In the concluding part in our series on chronic pelvic pain and chronic prostatitis, the authors look at issues around diagnosis and management, as well as considering the role of the GP
Dr Jonathon Rees. GP with special interest in Urology, Backwell & Nailsea Medical Group
Dr Alison Cooper, Prostate Cancer UK, On behalf of the Prostatitis Expert Reference Group, Prostate Cancer UK
NM, a 48 year old salesman presented to his GP with a one-year history of recurrent episodes of pain, felt in the perineum and at the tip of the penis during and for some time after passing urine. In addition, he experienced significant discomfort on ejaculation and, at the times of more severe symptoms, increased urine frequency and urgency.
As a result of these symptoms, he was becoming increasingly low in mood. He also noticed that symptoms would often flare up during times of fatigue or stress.
In the previous article we looked at the challenges around classification and assessment within a primary care setting. The following article will consider issues around diagnosis and management as well as onward referral.
The official definition of CP/CPPS requires men to have had symptoms for at least three of the preceding six months. However, in many men, typical symptoms will suggest this diagnosis far earlier in the condition, allowing early initiation of a symptom-based approach to treatment.1 There is no gold standard for a definitive diagnosis of CP/CPPS; instead, it is typically based on the history and the exclusion of other causes.
Treatment of CP/CPPS is difficult, but not impossible.
When the condition is suspected, it is vital that time spent discussing the diagnosis with the patient and understanding their individual symptom patterns and concerns, as this will be important in targeting appropriate therapies.
Probably the most common management strategy in primary care is the provision of recurrent courses of antibiotics, and simple pain relief, with referral to secondary care if unsuccessful. However, understanding the four main symptom domains, and taking a symptom-based approach to treatment, allows for a more holistic approach to treating this condition in primary care, hopefully improving outcomes for the patient, as well as potentially reducing unnecessary referral to secondary care. A suggested treatment algorithm is shown in Figure 1, which can be used in primary care to aid treatment decisions.1
Despite the frequent use of antibiotics in the treatment of patients with CP/CPPS, the evidence base for their use is relatively weak. However, antimicrobial therapy may have a moderate effect on pain, urinary symptoms and quality of life in CP/CPPS and should be considered as an initial treatment option.1 For early-stage CP/CPPS patients, it is usually worth a trial of a quinolone (eg, ciprofloxacin 500mg bd) for four to six weeks as first-line therapy. Even in the absence of proven infection, a minority of patients will show a significant response to this treatment. A repeated course of antibiotic therapy should only be offered if a bacterial cause is confirmed or there is a history of repeated UTI. If a bacterial cause is excluded and no patient symptom improvement is observed afterantibiotics, a different treatment modality, or referral to specialist care, should be considered. Although recurrent courses of antibiotics can have some impact on symptoms, it is likely this is more due to a placebo effect or the anti-inflammatory effect of antibiotics, than through anti-microbial activity.
If voiding LUTS are present (eg, slow flow, hesitancy etc.) then treatment with an alpha blocker (eg, tamsulosin 400μg od) may help. Pain should initially be treated with simple analgesics (eg, paracetamol), with or without a non-steroidal antiinflammatory (eg, naproxen). If symptoms persist despite this initial approach, it is suggested that treatment is targeted at individual symptom domains, as detailed in Figure 1.1
The majority of GPs will not treat men with chronic prostatitis on a regular basis, and may therefore require specialist help, particularly when the patient has severe symptoms, where there is significant diagnostic uncertainty, when symptoms fail to respond to initial management or when the patient has high levels of anxiety about his condition that may only be eased by specialist involvement. It is vital that, wherever possible, referral is made to a specialist with an interest in this condition, whether that be a urologist, pain physician or a sexual health specialist.1 This will allow involvement of a multi-disciplinary team that may also include specialist physiotherapists and pain psychologists.
The secondary care team will aim to optimise analgesic and anti-neuropathic medications, as well as more specialist therapies such as surgical pain interventions (eg, nerve block procedures), pain management strategies, as well as specialist physiotherapy which may include pelvic floor re-education, biofeedback, bladder retraining and a number of other techniques.1
A number of surgical techniques, including massage of the prostate under general anaesthetic, have been tried for men with CP/CPPS, but there is little evidence to support their use.1
Initial assessment in primary care did not detect any abnormalities – NM was reassured regarding the possibility of prostate cancer, which had been worrying him. He was initially treated with a course of ciprofloxacin and tamsulosin, which saw a marginal improvement in his symptoms.
However, the addition of amitriptyline, taken at night, saw a marked improvement in pain and anxiety, and enabled him to manage his symptoms with far less impact on his quality of life. Further flares were treated with a nn-steroidal anti-inflammatory. NM began to have a greater understanding of the nature of his condition and to accept that for the short to medium term, management was about controlling symptoms rather than seeking resolution.
CP/CPPS can present with a variety of symptoms which have led to under-diagnosis in primary care. Once recognised, initial assessment and management is relatively simple, but many men with symptoms that are difficult to treat will benefit from early specialist involvement.
1 Prostate Cancer UK. Diagnosis and treatment of chronic bacterial prostatitis and chronical prostatitis/chronic pelvic pain syndrome: a consensus guideline [Internet]. 2014. Available from: http://prostatecanceruk.org/prostatitisguideline