What is chronic prostatitis and its treatment for painful ejaculation?

Chronic Prostatitis and Painful Ejaculation

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by pain in the perineum, suprapubic region, testicles or tip of the penis, often exacerbated by ejaculation, and is frequently associated with urinary symptoms without evidence of bacterial infection. 1

Definition and Classification

Chronic prostatitis is categorized into four types according to the National Institutes of Health (NIH):

1. Category I: Acute bacterial prostatitis - acute infection with systemic symptoms
2. Category II: Chronic bacterial prostatitis - recurrent UTIs with the same pathogen
3. Category III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
   • Type IIIa: Inflammatory (white blood cells in semen/prostatic secretions)
   • Type IIIb: Non-inflammatory
4. Category IV: Asymptomatic inflammatory prostatitis

CP/CPPS (Category III) is the most common form, accounting for 90-95% of prostatitis cases.

Clinical Presentation

Key symptoms of CP/CPPS include:

• Pain in the perineum, suprapubic region, testicles, or penis
• Pain during or after ejaculation (reported in up to 37.2% of patients) 2
• Urinary symptoms (frequency, urgency, hesitancy)
• Sexual dysfunction (erectile dysfunction, premature ejaculation)

Diagnosis

The diagnosis of CP/CPPS is primarily clinical and involves:

1. History: Focus on pain characteristics, urinary symptoms, and sexual dysfunction
2. Physical examination: Digital rectal examination to assess prostate tenderness
3. Basic laboratory tests: Urinalysis and urine culture to exclude infection 1
4. NIH-Chronic Prostatitis Symptom Index (NIH-CPSI): To quantify symptoms and monitor treatment response 3

Treatment Approach

First-Line Treatments

1. Alpha-blockers (alfuzosin, doxazosin, tamsulosin, or terazosin)

   • More effective in alpha-blocker-naïve patients
   • Longer duration of therapy shows better results 3

2. Antibiotics (for suspected bacterial component)

   • For chronic bacterial prostatitis (Category II): Ciprofloxacin 500 mg twice daily for 28 days 4
   • Note: Antibiotics alone are often ineffective for non-bacterial CP/CPPS 5

Second-Line Treatments

1. Amitriptyline (Grade B evidence)

   • Start at 10 mg and titrate to 75-100 mg if tolerated
   • Side effects: sedation, drowsiness, nausea 3

2. Cimetidine (Grade B evidence)

   • Improves symptoms, pain, and nocturia with minimal side effects 3

3. Pentosan polysulfate (Grade B evidence)

   • FDA-approved for interstitial cystitis/bladder pain syndrome
   • Requires monitoring for macular damage 3

Physical Therapy and Behavioral Modifications

1. Pelvic floor muscle relaxation

   • Focus on relaxation rather than strengthening exercises 3
   • Manual physical therapy targeting pelvic floor muscles for patients with pelvic floor tenderness

2. Behavioral modifications

   • Stress management techniques (meditation, imagery)
   • Lifestyle changes: weight loss, regular exercise, smoking cessation
   • Dietary modifications and fluid management 3

Special Considerations for Painful Ejaculation

Painful ejaculation is a common symptom in CP/CPPS, affecting approximately 37.2% of patients 2. Consider:

1. Evaluation for ejaculatory duct obstruction (EDO)

   • A potentially correctable cause of CPPS with ejaculatory pain
   • Treatable with minor surgery 6

2. Combined therapy approach

   • Triple therapy with doxazosin + ibuprofen + thiocolchicoside has shown significant improvement in pain and voiding symptoms 5

Monitoring and Follow-up

1. Use the NIH-CPSI to objectively monitor treatment response
2. Expect gradual improvement over time - efficacy of treatments typically increases with duration 5
3. Consider referral for specialized interventions if standard treatments fail

Common Pitfalls

1. Overreliance on antibiotics: CP/CPPS is predominantly non-bacterial, and antibiotics alone often fail to provide relief 5

2. Neglecting sexual dysfunction: Sexual problems are common in CP/CPPS and should be actively addressed 7, 2

3. Single-modality treatment: CP/CPPS typically requires a multimodal approach rather than single treatments 3

4. Unrealistic expectations: Patient education about the chronic nature of the condition and setting realistic expectations for symptom control is essential 3