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==Prognosis==
==Prognosis==
In recent years the prognosis for CP/CPPS has improved greatly with the advent of multimodal treatment, phytotherapy, protocols aimed at quieting the pelvic nerves through myofascial trigger point release and anxiety control, and chronic pain therapy.<ref name="Duclos-2007">{{Cite journal | last1 = Duclos | first1 = AJ. | last2 = Lee | first2 = CT. | last3 = Shoskes | first3 = DA. | title = Current treatment options in the management of chronic prostatitis. | journal = Ther Clin Risk Manag | volume = 3 | issue = 4 | pages = 507–12 | month = Aug | year = 2007 | doi = | pmid = 18472971 | pmc = 2374945 }}</ref><ref name="Shoskes-2005">{{Cite journal | last1 = Shoskes | first1 = DA. | last2 = Katz | first2 = E. | title = Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. | journal = Curr Urol Rep | volume = 6 | issue = 4 | pages = 296–9 | month = Jul | year = 2005 | doi = 10.1007/s11934-005-0027-0| pmid = 15978233 }}</ref><ref name="Bergman-2007">{{Cite journal | last1 = Bergman | first1 = J. | last2 = Zeitlin | first2 = SI. | title = Prostatitis and chronic prostatitis/chronic pelvic pain syndrome. | journal = Expert Rev Neurother | volume = 7 | issue = 3 | pages = 301–7 | month = Mar | year = 2007 | doi = 10.1586/14737175.7.3.301 | pmid = 17341178 }}</ref>
In recent years the prognosis for CP/CPPS has improved greatly with the advent of multimodal treatment, phytotherapy, protocols aimed at quieting the pelvic nerves through anxiety control, and chronic pain therapy.<ref name="Duclos-2007">{{Cite journal | last1 = Duclos | first1 = AJ. | last2 = Lee | first2 = CT. | last3 = Shoskes | first3 = DA. | title = Current treatment options in the management of chronic prostatitis. | journal = Ther Clin Risk Manag | volume = 3 | issue = 4 | pages = 507–12 | month = Aug | year = 2007 | doi = | pmid = 18472971 | pmc = 2374945 }}</ref><ref name="Shoskes-2005">{{Cite journal | last1 = Shoskes | first1 = DA. | last2 = Katz | first2 = E. | title = Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. | journal = Curr Urol Rep | volume = 6 | issue = 4 | pages = 296–9 | month = Jul | year = 2005 | doi = 10.1007/s11934-005-0027-0| pmid = 15978233 }}</ref><ref name="Bergman-2007">{{Cite journal | last1 = Bergman | first1 = J. | last2 = Zeitlin | first2 = SI. | title = Prostatitis and chronic prostatitis/chronic pelvic pain syndrome. | journal = Expert Rev Neurother | volume = 7 | issue = 3 | pages = 301–7 | month = Mar | year = 2007 | doi = 10.1586/14737175.7.3.301 | pmid = 17341178 }}</ref>


==Notable cases==
==Notable cases==

Revision as of 15:27, 18 August 2010

Chronic prostatitis/chronic pelvic pain syndrome
SpecialtyUrology Edit this on Wikidata

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a pelvic pain condition in men, and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis. [1] This condition was previously known as chronic non-bacterial prostatitis, or prostatodynia (painful prostate).

Nomenclature

A distinction is sometimes made between "IIIa" (Inflammatory) and "IIIb" (Noninflammatory) forms of CP/CPPS,[2] depending on whether pus cells (WBCs) can be found in the expressed prostatic secretions (EPS) of the patient. Some researchers have questioned the usefulness of this categorisation, calling for the Meares-Stamey four-glass test to be abandoned.[3]

In 2007, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) began using the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS), for research purposes, to refer to pain syndromes associated with the bladder (i.e. interstitial cystitis/painful bladder syndrome, IC/PBS) and the prostate gland (i.e. chronic prostatitis/chronic pelvic pain syndrome, CP/CPPS).[4]

Older terms for this condition are "prostatodynia" (prostate pain) and non-bacterial chronic prostatitis.

