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Treatment of Chronic Prostatitis

welcome to this educational program this

module provides an overview of treatment

strategies for troubling condition

called chronic prostatitis or chronic

pelvic pain syndrome it is hoped that

you will already have viewed the

introductory module understanding

chronic prostatitis chronic pelvic pain

syndrome prior to this one this

information is taken from a recent

review of the medical literature and

attempts to be as comprehensive as

possible however it may not necessarily

reflect the experience of your

healthcare provider or the specifics of

your situation this program is strictly

informational in nature and no attempt

is made to provide opinion or

recommendation please feel free to view

this presentation as many times as

necessary you may also use the player on

your left to repeat slides or to skip

through them in any order you wish to

review prostatitis is a word that

describes a spectrum of diseases of the

prostate and pelvic area of men this

disease spectrum is very common

affecting over 8 million males every

year throughout the world in fact up to

one out of every two men may experience

prostatitis in his lifetime

men with prostatitis may present with

urinary symptoms such as frequent urgent

or painful urination sexual symptoms

such as a change to ejaculation or blood

in the ejaculate or pain in the pelvic


simply put prostatitis is inflammation

or swelling of the prostate this may be

either acute with the sudden onset or

chronic and slow to develop having said

this not all prostatitis cases involve

inflammation of the prostate

doctors have identified four distinct

prostatitis syndromes as listed here

acute infectious prostatitis chronic

infectious prostatitis chronic

prostatitis chronic pelvic pain syndrome

and asymptomatic inflammatory

prostatitis these are all defined in the

introductory module on prostatitis

chronic prostatitis also called chronic

pelvic pain syndrome and now category

three prostatitis is the most common

syndrome and is unfortunately the most

troublesome to diagnose and treat this

is the focus of the rest of this module

this is a condition a persistent or

reoccurring urinary symptoms and pain

where no bacteria or other germs can be

found in the prostate patients with this

condition may or may not have any

evidence of inflammation in the prostate

at all in other words the process is not

always localized to the prostate itself

because of this treatment with

antibiotics alone does not cure the

symptoms to review chronic prostatitis

chronic pelvic pain syndrome begins with

some sort of triggering event which

leads to inflammation and nerve injury

inflammation is the body's response to

injury infection and other stimuli

inflammation and nerve injury in turn

lead to changes in the nervous system

and in time this leads to an abnormal

pain response and to a cycle of chronic

pain chronic prostatitis chronic pelvic

pain syndrome is diagnosed using a

combination of a careful medical

interview physical exam including a

digital rectal exam or dr e and lab

tests this is all reviewed in detail in

the introductory module a physician's

first goal is to rule out other

treatable causes of the same symptoms

there are many treatment options

available for chronic prostatitis as

shown on this slide the mainstay of

treatment has been the so called three

A's antibiotics alpha blockers and

anti-inflammatories the other items

listed here are supplemental therapies

we will review all of this in more

detail in the next several slides

ideally the best treatment of any

chronic condition is prevention any

acute infection should be treated

promptly and thoroughly and this will

usually involve the use of appropriate

antibiotics for four to six weeks

possibly with an alpha blocker to

prevent another infection sexually

transmitted diseases where STDs are

those caused by bacteria or viruses that

can be transmitted through sexual

contact from one partner to another for

men who are not in a monogamous

relationship condoms should be used and

regular visits to your doctor or an STD

clinic are recommended furthermore when

possible a man's partner should be

evaluated to be sure that she or he is

not a silent carrier of an organism that

could be reinfecting him finally injury

to the pelvic area should be avoided

through the use of appropriate

protective equipment well-designed

bicycle seats etc long drives without

interruption should be avoided but when

this is not practical a well cushioned

seat is important antibiotics are the

key to treatment of acute and chronic

bacterial prostatitis in CPC PPS they

have had mixed success

if long-standing disease is present and

previous antibiotics have been tried

then further antibiotic treatment is not

recommended as only 22 to 33 percent

will respond which is not different than

the response to placebo

if started within one month symptoms

however and no previous antibiotics have

been tried then the success rate is as

high as 75% and in these cases treatment

is recommended

the most common antimicrobial drugs used

are a class called the quinolones and an

older medication called trimethoprim

sulfamethoxazole by far the two most

