Chronic Prostatitis/Chronic Pelvic Pain Clinic: Approach to Diagnosis and Treatment

Initial Appointment

Patients should arrive with a fairly full bladder and be off of all antibiotics for at least 2 weeks (preferably 4 weeks) in order for the cultures to be accurate. If you are unable or unwilling to stop taking antibiotics, an appointment can still be made, but cultures will not be done. After registering and filling out a brief questionnaire, patients are asked to urinate into a machine to measure urine flow (Uroflow) and have an ultrasound of their bladder to assess adequate bladder emptying. A full history and physical exam is then performed along with review of any past medical records. Cultures are obtained from urine and from prostatic fluid expressed during a rectal exam.

The cultures may take 2-7 days to be reported, particularly if they are sterile or contain low counts of fastidious organisms. Based on these results and any symptomatic improvement from the initial prostatic massage, any further necessary investigations (transrectal ultrasound, cystoscopy, urodynamics, penile Doppler Ultrasound) are arranged and a treatment plan formulated in consultation with the patient. It is very difficult to predict duration of treatment ahead of time, which may vary from a couple of weeks to several months. It is important to understand the limitations we face with out of town patients; we can make recommendations to follow back home, but cannot treat patients over time in a long distance fashion.

Approach to Prostatitis

Conceptually, there are 3 aspects of all forms of inflammatory prostatic disorders:

1. Prostatic Injury: The injury to the prostate is usually from an initial infection but could possibly be traumatic (vigorous mountain biking), mechanical (obstruction of ejaculatory ducts) or chemical (reflux of urine into prostatic ducts). The injury itself does not produce symptoms
2. Injury Response - Inflammation: In response to the injury and release of chemical messengers (chemokines and cytokines), an inflammatory infiltrate may develop. It's purpose is to remove the source of injury (eg bacteria) and assist in the healing process. This inflammatory response can produce pain and swelling. Because of the variable and interconnected innervation of the area, the pain may be felt in the area of the prostate (perineum), penis, lower back or scrotum.

3. Injury Response - Neuromuscular: In response to the injury, inflammation and pain, there can be a constellation of voiding symptoms and pain related to the pelvic muscles, nerves and bladder neck. These may include reduced stream, double voiding, frequency, nocturia, and urgency. Pelvic muscle spasm in response to infection or inflammation can propagate all the symptoms (pain, voiding, sexual). Longstanding chronic pain can change the nervous system's responses to pain and can lead to hyperalgesia (non-painful stimulus felt as painful) and allodynia (pain without a painful stimulus). Chronic pain can also lead to depression, increased stress, helplessness and hopelessness which can interfere with all aspects of quality of life.

Our approach is to determine the relative contribution of each of these factors and tailor the therapy accordingly. We use a 6 point classification that covers Urinary dysfunction, Psychosocial, Organ specific changes (bladder and prostate), Infection, Neurologic/systemic dysfunction and pelvic muscle Tenderness (UPOINT classification). Therapy is then directed at all domains that are present, combining therapies as necessary. More information is available on the UPOINT FAQ page.

Therapies

Based on the classification of the prostatic disorder using the above scheme, some or all of the following treatment options are available.

Supportive Measures:

All chronic prostatitis patients may derive some benefit from general supportive measures such as hot (sitz) baths, avoiding food triggers (caffeine, spicy foods, alcohol) and using a cushion for prolonged sitting. If these don't help the symptoms however, then they need not be continued.

Antibiotics:

Antibiotics alone, especially if chosen on the basis of cultures of prostatic fluid and degree of prostatic penetration can be effective, although protracted courses are often required. Up to 60% of men with a first occurrence of chronic prostatitis will respond completely to antibiotics alone. Since most of our patients have typically failed multiple previous courses of antibiotics, we seldom use them as the only therapy. We do look for yeast/fungi in our cultures and treat with antifungal medications if the cultures are positive. We have not found anti-fungal therapy to be helpful if these cultures are negative. Most men with chronic prostatitis will have positive cultures for low counts of typical skin bacteria. It is unlikely that treatment of these bacteria will improve symptoms. If treatment eliminates the bacteria but symptoms are not improved, prolonged courses of antibiotics are not helpful and may be harmful. Most antibiotics typically used for prostatitis have anti-inflammatory properties as well, so having symptoms improve temporarily while taking antibiotics is not proof that an infection is present.

