha-blocker + anti-inflammatory)
   • Consider pentosan polysulfate if bladder symptoms predominate
   • Consider intravesical therapies if IC/BPS overlap

5. Fourth-Line Approach:

   • Botulinum toxin A injections
   • Referral to pain specialist for multimodal pain management

Common Pitfalls and Caveats

1. Overreliance on antibiotics: Despite common practice, evidence for antibiotics in CP/CPPS is limited unless infection is confirmed 5

2. Expecting quick results: Treatment efficacy often increases over time; patience is required 5

3. Neglecting pelvic floor dysfunction: Physical therapy addressing pelvic floor dysfunction is a critical component of treatment 1

4. Focusing on single therapies: Meta-analyses show that monotherapy is rarely effective; combination approaches are usually needed 6

5. Ignoring psychological aspects: Stress management and psychological support are essential components of treatment 1

6. Performing Kegel exercises: These can worsen symptoms and should be avoided 1