Common Questions About Chronic Prostatitis

 

Am Fam Physician. 2016 Feb 15;93(4):290-296.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/prostatitis.html.

  Related letter: Exercise Is Effective Therapy for Chronic Nonbacterial Prostatitis and Chronic Pelvic Pain Syndrome

Author disclosure: No relevant financial affiliations.

Chronic prostatitis is relatively common, with a lifetime prevalence of 1.8% to 8.2%. Risk factors include conditions that facilitate introduction of bacteria into the urethra and prostate (which also predispose the patient to urinary tract infections) and conditions that can lead to chronic neuropathic pain. Chronic prostatitis must be differentiated from other causes of chronic pelvic pain, such as interstitial cystitis/bladder pain syndrome and pelvic floor dysfunction; prostate and bladder cancers; benign prostatic hyperplasia; urolithiasis; and other causes of dysuria, urinary frequency, and nocturia. The National Institutes of Health divides prostatitis into four syndromes: acute bacterial prostatitis, chronic bacterial prostatitis (CBP), chronic nonbacterial prostatitis (CNP)/chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis. CBP and CNP/CPPS both lead to pelvic pain and lower urinary tract symptoms. CBP presents as recurrent urinary tract infections with the same organism identified on repeated cultures; it responds to a prolonged course of an antibiotic that adequately penetrates the prostate, if the urine culture suggests sensitivity. If four to six weeks of antibiotic therapy is effective but symptoms recur, another course may be prescribed, perhaps in combination with alpha blockers or nonopioid analgesics. CNP/CPPS, accounting for more than 90% of chronic prostatitis cases, presents as prostatic pain lasting at least three months without consistent culture results. Weak evidence supports the use of alpha blockers, pain medications, and a four- to six-week course of antibiotics for the treatment of CNP/CPPS. Patients may also be referred to a psychologist experienced in managing chronic pain. Experts on this condition recommend a combination of treatments tailored to the patient's phenotypic presentation. Urology referral should be considered when appropriate treatment is ineffective. Additional treatments include pelvic floor physical therapy, phytotherapy, and pain management techniques. The UPOINT (urinary, psychosocial, organ-specific, infection, neurologic/systemic, tenderness) approach summarizes the various factors that may contribute to presentation and can guide treatment.

Lifetime prevalence of chronic prostatitis ranges from 1.8% to 8.2%,1,2 and may be even higher.3 This article provides answers to common questions about the chronic, symptomatic subtypes using the best evidence available.

What Is Chronic Prostatitis?

The National Institutes of Health (NIH) classifies prostatitis into four syndromes (Table 1).4 The chronic, symptomatic forms are chronic bacterial prostatitis (CBP) and chronic nonbacterial prostatitis (CNP), also called chronic pelvic pain syndrome (CPPS).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Chronic prostatitis should be considered in men with persistent pain associated with urination or ejaculation, or lower urinary tract symptoms related to voiding or storage.

C

3

CBP is recognized by multiple urine cultures positive for the same organism. These cultures can be from post-prostatic massage urine, midstream clean-catch urine, or prostate secretions.

C

5

CNP/CPPS presents similarly to CBP, but it is much more common and urine culture results are negative or inconsistent.

C

3, 5

CBP should be treated with a 4- to 6-week course of a fluoroquinolone antibiotic (preferably levofloxacin [Levaquin], but a macrolide can be used if chlamydia is suspected), and pain medication. If the patient responds, but then relapses, a second 4- to 6-week course of an antibiotic plus an alpha blocker should be considered.

B

3, 11, 14

CNP/CPPS should be treated for 4 to 6 weeks, preferably with an alpha blocker, antibiotic, and pain medication.

C

21

If CBP or CNP/CPPS does not improve significantly with initial treatment, the patient should be referred to a urologist.

C

3


CBP = chronic bacterial prostatitis; CNP = chronic nonbacterial prostatitis; CPPS = chronic pelvic pain syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

The Authors

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JAMES D. HOLT, MD, is associate program director for the Johnson City Family Medicine Residency and is a professor of family medicine and geriatrics at the East Tennessee State University Quillen College of Medicine in Johnson City....

W. ALLAN GARRETT, MD, is clerkship director of the Johnson City Family Medicine Residency Program and is an assistant professor of family medicine at the East Tennessee State University Quillen College of Medicine.

TYLER K. McCURRY, DO, is a third-year resident in the Johnson City Family Medicine Residency at the East Tennessee State University Quillen College of Medicine.

JOEL M.H. TEICHMAN, MD, is a professor of urologic sciences at the University of British Columbia in Vancouver, Canada, and is a staff urologist at St. Paul's Hospital in Vancouver.

The authors thank the medical librarians at the East Tennessee State University Quillen College of Medicine, particularly Sharon Brown, MLS, and Rick Wallace, MPH, MSLS, for their assistance with the literature search.

Address correspondence to James D. Holt, MD, ETSU Johnson City Family Medicine Residency Program, 917 West Walnut St., Johnson City, TN 37604 (e-mail: holtj@mail.etsu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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2. Krieger JN, Lee SW, Jeon J, Cheah PY, Liong ML, Riley DE. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008;31(suppl 1):S85–S90.

3. Rees J, Abrahams M, Doble A, Cooper A; Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015;116(4):509–525.

4. Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236–237.

5. Nickel JC, Shoskes D, Wang Y, et al. How does the pre-massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119–124.

6. Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010;82(4):397–406.

7. Nickel JC, Alexander RB, Schaeffer AJ, Landis JR, Knauss JS, Propert KJ; Chronic Prostatitis Collaborative Research Network Study Group. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol. 2003;170(3):818–822.

8. Landis JR, Williams DA, Lucia MS, et al. The MAPP research network: design, patient characterization and operations [published ahead of print August 1, 2014]. BMC Urol. http://www.biomedcentral.com/1471-2490/14/58. Accessed September 28, 2015.

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11. Zhang ZC, Jin FS, Liu DM, Shen ZJ, Sun YH, Guo YL. Safety and efficacy of levofloxacin versus ciprofloxacin for the treatment of chronic bacterial prostatitis in Chinese patients. Asian J Androl. 2012;14(6):870–874.

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15. Cunha BA, Gran A, Raza M. Persistent extended-spectrum β-lactamase-positive Escherichia coli chronic prostatitis successfully treated with a combination of fosfomycin and doxycycline. Int J Antimicrob Agents. 2015;45(4):427–429.

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18. National Institute for Health and Care Excellence. Neuropathic pain—pharmacological management. November 2013. https://www.nice.org.uk/guidance/cg173. Accessed September 26, 2014.

19. Chronic prostatitis. DynaMed. Updated Nov 7, 2013. http://www.dynamed.com.iris.etsu.edu:2048/topics/dmp~AN~T115325/Chronic-prostatitis-Chronic-pelvic-pain-syndrome [subscription required]. Accessed January 16, 2015.

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