Management of Chronic Prostatitis and Chronic Pelvic Pain

Educational Objectives

The goal of this program is to improve the management of chronic prostatitis. After hearing and assimilating this program, the clinician will be better able to:

1. Establish the diagnosis of chronic prostatitis.
2. Develop strategies to treat patients with chronic prostatitis.

Summary

Etiology of chronic prostatitis: associated with initiating event, eg, sexually transmitted infection, dysfunctional voiding, sexual assault, trauma; in susceptible individuals, initiating event leads to chronic neuropathic pain syndrome

Impact on quality of life: incidence of prostatitis ≈8% (as defined by symptoms within previous year); significant impact on quality of life reported by 33% of symptomatic men; prevalent throughout world; impact similar to insulin-dependent diabetes, active Crohn disease, and acute myocardial infarction

Evaluation of patient: exclude bacterial infection (absent in 90%); chronic prostatitis symptom index — consists of 9 questions focusing on location, frequency, and severity of pain, symptoms of voiding and storage, and impact on quality of life; completion by patient before interview expedites evaluation

Diagnosis: not established by laboratory testing or imaging; history and physical examination necessary; examine perineum, pelvic floor, and pelvic side walls (noting myofascial tenderness and trigger points); perform digital rectal examination; prostate massage — pushes small amount of prostate fluid into prostatic urethra and urine; performed by rolling examining finger over prostate from base to apex; diagnostic considerations — consider other diagnoses in patients with pain limited to time of ejaculation, symptoms of obstruction, or failure to respond to α-blocking agents; for these patients, proceed with, eg, videourodynamic study, ultrasonography, computed tomography, or magnetic resonance imaging; diagnosis of prostatitis established by overall clinical picture; 6-point symptoms complex (UPOINT) — urinary symptoms; psychosocial parameters; “organcentricity” of symptoms (eg, bladder, prostate); infection (present in 8% to 16%); neurologic or systemic symptoms; tenderness of pelvic floor; consider sexual dysfunction as well

Challenges in treatment: most common symptoms in domains in which urologists lack training (eg, psychosocial domain, neurogenic symptoms, tenderness, irritable bowel syndrome, pelvic floor pain); monotherapy ineffective in 70% of cases; recommended to develop treatment plan based on specific symptoms of each patient; 2010 Canadian guidelines flawed and American Urological Association guidelines nonexistent

Strategies in treatment: individual patient data meta-analysis compared results from trials studying α-blocking agents, antibiotics, anti-inflammatory agents, and placebo; found lack of correlation between effects of therapies on populations with effects on individuals; concluded that treatment should be directed by individual phenotypes; recommended approaches — α-blocking agents for patients with symptoms of obstructed voiding; antimuscarinic agents for patients with symptoms of overactive bladder; antibiotics for infections; physiotherapy and muscle-relaxing agents for patients with pelvic floor symptoms; individualized approach results in significant reduction of pain and urinary symptoms, and improvement in quality of life

Establish goals and expectations: key to successful outcome; perform comprehensive evaluation but avoid excessive investigations); inform patient that cure usually not possible and goals of treatment are amelioration of symptoms and improvement in quality of life

Prostate biome and antibiotics: antibiotics administered for other reasons can exacerbate or improve symptoms of prostatitis; when associated with recurrent urinary tract infections, symptoms improve with antibiotics; infection typically recurs with discontinuation of antibiotics; treatment of acute bacterial prostatitis with antibiotics that fail to penetrate prostate (eg, ampicillin) associated with higher risk for development of chronic bacterial prostatitis

Readings

Franco JV et al: Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev 2018 Jan 26;1:CD012551; Nickel JC et al: Prevalence, diagnosis, characterization, and treatment of prostatitis, interstitial cystitis, and epididymitis in outpatient urological practice: the Canadian PIE Study. Urology 2005 Nov;66(5):935-40.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Nickel was recorded at the 3rd Annual Conference: Practical Urology, presented by the University of Southern California Institute of Urology and held February 1-3, 2018, in Los Angeles, CA. For information on other CME programs from the Keck School of Medicine of USC, please visit usc.edu/cme. The Audio Digest Foundation thanks the speakers and the University of Southern California Institute of Urology for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR411301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.