Chronic nonbacterial prostatitis (chronic pelvic pain syndrome)

Current options for dealing with the most common form of prostatitis

Chronic nonbacterial prostatitis (also known as chronic pelvic pain syndrome) is an all-too-common male genitourinary condition characterized by episodes of pain and discomfort that come and go unpredictably. It may also involve inflammation and difficulties with urination. Although not life-threatening, chronic pelvic pain syndrome has the power to stop a sufferer dead in his tracks — degrading the quality of his personal and work lives and leaving him confounded and depressed.

Of the four categories of prostatitis defined by the National Institutes of Health (see Table 1), chronic pelvic pain syndrome is most common, accounting for about 90% of all cases. It’s also notorious for being the most difficult type of prostatitis to live with. A major difficulty is that in most instances, doctors are unable to definitively diagnose the condition and confidently identify a causative agent. Not surprisingly, with so little to go on, treatment is empiric — guided by a doctor’s clinical experience and instincts rather than hard evidence of what actually works. When they have prescribed standard treatments only to have patients experience little or merely temporary relief, many practitioners don’t know what to do next for chronic pelvic pain syndrome, other than to keep cycling through the same standard treatment options.

Many men with this syndrome resort to fending for themselves as they move from doctor to doctor and from one online chat group to another in the hope that someone will be able to help them (for example, see “A patient’s story”). But a recent wave of rigorous research is shedding light on nuances of chronic pelvic pain syndrome and suggesting more effective ways to manage it.

Diagnosing chronic pelvic pain syndrome

Chronic pelvic pain syndrome causes three types of symptoms: pain (including pain upon urination), urinary “voiding” difficulties, and sexual dysfunction. Of course, some of these symptoms may also occur in other urologic disorders, such as benign prostatic hyperplasia (BPH). Pain, however, is the predominant feature of chronic pelvic pain syndrome — and that usually helps your doctor to differentiate it from BPH (see Table 2). If you experience painful or burning urination or pain in the pelvic area, your doctor will look for signs of inflammation and infection by performing a digital rectal examination, getting a urine sample, and perhaps testing your prostate’s secretions.

Your doctor should also do a simple urine test to check for bacteria and excessive white blood cells, which indicate an infection. If urinalysis reveals bacteria and white blood cells, your condition is probably a bacterial form of prostatitis. If only white blood cells are discovered, as is usually the case, you may have one of the nonbacterial forms of prostatitis. Most bacteria that are found probably come from the gastrointestinal tract or bowel. Some doctors also perform a more complex urinalysis (see “Meares-Stamey test”).

Why the condition develops

Many researchers now believe that chronic pelvic pain syndrome develops after a complex series of interconnected events that somehow build on one another, giving rise to the signature symptoms of genitourinary and pelvic pain and urologic and ejaculatory dysfunction.

The initiating event may be an undetectable infectious agent or a physical trauma that causes inflammation or nerve damage in the genitourinary area. Over time this causes damage to organs and tissues in the area — bladder, ligaments, pelvic floor muscles, and so forth — that takes on a life of its own in susceptible individuals. If not controlled quickly enough, this damage and the body’s response to it can lead to a heightened sensitivity of the nervous system. In other words, for some men with chronic pelvic pain syndrome, the pain sensitivity “switch” more readily flicks to the “on” position. Stress and tension can exacerbate this response.

Reassessing the “three A’s” of treatment

During the past several years, researchers have begun testing and evaluating the traditional treatments of chronic pelvic pain syndrome, known collectively as the “three A’s”: antibiotics, anti-inflammatory medications, and alpha blockers. For more information about the science behind these recommendations, see “Evaluating the evidence.”

Antibiotics

The use of antibiotics — medications that eradicate bacterial infections — remains controversial. For starters, only a very small percentage of men with chronic pelvic pain syndrome test positive for bacterial infection. This suggests that antibiotics would not be effective for most men. Randomized clinical trials bear this out.

Some researchers argue, however, that a negative test for bacteria doesn’t mean bacteria aren’t present. The best explanation for why this might be so is that bacteria can be present in the glands or stroma (connective tissue) of the prostate without entering into the urine. Another is that the bacteria can’t be detected with current methods. To further complicate matters, although a positive test indicates bacteria are present, it doesn’t necessarily mean that bacteria are the cause of that individual’s prostatitis. Where do these uncertainties leave men affected with the condition?

At the time of diagnosis, even when a culture does not reveal bacteria, most researchers still recommend that men newly diagnosed with chronic pelvic pain syndrome take an antibiotic for a limited time, lasting not more than four weeks. This strategy may help some men even when their symptoms are not caused by a bacterial infection, but rather by inflammation. Some antibiotics have anti-inflammatory properties, yet work in a different way from nonsteroidal anti-inflammatory drugs (NSAIDs).

But repeat courses of antibiotics are probably not helpful. Although antibiotics have few side effects, they are not completely without risk. They can cause problems such as nausea and diarrhea, and interfere with medications for other conditions. Use of quinolone antibiotics — the type prescribed for chronic pelvic pain syndrome — increases the chance of suffering an Achilles’ tendon rupture, for reasons that are not completely understood.

Anti-inflammatory medications

Anti-inflammatory medications, notably aspirin or NSAIDs such as ibuprofen, help some men cope with the pain of chronic pelvic pain syndrome. Yet there is no evidence that these medications are helpful on their own.