common prescriptions for this condition

in North America are ciprofloxacin or

cipro and levofloxacin or levaquin other

quinolone drugs include ofloxacin or

phlox in' nor Fluxus in' or Noxon and

gat ofloxacin or Tec one trimethoprim

sulfamethoxazole comes by several trade

names such as cetera and bactrim and

many generics are also available for

patients with the sulfa allergy

trimethoprim alone also called pro-law

prim can be prescribed which does not

have the added sulfamethoxazole

component the prostate contains many

muscle fibers these fibers squeeze or

grip around the urine channel called the

urethra this squeezing effect blocks the

flow of urine out of the bladder worsens

urinary symptoms and may contribute to

prostatitis by creating more turbulent

flow of urine through the prostate which

might wash urine up into the ducts of

the prostate prostate muscle fibers are

activated when certain chemicals trigger

what are called alpha receptors on the

muscle cells these alpha receptors can

be blocked by medications to prevent

them from being activated and this

causes the prostate muscle fibers to

relax loosening their grip around the

urethra easing urinary symptoms and

possibly helping to prevent recurrent

episodes of prostatitis for patients

with CPC PPS more than 6 weeks of

treatment with these medications

probably twelve weeks seems to be

necessary to have a beneficial effect

and this is being studied in large

clinical trials

there are four common alpha blockers as

listed here the so called selective

alpha blockers are able to target the

prostate more with less action on other

alpha receptors in other parts of the

body these drugs alphas hacen or is a

trial and temps losen which is flomax or

flomax er generally have lesser side

effects and can be started and capped at

one simple dose the non selective drugs

Ducks assassin or card era and Torres

Essen or Hytrin are more likely to cause

some side effects and typically they

have to be started at a lower dose and

gradually increased if you are

prescribed one of these medications it

is important to follow the dosage

schedule set out by your doctor and try

to get to the maximum dose that you can

tolerate alpha blockers are safe and

they are well tolerated by patients like

any medication however side effects may

be experienced some patients may

experience sleep disturbances weakness

or dizziness the latter which may result

from a drop in blood pressure is an

important effect to watch for if you

drive or handle heavy machinery stomach

problems fever and eggs may also be

experienced as well as skin irritations

swelling of mucous membranes and

tingling some people may develop an

irregular heartbeat a few patients may

experience a painful and lasting

erection more commonly a man's

ejaculation may change whereby there is

less fluid that comes out when he has an

orgasm or climax this happens because

the opening to the bladder is more

relaxed so during ejaculation most of

the fluid actually goes backwards into

the bladder this is called retrograde

ejaculation all of these effects are

reversible if the drug is stopped

patients should notify their doctor if

they are taking blood pressure

medications as some alpha blockers can

further lower your blood pressure also

some alpha blockers should not be taken

if you are taking certain erection

medications such as levitra

in theory anti-inflammatories should

relieve the inflammation component of

CPC PPS while good results compared to

placebo have not been proven they are

recommended as part of a

multi-dimensional treatment program

there are two main classes of

anti-inflammatory drugs the

non-steroidal anti-inflammatory drugs or

NSAIDs and the cox-2 inhibitors examples

of NSAIDs include ibuprofen such as

motrin advil and nuprin ketorolac or

toradol into medicine or Indesit

diclofenac such as voltaren and Arthur

Tech and naproxen such as nasan or Aleve

examples of cox-2 inhibitors include

celecoxib and Valda coccyx which go by

the brand names

celebrex and Bextra respectively

Aylmer on or pentas on poly sulfate is

the only oral medication available that

works to improve the lining of the

bladder for some people exactly how it

works is not well understood one theory

is that Elmer on helps to restore the

bladder walls protective coating to

prevent substances from leaking across

into the bladder wall and causing

inflammation it may also decrease

inflammation directly it is not unusual

for improvement to take six months or

more to become apparent on this

medication hormone therapy is the use of

medication or surgery to lower levels of

specific types of hormones in the body a

class of drugs called 5-alpha reductase

inhibitors which includes the agents

financier I'd marketed as proscar and

doot asteroid or avid art work to lower

the levels of the male hormone

dihydrotestosterone these are discussed

in detail on the next few slides the

drug map artisan lowers levels of the

female hormone estrogen in the prostate

a very small clinical trial suggested a

benefit of this drug in patients with

CPC PPS the larger controlled studies

are needed

the male hormone dihydrotestosterone or

DHT fuels the growth of prostate cells

DHT is a product converted from the

primary male hormone testosterone

