What is the treatment for non-infectious prostatitis, specifically chronic pelvic pain syndrome (CPPS)?

Treatment of Non-Infectious Prostatitis (Chronic Pelvic Pain Syndrome)

A multimodal therapeutic approach addressing behavioral modifications, pharmacotherapy, and physical therapy is the most effective treatment strategy for non-infectious prostatitis/chronic pelvic pain syndrome (CP/CPPS). 1, 2

First-Line Treatments

Self-Care and Behavioral Modifications

• Dietary changes: Identify and avoid bladder irritants through elimination diet
• Fluid management: Either fluid restriction or additional hydration based on individual response
• Heat/cold application: Apply to perineum or bladder area for symptom relief
• Stress management techniques: Implement meditation, imagery, and other coping strategies to manage stress-induced symptom exacerbations 1
• Pelvic floor muscle relaxation: Focus on relaxation rather than strengthening exercises (avoid Kegel exercises) 1

Physical Therapy

• Manual physical therapy targeting pelvic floor muscles should be offered to patients with pelvic floor tenderness 1
• Techniques include:
  • Releasing muscular trigger points
  • Lengthening muscle contractures
  • Releasing painful scars and connective tissue restrictions
  • Myofascial release

Second-Line Treatments (Pharmacotherapy)

Alpha-Blockers

• Recommended agents: Alfuzosin, doxazosin, tamsulosin, or terazosin 2
• Dosing: For alfuzosin, 10 mg once daily 3
• Duration: Longer treatment courses (12 weeks to 6 months) are more effective than shorter courses 4
• Best candidates: Treatment-naïve and/or newly diagnosed patients respond better than chronic refractory patients 4
• Mechanism: Promotes smooth muscle relaxation in the bladder and prostate 5

Other Oral Medications

• Amitriptyline (Grade B evidence): Start at low doses (10 mg) and titrate gradually to 75-100 mg if tolerated 1
  • Side effects: Sedation, drowsiness, nausea
• Cimetidine (Grade B evidence): Shown to improve symptoms, pain, and nocturia with minimal side effects 1
• Hydroxyzine (Grade C evidence): May be particularly effective in patients with systemic allergies 1
  • Side effects: Short-term sedation, weakness
• Pentosan polysulfate (Grade B evidence): FDA-approved for interstitial cystitis/bladder pain syndrome 1
  • Requires monitoring for macular damage with ophthalmologic exams

Third-Line Treatments

Intradetrusor Botulinum Toxin A (BTX-A)

• Consider if other treatments have not provided adequate symptom control
• May be combined with hydrodistension
• Recommended dose: 100 U rather than 200 U to minimize adverse events
• Patient must accept possibility of needing intermittent self-catheterization post-treatment 1

Hunner Lesion Treatment (if present)

• Fulguration with electrocautery and/or injection of triamcinolone should be performed 1

Treatment Algorithm Based on Symptom Phenotype

1. For predominantly pain symptoms:

   • Begin with behavioral modifications and physical therapy
   • Add amitriptyline or cimetidine
   • Consider alpha-blockers if urinary symptoms are also present

2. For predominantly urinary symptoms:

   • Begin with alpha-blockers (alfuzosin 10 mg daily)
   • Add behavioral modifications
   • Consider physical therapy if pelvic floor tenderness is present

3. For mixed symptoms:

   • Implement comprehensive approach with behavioral modifications, physical therapy, and pharmacotherapy
   • Alpha-blockers plus amitriptyline or cimetidine

Important Considerations

• Pain management alone is typically insufficient; treatment should address underlying bladder-related symptoms 1
• Non-opioid alternatives should be used preferentially for pain management 1
• In men, symptoms of CP/CPPS can overlap with interstitial cystitis/bladder pain syndrome (IC/BPS), requiring a tailored treatment approach 1
• Patient education about the chronic nature of the condition and realistic expectations for symptom control is essential 1

Monitoring and Follow-up

• Use validated symptom indices like NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify symptoms and monitor treatment response 2
• Reassess clinical response after 2-4 weeks of initial therapy
• Be prepared to modify treatment approach if inadequate response

The treatment of non-infectious prostatitis/CPPS requires patience and persistence, as no single treatment reliably benefits all patients. The best outcomes are achieved through a phenotypic-directed approach addressing the individual clinical profile of each patient.