Signs and symptoms

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterised by pelvic or perineal pain without evidence of urinary tract infection,[5] lasting longer than 3 months,[6] as the key symptom. Symptoms may wax and wane. Pain can range from mild discomfort to debilitating. Pain may radiate to back and rectum, making sitting difficult. Dysuria, arthralgia, myalgia, unexplained fatigue, abdominal pain, constant burning pain in the penis, and frequency may all be present. Frequent urination and increased urgency may suggest interstitial cystitis (inflammation centred in bladder rather than prostate). Post-ejaculatory pain, mediated by nerves and muscles, is a hallmark of the condition,[7] and serves to distinguish CP/CPPS patients from men with BPH or normal men. Some patients report low libido, sexual dysfunction and erectile difficulties.

Prevalence

The annual prevalence in the general population of chronic pelvic pain syndrome is 0.5%.[8] 38% of primary care providers, when presented with a vignette of a man with CPPS, indicate that they have never seen such a patient.[9] However, the overall prevalence of symptoms suggestive of CP/CPPS is 6.3%.[10] The role of the prostate was questioned in the etiology of CP/CPPS when both men and women in the general population were tested using the (1) National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI[11]) —with the female homolog of each male anatomical term use on questionnaires for female participants— (2) the International Prostate Symptom Score (IPSS), and (3) additional questions on pelvic pain. The prevalence of symptoms suggestive of CPPS in this selected population was 5.7% in women and 2.7% in men, placing in doubt the role of the prostate gland.[12] New evidence suggests that the prevalence of CP/CPPS is much higher in teenage males than once suspected.[13]

Theories of etiology

Nerves, stress and hormones

In 2008, a literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine, finding that the symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.[14]

Theories behind the disease include stress-driven hypothalamic-pituitary-adrenal axis dysfunction and adrenocortical hormone (endocrine) abnormalities,[15][16] neurogenic inflammation,[17][18][19] and myofascial pain syndrome.[20][21] In the latter two categories, dysregulation of the local nervous system due to past trauma, infection or an anxious disposition and chronic albeit unconscious pelvic tensing lead to inflammation that is mediated by substances released by nerve cells (such as substance P). The prostate (and other areas of the genitourinary tract: bladder, urethra, testicles) can become inflamed by the action of the chronically activated pelvic nerves on the mast cells at the end of the nerve pathways. Similar stress-induced genitourinary inflammation has been shown experimentally in other mammals.[22] However, there is no correlation between inflammation on histological examination of the prostate and the National Institutes of Health Chronic Prostatitis Symptom Index.[23]

The bacterial infection theory that for so long had held sway in this field was shown to be unimportant in a 2003 study from the University of Washington team led by Dr Lee and Professor Richard Berger. The study found that one third of both normal men and patients had equal counts of similar bacteria colonizing their prostates.[24] This view was endorsed by Dr Anthony Schaeffer, Professor and Chairman of the Department of Urology at Northwestern University, in a 2003 editorial of The Journal of Urology, in which he stated that "...these data suggest that bacteria do not have a significant role in the development of the chronic pelvic pain syndrome",[25] and a year later with his colleagues he published studies showing that antibiotics are essentially useless for CP/CPPS.[26][27]

Overlap with BPS/IC

Some researchers have suggested that CPPS is a form of bladder pain syndrome/interstitial cystitis (BPS/IC). In 2007 the NIDDK began to group IC/PBS and CP/CPPS under the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS). Therapies shown to be effective in treating IC/PBS, such as quercetin,[28] have also shown some efficacy in CP/CPPS.[29] Recent research has focused on genomic and proteomic aspects of the related conditions.[30]

Infection

Additional theories and observations include:

  • Nanobacteria — In a preliminary 2005 open label study of 16 treatment-recalcitrant CPPS patients, controversial entities known as nanobacteria were proposed as a cause of prostatic calcification and symptoms found in CPPS.[31] Patients were treated with EDTA (to dissolve the calcifications) and 3 months of tetracycline (a calcium-leaching antibiotic with anti-inflammatory effects,[32] used here to kill the "pathogens"), and half had significant improvement in symptoms. Scientists have expressed strong doubts about whether nanobacteria are living organisms.[33][34] Research in 2008 showed that "nanobacteria" are merely tiny lumps of abiotic limestone.[35][36] Confirmation of the clinical efficacy of the treatment awaits placebo controlled studies.
  • Viruses — The evidence supporting a viral cause of prostatitis and chronic pelvic pain syndrome is weak. Single case reports have implicated Herpes simplex virus (HSV) and Cytomegalovirus (CMV) but a study using PCR failed to demonstrate the presence of viral DNA in patients with chronic pelvic pain syndrome undergoing radical prostatectomy for localized prostate cancer.[37] The reports implicating CMV must be interpreted with caution because in all cases the patients were immunocompromised.[38][39][40] For HSV the evidence is weaker still and there is only one reported case and the causative role of the virus was not proven,[41] and there are no reports of successful treatments using antiviral drugs such as aciclovir.

