CPPS data document its impact, but more work is needed

November 1, 2005

Paris--Most cases of chronic pelvic pain syndrome (CPPS) are spontaneous with unknown causes, and more studies are needed on all aspects of the condition, said Anthony Schaeffer, MD, who chaired the Committee on Prostatitis and Chronic Pelvic Pain at the International Consultation on New Developments in Prostate Cancer and Prostate Diseases here.

"We have good data to support the epidemiology and impact of this syndrome. We also have a good way of assessing the symptoms with the Chronic Prostatitis Symptom Index [CPSI] questionnaire. What we don't have is any good diagnostic and, particularly, therapeutic data-that is where a lot of work needs to be done-and the research to understand the pathogenesis," Dr. Schaeffer said.

"The etiology is very poorly defined, but many lifestyle factors are thought to have a role. The impact on patients' quality of life is very substantial and measurable," he pointed out, adding that a National Institutes of Health-sponsored study of a large group of CPPS patients has been helpful in assessing treatment response.

Evaluation and treatment

Evaluation of acute forms of CPPS should be carried out with urinalysis and culture. Ultrasound should only be performed if an abscess is suspected because the patient is not responding to antimicrobial therapy. If chronic bacterial prostatitis is suspected, the Meares-Stamey four-glass test for determining white blood cell counts and bacteria type is the recommended evaluation method, and about 50% of these patients will have an infection, noted Dr. Schaeffer.

"We do not feel that culture of semen is necessary, but it is reasonable in selected men," Dr. Schaeffer told Urology Times.

He told attendees at the consultation that imaging is not recommended except in treatment-refractory patients.

For patients with CPPS, a thorough history and CPSI should be obtained. A physical examination of the prostate and myofacial trigger points should be carried out, and post-voiding residual studies should be considered. Dr. Schaeffer did not recommend cystoscopy, routine imaging, testing for chronic trachomatis, urea plasma, serum PSA, or the potassium chloride sensitivity test. However, immune cell mediators and the histopathology of the prostate should be further evaluated, he said.

Asymptomatic prostatitis does not require evaluation unless PSA and infertility issues are prominent, in which case appropriate testing should be conducted and the patient treated if necessary, Dr. Schaeffer said.

Acute prostatitis patients often require hospitalization with wide-spectrum antimicrobial medications and bladder drainage, if necessary. There is good evidence supporting the use of aminoglycosides with ampicillin or broad-spectrum penicillin with a beta-lactamase inhibitor for 2 to 4 weeks. A third-generation cephalosporin or fluoroquinolone should be used until urosepsis levels return to normal.

Fluoroquinolones, given orally for 4 to 6 weeks, is a very effective therapy for patients with chronic bacterial prostatitis. It has a cure rate of up to 90%, Dr. Schaeffer said. A good second choice is trimethoprim-sulfamethoxazole (Bactrim, Septra, et al), he said.

The treatment of patients with refractory chronic bacterial prostatitis is poorly supported by evidence, but Dr. Schaeffer recommends intermittent therapy when men are symptomatic. Alternative treatments include low-dose antimicrobial suppression and transurethral resection of the prostate, or simple prostatectomy, if no other options are available.

Alpha-blockers are the best-supported initial treatments for CPPS, but should be discontinued if there is no response, said Dr. Schaeffer. Antimicrobial therapy is controversial in these patients, but a short course could be tried, he suggested, adding that 5-alpha-reductase inhibitor monotherapy and anti-inflammatory monotherapy are not recommended.

A number of other treatments for CPPS patients require further study, including physical therapy, acupuncture, and the antifungal mepartricin, he said.