What is the treatment for chronic prostatitis/chronic pelvic pain syndrome (CPPS) in men?

Treatment for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) in Men

A multimodal therapeutic approach addressing the individual clinical phenotypic profile is the most effective treatment strategy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men, as no efficient monotherapy has been identified. 1

Understanding CP/CPPS

CP/CPPS is characterized by:

• Pain in the perineum, suprapubic region, testicles, or tip of the penis 2
• Pain often exacerbated by urination or ejaculation 2
• Urinary symptoms including frequency, urgency, and sense of incomplete emptying 2
• Symptoms persisting for at least 3 months 3

Overlap with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

• The clinical characteristics of CP/CPPS are very similar to those of IC/BPS 2
• Some men have symptoms that meet criteria for both conditions 2
• In cases where symptoms overlap, treatment approaches can include both CP/CPPS-specific therapies and IC/BPS therapies 2

First-Line Treatment Options

Alpha-Blockers

• First-line oral therapy for CP/CPPS with urinary symptoms 3
• Examples: tamsulosin, alfuzosin 3, 4
• Can provide significant symptom improvement with NIH-CPSI score differences of -10.8 to -4.8 compared to placebo 3
• Note: A large randomized controlled trial found alfuzosin not effective in men who had not received prior treatment with alpha-blockers 4

Antibiotics

• Commonly used as first-line agents, particularly fluoroquinolones like levofloxacin 5
• Alternative: trimethoprim/sulfamethoxazole 5
• Many men experience significant improvement with a 4-6 week regimen 5
• Note: Use should be judicious given the lack of evidence for bacterial infection in most CP/CPPS cases

Second-Line Treatment Options

Anti-inflammatory Medications

• NSAIDs (e.g., ibuprofen) can provide modest symptom improvement 3
• NIH-CPSI score difference vs. placebo = -2.5 to -1.7 3

Neuromodulatory Medications

• Pregabalin has shown modest benefits 3
• NIH-CPSI score difference vs. placebo = -2.4 3

Physical Therapy

• Manual physical therapy techniques should be offered to patients with pelvic floor tenderness 2
• Techniques include resolving pelvic, abdominal and/or hip muscular trigger points, lengthening muscle contractures, and releasing painful scars 2
• Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided 2

Stress Management

• Patients should be encouraged to implement stress management practices 2
• These help improve coping techniques and manage stress-induced symptom exacerbations 2

Additional Treatment Options

Phytotherapy

• Pollen extract has shown modest benefits 3
• NIH-CPSI score difference vs. placebo = -2.49 3

Self-care and Behavioral Modifications

• Modifying certain behaviors can improve symptoms 2
• Strategies include:
  • Altering urine concentration/volume through fluid management 2
  • Avoiding trigger foods 2
  • Application of heat or cold over affected areas 2
  • Meditation and imagery techniques for flare-ups 2
  • Pelvic floor muscle relaxation 2

For Patients with Overlapping IC/BPS Symptoms

Oral Medications

• Amitriptyline: Start at low doses (10 mg) and titrate gradually to 75-100 mg if tolerated 2
• Cimetidine: Has shown clinically significant improvement of symptoms, pain, and nocturia 2
• Hydroxyzine: May be particularly effective in patients with systemic allergies 2
• Pentosan polysulfate: FDA-approved for IC/BPS but has contradictory evidence; requires monitoring for potential macular damage 2

Treatment Algorithm

1. Initial Assessment:

   • Evaluate predominant symptom domain (pain, urinary symptoms, or both) 1, 5
   • Assess for pelvic floor tenderness 2
   • Rule out active infection with urinalysis and culture 2

2. First-Line Approach:

   • For predominant urinary symptoms: Alpha-blockers 3, 5
   • For pain-predominant symptoms: NSAIDs and/or neuromodulatory medications 3, 5
   • Consider a 4-6 week course of antibiotics, especially in patients with no prior antibiotic treatment 5

3. Second-Line Approach (if inadequate response):

   • Add physical therapy for patients with pelvic floor tenderness 2
   • Implement stress management techniques 2
   • Consider phytotherapy (pollen extract) 3

4. For Refractory Cases:

   • Evaluate for overlapping IC/BPS 2
   • Consider IC/BPS-specific treatments if appropriate 2
   • Multimodal pain management approach 2

Important Considerations

• CP/CPPS is often a waxing and waning illness with symptoms in multiple domains 5
• No single treatment reliably benefits most patients 2
• Treatment response is highly variable between individuals 1, 5
• Surgical options are generally not recommended for CP/CPPS 5
• Opioids should be used judiciously, with non-opioid alternatives preferred for pain management 2