Climate

The ambient temperature appears to play a role as cold is frequently reported as causing symptom aggravation and heat is often reported to be ameliorating.[42] It appears that cold is one of the factors that can trigger a process resulting in CP/CPPS.[43] Cold also causes aggravation of symptoms and can initiate a relapse.[43][44] A survey showed that the occurrence of prostatitis symptoms in men living in northern Finland —a cold climate—is higher than that reported in other parts of the world. This could be partly caused by the cold climate.[45]

Diagnosis

There are no definitive diagnostic tests for CP/CPPS. This is a poorly understood disorder, even though it accounts for 90%-95% of prostatitis diagnoses.[46] It is found in men of any age, with the peak incidence in men aged 35—45 years.[47] CP/CPPS may be inflammatory (Category IIIa) or non-inflammatory (Category IIIb), based on levels of pus cells in expressed prostatic secretions (EPS), but these subcategories are of limited use clinically. In the inflammatory form, urine, semen, and other fluids from the prostate contain pus cells (dead white blood cells or WBCs), whereas in the non-inflammatory form no pus cells are present. Recent studies have questioned the distinction between categories IIIa and IIIb, since both categories show evidence of inflammation if pus cells are ignored and other more subtle signs of inflammation, like cytokines, are measured.[48] In 2006, Chinese researchers found that men with categories IIIa and IIIb both had significantly and similarly raised levels of anti-inflammatory cytokine TGFβ1 and pro-inflammatory cytokine IFN-γ in their EPS when compared with controls; therefore measurement of these cytokines could be used to diagnose category III prostatitis.[49]

For CP/CPPS patients, analysis of urine and expressed prostatic secretions for leukocytes is debatable, especially due to the fact that the differentiation between patients with inflammatory and non-inflammatory subgroups of CP/CPPS is not useful.[50] Serum PSA tests, routine imaging of the prostate, and tests for Chlamydia trachomatis and Ureaplasma provide no benefit for the patient.[50]

Extraprostatic abdominal/pelvic tenderness is present in >50% of patients with chronic pelvic pain syndrome but only 7% of controls.[51] Healthy men have slightly more bacteria in their semen than men with CPPS.[52] The high prevalence of WBCs and positive bacterial cultures in the asymptomatic control population raises questions about the clinical usefulness of the standard 4-glass test as a diagnostic tool in men with CP/CPPS.[52] The use of the four-glass test by American urologists is now rare, with only 4% using it regularly.[53]

Men with CP/CPPS are more likely than the general population to suffer from Chronic Fatigue Syndrome (CFS),[54] and Irritable Bowel Syndrome (IBS).

Experimental tests that could be useful in the future include tests to measure semen and prostate fluid cytokine levels. Various studies have shown increases in markers for inflammation such as elevated levels of cytokines,[55] myeloperoxidase,[56] and chemokines.[57][58]

Conditions with similar symptoms

Some conditions have similar symptoms to chronic prostatitis: Bladder neck hypertrophy and urethral stricture may both cause similar symptoms through urinary reflux (inter alia), and can be excluded through flexible cytoscopy and urodynamic tests.[59][60][61]

Treatment

A 2007 review article by Drs Potts and Payne in the Cleveland Clinic Journal of Medicine states:

"Indeed, chronic abacterial prostatitis (also known as chronic pelvic pain syndrome) is both the most prevalent form and also the least understood and the most challenging to evaluate and treat. This form of prostatitis may respond to non-prostate-centered treatment strategies such as physical therapy, myofascial trigger point release, and relaxation techniques."[62]

Nonpharmalogical/noninvasive

Physical and psychological therapy

Category III prostatitis may have no initial trigger other than anxiety, often with an element of OCD, panic disorder, or other anxiety-spectrum problem.[63][64][65] This is theorized to leave the pelvic area in a sensitized condition resulting in a loop of muscle tension and heightened neurological feedback (neural pain wind-up). Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress.