produced mostly by the testicles and

partly by the adrenal glands 5 alpha

reductase inhibitors block the

conversion of testosterone to DHT and

stop the growth of prostate gland cells

5 alpha reductase inhibitors can in fact

actually shrink the physical size of the

prostate and this may improve urine flow

out of the bladder through the urethra

as it runs through the prostate these

drugs may also take 3 to 6 months or

more to achieve their maximum effect and

they do not work on all men who take

them it is possible that these drugs may

help alleviate the symptoms of chronic

prostatitis in some men but presently

they are only suggested for men who also

have an enlarged prostate possible side

effects of hormone therapy include back

or abdominal pain diarrhea a lowered

sexual desire erectile dysfunction hair

growth skin rash swelling of the lips or

breasts headache and dizziness

the use of plant extracts or

phytotherapy has been popular by

patients with CPC PPS such agents

include quercetin an antioxidant


found in red wine grapeseed green tea

onions and other foods and Sur nilton

which is a pollen extract these products

are generally safe to take and cause few

side effects saw palmetto or Sarah Noah

repens has also been very popular in

patients with prostate problems these

products are generally safe to take and

cause few side effects while some small

studies have been done and are promising

it is still not clear just how effective

they truly are for chronic prostatitis

properly conducted clinical trials are

needed and some are now underway surgery

is a last resort for some patients there

are many types of surgical options

available although not all centers and

not all doctors will offer each one of

these this slide shows that the choice

of surgical treatment progresses from

minimally invasive to more aggressive

depending on the situation minimally

invasive techniques performed through a

telescope passed down the urethra called

a cystoscope include microwave thermal

therapy or tea um tea needle ablation or

tuna laser vaporization PvP and

transurethral incision or TOI P more

aggressive surgeries that can be done

through a cystoscope include the laser

prostatectomy properly called a holmium

laser enucleation of the prostate or

whole app and the classic operation

called a trans urethral resection of the

prostate also called a Terp or Tupper

very very rarely performed is an open

surgical removal of all or part of the

prostate open surgery and radical trans

urethral resection of the prostate while

written about are not recommended

treatment options

surgery should be avoided in fact

whenever possible as it may worsen a

man's condition when performed only

therapies with some proven benefit

should be attempted and the least

invasive treatment possible should be


to be a candidate for surgical treatment

for CPC PPS there must be evidence that

the prostate or bladder neck is causing

obstruction to urine flow and that all

appropriate medications have been tried

first surgery is an absolute last resort

furthermore any active infection must be

treated prior to surgery otherwise major

complications can result other drugs

that can be used to help alleviate the

symptoms and effects of long-standing

chronic prostatitis which do not

directly treat the underlying problem

include drugs aimed at the nervous

system and painkillers

the most common nervous system

medications fall within a class called

tricyclic antidepressants especially the

drug amitriptyline or elavil these drugs

have multiple benefits including

reducing sensitivity to bladder filling

relaxing the bladder muscle relief of

chronic pain improvement in sleep and

improvement in mood depending on your

situation you may need to take

painkillers only occasionally or you may

need to take them more regularly this is

an important discussion to have with

your physician if your pain is mild the

most commonly used drugs are

anti-inflammatories such as ibuprofen as

we've discussed the drugs pregabalin or

lyrica and gabapentin or neurontin are

increasingly being used for certain

patients with chronic pain conditions

and are an excellent treatment choice

the highest dose that can be tolerated

is recommended finally if your pain is

very severe stronger medication which

contains narcotics may be an option

however understand that these drugs may

not totally relieve all pain and they

can lead to a lesser quality of life and

more disability overall furthermore

since these types of medications are

habit-forming over the long term you

should discuss their use very carefully

with your physician they can also cause

severe constipation when taken regularly

so you must take measures to keep your

stools loose if you are taking them

massage of the prostate is recommended

by some physicians to drain fluid from

the inflamed prostate and thereby

relieve pressure and pain more commonly

prostate massage is done as part of the

diagnostic workup in order to recover

prostate secretions for lab testing as

for the digital rectal examination the

doctor inserts a finger into the rectum

and applies gentle pressure to the

prostate in order to release fluid this

procedure can be uncomfortable but for a

few patients it can provide some lasting

