William Aiken

Chronic prostatitis (CP)/ chronic pelvic pain syndrome (CPPS) is a poorly understood chronic genitourinary condition afflicting men. It is characterised by varying degrees of pain (arising from the genitourinary organs) for at least three months and the pain is not related to infection on standard tests.

The pain is usually accompanied by varying degrees of urinary and/or sexual symptoms. It may be felt in the lower abdomen, penis, testicles, perineum, rectum and lower back. There may be associated urinary symptoms such as urgency and/or frequency of urination. Burning on passing urine may also be experienced, especially close to the end of the urinary stream. Blood in the urine may be seen, again usually at the end of the stream. On occasion, sexual dysfunction may accompany the pain during or after ejaculation, sometimes with blood in the semen. Some men may also complain about premature ejaculation during flare-ups of the CP/CPPS.

Possible infection

Several factors are believed responsible for initiating CP/ CPPS. The process may start with an infection of the prostate gland, reflux of urine into the prostate, repeated trauma of the prostate and muscular spasm of the surrounding pelvic muscles. Regardless of the triggering event, inflammation within the prostate activates and sensitises the nerves which supply it. This causes further muscle spasms stimulating further pain thereby establishing a vicious self-perpetuating cycle of pain. This cycle is difficult to break, partly because of changes which take place within the pain pathways of the brain and spinal cord.

Chronic prostatitis may be differentiated from CPPS by finding many inflammatory cells in prostatic secretions expressed from the prostate whereas none or few is present in the non-inflammatory condition, CPPS. This differentiation is largely academic, however, as the symptoms and responses of these two conditions to treatment are identical. An objective assessment of symptom severity and the extent to which it affects quality of life can be ascertained using a validated symptom severity questionnaire called the NIH - Chronic Prostatitis Symptom Index. This provides a symptom score which may be used to monitor the effect of treatment.

Although no germs are usually identified in this condition, up to 40 to 50 per cent of persons suffering from CP/CPPS may nevertheless positively respond to treatment with an appropriate (fluoroquinolone) antibiotic given for at least one month. Failure to respond suggests that no further antibiotics are warranted. Drugs to relax the muscles of the prostate, called alpha-blockers (ABs) are very useful in relieving the symptoms of CP / CPPS.

In men who have been previously treated with ABs without a response, further treatment with these drugs is unwarranted. Anti-inflammatory drugs called non-steroidal anti-inflammatory drugs (NSAIDs) have been traditionally used as a component of treatment of CP/CPPS as it made intuitive sense. Recent well conducted trials have however not shown this class of drug helpful in relieving the symptoms of CP / CPPS.

Relax the muscles

Another class of drugs which relax the muscles of the pelvic floor surrounding the prostate as well as modulate pain of nerve origin is thought to be helpful in treating CP/CPPS but the outcome of rigorous studies evaluating their efficacy in this area are eagerly awaited. In the meantime, it is reasonable to use this class of drugs which include valium, amitriptyline and neurontin to name a few. Other therapies, some novel and some which have been around for a long time, including alternative therapies are currently under investigation to determine their efficacy in treating this condition.

Men suffering from this condition must understand the recurrent nature of this disease which is characterised by relapses interspersed with varying periods of relief,sometimes lasting a short time, while on other occasions relatively short-lived.