In 2004, a paper published in BJU International, which reviewed a number of studies, found only one controlled study to support the use of NSAIDs as a primary treatment for chronic pelvic pain syndrome. Most doctors agree that if NSAIDs are used, they should be used for a limited period of time, to control pain, and preferably in combination with another medication, such as an alpha blocker, that may actually address an underlying problem in chronic pelvic pain syndrome.

Alpha blockers

Alpha blockers are used primarily to treat BPH. However, they may also be prescribed for chronic pelvic pain syndrome because they relax muscles in the urinary tract, allowing urine to flow more freely — and thus alleviating urinary dysfunction. The research indicates that these medications are not only effective treatments for chronic pelvic pain syndrome, but should be used more often, and in a more targeted way, for greater effect. (For more information, see “Reviewing the evidence about alpha blockers.”)

For example, a 2007 review published in Urologia Internationalis looked at 10 studies of alpha-blocker therapy. The authors concluded that men who were newly diagnosed with chronic pelvic pain syndrome were more likely to respond to alpha blockers than were men who’d been dealing with the condition for years. They also concluded that an extended course of treatment (three to six months) was more effective than a shorter course. And less selective alpha blockers were more effective than the more selective agents. (See Table 3 for a list of alpha blockers and how they work in the body.)

But these are not magic bullets, and some studies have indicated that the more selective agents are also effective. A 2003 paper in Urology reported that the benefits gained by taking alfuzosin (Uroxatral) required a treatment course of several months’ duration, but that these benefits disappeared when treatment stopped. A 2004 study in Urology indicated that terazosin (Hytrin) provided both initial and long-lasting relief. A 2004 study in the Journal of Urology reported that a six-week course of tamsulosin (Flomax) relieved the symptoms of men with moderate-to-severe chronic pelvic pain syndrome more effectively than those of men with mild symptoms.

Another study compared a placebo and the alpha blocker tamsulosin, with or without the antibiotic ciprofloxacin (Cipro). In contrast to the three studies just cited, this trial found no benefit from the alpha blocker — in fact, none of the treatments seemed to work. A possible explanation may have been the inclusion of men with very long-term symptoms, who had previously undergone several rounds of treatments, including alpha-blocker treatments.

Our Harvard expert thinks alfuzosin is probably the most effective alpha blocker to use. A study currently under way is evaluating the use of alfuzosin in men who have been recently diagnosed with chronic pelvic pain syndrome and who have not previously received alpha-blocker treatment. The hope is that this study will shed more light on which subset of men would benefit most from this alpha blocker, and will help determine the optimal duration of treatment.

Other treatments

Few other treatments have proved effective. The 5-alpha-reductase inhibitor finasteride (Proscar), for example, gets only mixed reviews. One randomized controlled study suggested that this drug could reduce some symptoms of chronic pelvic pain syndrome, but not the signature symptom of pain. Another study found that finasteride was not much more effective than a placebo.

One small study has suggested that quercetin, a bioflavonoid (a chemical that contributes to color in plants), may be effective. Acupuncture and biofeedback may be helpful in some cases, but further research is needed to say for sure.

Unfortunately, the list of therapies that don’t appear to provide significant relief is lengthy, and includes rofecoxib (Vioxx), gabapentin (Neurontin), muscle relaxants, corticosteroids, allopurinol, and two complementary therapies, saw palmetto and cernilton, a pollen extract.

Treatments under investigation

Given the limited number and effectiveness of treatments for chronic pelvic pain syndrome, scientists continue to search for more therapies.

The Stanford Protocol

One approach gaining a lot of attention is the Stanford Protocol, developed by urologists at Stanford University who think chronic pelvic pain syndrome develops not because of infection, but because chronic tension wreaks havoc on pelvic floor muscles and sets in motion a cycle of anxiety and pain.

The Stanford Protocol involves two major components: a specialized type of physical therapy to release so-called trigger points (specific areas that trigger pain) in pelvic floor muscles, and instruction in “paradoxical” relaxation techniques (educating men to accept their tension in order to release it). The goal is to train men to self-administer the protocol and eliminate the need for additional treatments to relieve their symptoms.

The Stanford team reports that this specialized protocol moderately improves pelvic pain, urinary symptoms, libido, ejaculatory pain, and erectile and ejaculatory dysfunction (see “For more information: The Stanford Protocol”). Our Harvard expert says some of his patients report they have been helped by this therapy. Just keep in mind that the studies are preliminary and this technique is still considered investigational.

Botulinum toxin A

Another therapy under investigation is botulinum toxin A, the active ingredient in Botox, a treatment for facial wrinkles. This therapy is of interest because botulinum toxin A works by temporarily paralyzing injected muscles, and by preventing painful muscle spasms. A preliminary study found that symptoms improved in more than half of 78 men with chronic pelvic pain syndrome who received botulinum toxin A injections in the pelvic area, and that results lasted from 6 to 18 months.

Be persistent

Chronic pelvic pain syndrome develops for a number of reasons — and each likely requires a different management strategy. There is no single cure-all for this condition.

It’s important to keep abreast of research and work with your doctor to find an individualized treatment plan. And if your doctor seems reluctant to work with you, find another doctor. Life is too short to put up with so much pain.