Bioflavonoids:

Quercetin is a natural antioxidant bioflavonoid which has been shown to improve inflammation and symptoms in men with nonbacterial prostatitis/chronic pelvic pain syndrome. We have been using quercetin either alone or in combination with pollen extract , which has shown beneficial effects in European studies. Farr Labs make a variety of quercetin based products designed specifically for chronic pelvic pain syndromes and BPH.

Alpha Blockers:

Use of alpha blocking agents can improve the urinary stream and often reduce the other voiding symptoms in patients with chronic prostatitis. We usually start with tamsulosin (Flomax) or alfusozin (Uroxatral) in patients with voiding symptoms and those who do not empty their bladders well.

Neuromuscular Therapy:

If infection and inflammation have been ruled out, symptoms may be caused by a primary neuromuscular problem such as pelvic muscle spasm. Therapies include pelvic floor physical therapy, biofeedback, acupuncture, muscle relaxants, and anti-spasmodics. Referral to a pain specialist may be necessary. If chronic pain has led to stress, depression or an inability to cope, psychologic or psychiatric referral can be helpful (and it's use in conjunction with other therapies does NOT mean that the condition is "all in your head"!).

Interstitial Cystitis Therapies:

The symptoms of interstitial cystitis and chronic prostatitis can significantly overlap. In our experience, men with interstitial cystitis typically have more urinary pain and frequency than those with prostatitis and their pain is worse with a full bladder and better or even gone after urination. Therapies we have used with success in men with interstitial cystitis include quercetin , Atarax, Elavil, Lyrica, Neurontin and Cyclosporine. For refractory voiding dysfunction, neuromodulation (posterior tibial nerve stimulation, Interstim) or Botox can be used.

Transurethral Resection (TUR):

Transurethral resection of the prostate is rarely indicated in chronic prostatitis and can make the patient worse if done in the face of ongoing infection and inflammation. Resection of prostatic calcifications, especially those along the "surgical capsule" of the prostate is risky and seldom effective. There are however unusual specific circumstances where TUR may play a role.
1) In the patient with recurrent bacterial prostatitis and concurrent significant benign enlargement of the prostate (BPH). Recurrent infections may be due to incomplete emptying of the bladder due to BPH. If medical therapy of the BPH is not effective, then TUR of the prostate after ensuring that ALL INFECTION IS CLEARED is a reasonable approach.

2) Central prostatic stones associated with recurrent infection or obstruction of the ejaculatory ducts that drain the seminal vesicles. In contrast to the peripheral speckled calcifications seen most often in patients with chronic prostatitis, rarely some patients will have larger stones that are nearer to the urethra and may cause blockage, which is seen by transrectal ultrasound. A very limited TUR of the prostate and/or ejaculatory ducts can clear these stones, removing the source of infection or obstruction.

3) Ejaculatory duct obstruction. Occasionally transrectal ultrasound will demonstrate obstruction of the seminal vesicles, either by scar tissue, prostatic cysts or stones. An incision of the duct or cyst can provide relief in these rare cases.

Cord Denervation Surgery for Orchialgia:

Some men will have persistent isolated pain felt in the testicle despite nothing being wrong with the testicle itself. This may develop on its own or following infection, trauma, inflammation or surgery (vasectomy, hernia repair). In many of these cases, injection of the spermatic cord (the structure carrying the vas, nerves, blood vessels and lymphatics to the testicle) with local anesthetic will give relief of the pain. If such a "cord block" relieves the pain, we offer microsurgical cord denervation. In this outpatient surgery, the cord is exposed and using an operating microscope and meticulous microsurgical technique, the blood and lymphatic supply of the testicle are preserved and the remaining structures (which contain the nerves) are transected. For properly selected patients (pain duration > 6 months, failure of all other medical therapies, complete temporary relief with a cord block), over 85% of patients have long term pain relief.