relief there is presently no good

evidence to recommend routine prostatic

massage as a standard treatment option

for chronic prostatitis

Payne is registered by the nervous

system for this reason relieving

stimulation of the nerves in the pelvic

region can greatly alleviate pain in

chronic prostatitis patients many

patients find relief by something as

simple as a hot bath and in fact sitz

baths which are warm hip deep baths are

recommended by most physicians when

symptoms are bothersome patients should

try to find time to sit in a warm bath

for 20 minutes or so two to three times

per day during the day many patients

find that cushioned seating in

particular doughnut shaped cushions help

with the pain muscle relaxants are

sometimes also prescribed as well as

physiotherapy of the pelvic floor and

acupuncture to achieve success in

managing prostatitis one should firstly

follow the advice of his doctor and

consider trying any prescribed therapies

symptoms can further be managed with

some simple lifestyle changes eating a

balanced diet low in alcohol and

caffeine and complete with essential

vitamins and minerals and perhaps low

and spicy foods may help ease symptoms

keeping your weight to a healthy level

through good eating habits and regular

exercise is also helpful finally as

stress can be a contributing factor in

chronic prostatitis stress management

techniques and even counselling may be

recommended to you now that we have

discussed the various treatment options

that can be used for chronic prostatitis

how does your physician measure the

success of a treatment regimen for

bacterial prostatitis a test of urine

and prostate secretions should be

negative that is bacteria are no longer

detectable this would indicate that the

antibiotics have worked for patients

suffering from chronic prostatitis

chronic pelvic pain syndrome the goal of

treatment is to relieve symptoms and

improve quality of life this can be

measured by an improvement in symptoms

scores of any of the standard

questionnaires that physicians use with

the nih chronic prostatitis symptom

index being the most widely used and

accepted one ultimately you the patient

will determine if your treatment program

has been successful

research continues into studying the

cause of CPC PPS and into development of

new classes of drugs for treatment of

all types of prostatitis current

treatments and their combinations will

continue to be properly assessed in

large scale controlled clinical trials

while new treatments are developed what

does the future hold for chronic

prostatitis treatment researchers are

addressing two issues with regards to

antibiotic treatment of prostatitis a

common drawback of the overuse of

antibiotics is the development of

resistant bacteria

thus research is concentrating on

developing new antibiotics to combat

antibiotic resistant prostatitis the

second issue is the presence of bacteria

trapped in calcium inclusions within the


this phenomenon is believed to be more

common in older chronic prostatitis

patients these so-called nano bacteria

are not targeted by traditional

antibiotic treatments however a new

therapy called Comi T or comet has been

derived comet is a combination of

tetracycline antibiotic and a mix of

vitamins minerals and EDTA which allow

the antibiotic to penetrate the calcium

inclusions and target the Nano bacteria

finally the chronic prostatitis

collaborative research network is

researching better means of managing

prostatitis with ongoing efforts from

the medical community and feedback from

patients like you optimal treatment of

chronic prostatitis are within our grasp

in summary chronic prostatitis can best

be treated when detected early in these

cases treatment with antibiotics and

drugs called alpha blockers can be

effective when the condition is more

long-standing the primary goal is to

relieve symptoms this can be

accomplished through a so called

multimodal approach that is

individualized to each patient and will

involve a combination of conservative

measures such as lifestyle changes and

medications which may include one or

more of several options as deemed

appropriate for your situation by your

doctor types of medications used include

antibiotics alpha blockers

anti-inflammatories hormone therapy


plant extracts and pain medications

surgical interventions which can be

minimally invasive to more aggressive

are a very last resort for very select

patients only treatment progresses from

the simplest effective approach to a

more complex or aggressive approach as

necessary remember that there are things

that you can do on your own to relieve

the symptoms and impact of chronic

prostatitis chronic pelvic pain syndrome

these resources on the Internet may help

you find further information or support

about your condition these current

references were also used to assist in

the preparation of this module all of

these are available through your local

medical library or the internet if you

are interested in more detailed reading

on this subject

we sincerely hope that this module has

furthered your understanding of

treatment for chronic prostatitis

chronic pelvic pain syndrome we wish you

the best for the future and thank you

once again for viewing this educational