Aerobic exercise can help those sufferers who are not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms are not exacerbated by exercise.[66] Acupuncture has reportedly benefited some patients.[67]

For chronic nonbacterial prostatitis (Cat III), also known as CP/CPPS, which makes up the majority of men diagnosed with "prostatitis", a treatment called the "Wise-Anderson Protocol" (aka the "Stanford Protocol"),[20][21][68] has recently been published. This is a combination of:

  • Medication (using tricyclic antidepressants and benzodiazepines)
  • Psychological therapy (paradoxical relaxation, an advancement and adaptation, specifically for pelvic pain, of a type of progressive relaxation technique developed by Edmund Jacobson during the early 20th century)
  • Physical therapy (trigger point release therapy on pelvic floor and abdominal muscles, and also yoga-type exercises with the aim of relaxing pelvic floor and abdominal muscles).[20][21]

Biofeedback

Biofeedback physical therapy to relearn how to control pelvic floor muscles may be useful.[69] [70] [71] [72] According to an article by Yuan Li biofeedback is satisfactory for treatment of chronic prostatitis (with mainly voiding problems) during puberty [73].

Food allergies

Anecdotal evidence suggests that food allergies and intolerances may have a role in exacerbating CP/CPPS, perhaps through mast cell mediated mechanisms. Specifically patients with gluten intolerance or celiac disease report severe symptom flares after sustained gluten ingestion.[74] Patients may therefore find an elimination diet helpful in lessening symptoms by identifying problem foods. Studies are lacking in this area.

Pharmacological treatment

There is now a substantial list of medications used to treat this disorder.[75] A brief mention of the more common drugs used to treat this condition is:

  • Antibiotics: Antibiotics, the old mainstay of treatment, cannot be recommended for men with longstanding, previously treated CP/CPPS.[13] However, even though well-designed clinical trials have failed to demonstrate their efficacy, standard treatment often still consists of prolonged courses of antibiotics.[76] The utility of a trial of antimicrobial treatment is debatable in treatment-naive patients.[77] The use of antibiotics is generally discouraged.[27] Some state improvement on antibiotics is likely to be evanescent, and due to the anti-inflammatory effects of the antibiotic.[78]
  • Heparinoids: A large multicenter prospective randomized controlled study showed that Elmiron was slightly better than placebo in treating the symptoms of CPPS, however the primary endpoint did not reach statistical significance.[79]
  • Quercetin has shown effective in a randomized, placebo-controlled trial in chronic prostatitis using 500 mg twice a day for 4 weeks[80] Subsequent studies showed that quercetin, a mast cell inhibitor, reduces inflammation and oxidative stress in the prostate.[81][82]
  • Pollen extract (Cernilton) has also been shown effective in randomized placebo controlled trials.[83][84]
  • At least one study suggests that multi-modal therapy (aimed at different pathways such as inflammation and neuromuscular dysfunction simultaneously) is better long term than monotherapy.[85]
  • Alpha blockers. The effectiveness of alpha blockers (tamsulosin, alfuzosin) is questionable in men with CPPS. A 2006 meta analysis found that they are moderately beneficial when the duration of therapy was at least 3 months.[87] However a 2004 trial found no benefit from alfuzosin during 6 weeks of treatment[26] and a 2008 clinical trial of alfuzosin found it was no better than placebo for treating CPPS in treatment naive recently diagnosed men.[88]

Surgery

Surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.[89]

Transurethral needle ablation of the prostate (TUNA) has been shown to be ineffective in trials.[90]

In an ongoing trial http://clinicaltrials.gov/ct2/show/NCT00775515 conducted by Arnon Krongrad, the pioneer of Laparascopic Radical Prostatectomy in the United States, a significant proportion of CP/CPPS patients are reporting large to complete reductions in their symptoms after LRP (an operation usually reserved for prostate cancer). This is a very last resort however, only to be considered after all other treatments have failed, due to the potentially serious side effects of the surgery. It does however, seem to indicate that the prostate and seminal vesicles may have a significant involvement in the symptoms of these men.

Prognosis

In recent years the prognosis for CP/CPPS has improved greatly with the advent of multimodal treatment, phytotherapy, protocols aimed at quieting the pelvic nerves through anxiety control, and chronic pain therapy.[76][91][92]

Notable cases

See also

External links

References

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