Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicenter, randomized, placebo controlled study

Intravesical instillation of platelet-rich plasma for treatment of interstitial cystitis/bladder pain syndrome: A pilot study

Objective

The aim of this study was to evaluate the feasibility of intravesical instillation of platelet-rich plasma (PRP) to treat interstitial cystitis/bladder pain syndrome (IC/BPS).

Materials and methods

Twenty PRP samples were tested in vitro for stability after exposure to urine samples with different pH. A pilot study involving 21 female patients with IC/BPS was conducted, and 6 weekly doses of autologous PRP (50 mL) were administered. Patients were followed up at the 2nd, 4th, 8th, and 12th weeks after terminating instillation. The primary endpoint was the visual analog scale (VAS) for pain, and the secondary endpoints included the IC symptom index, IC problem index of the O'Leary-Sant questionnaire and global response assessment, urine culture, and uroflowmetry. Success was defined as a reduction in VAS by 30% or more compared with basal level, and adverse events were recorded.

Results

The mean ± SD of VAS was significantly reduced compared with basal level (4.4 ± 2.6 vs. 8.8 ± 1.1, respectively, p = 0.001). Meanwhile, 80% of cases were considered successful, with a 50.1% reduction in the mean score compared with the basal level. The mean ± SD of IC symptom index and IC problem index significantly improved compared with the basal level. Global response assessment was markedly, moderately, and slightly improved in 2 (10%), 10 (50%), and 5 (25%) patients, respectively, and showed no change in 3 (15%). Three patients had positive urine cultures at follow-up, but 1 withdrew after 2 sessions because of a lack of efficacy.

Conclusions

Repeated intravesical instillation of PRP could be considered an effective and safe approach for treating IC/BPS.

Pentosan Polysulfate Affords Pleotropic Protection to Multiple Cells and Tissues

Pentosan polysulfate (PPS), a small semi-synthetic highly sulfated heparan sulfate (HS)-like molecule, shares many of the interactive properties of HS. The aim of this review was to outline the potential of PPS as an interventional therapeutic protective agent in physiological processes affecting pathological tissues. PPS is a multifunctional molecule with diverse therapeutic actions against many disease processes. PPS has been used for decades in the treatment of interstitial cystitis and painful bowel disease, it has tissue-protective properties as a protease inhibitor in cartilage, tendon and IVD, and it has been used as a cell-directive component in bioscaffolds in tissue engineering applications. PPS regulates complement activation, coagulation, fibrinolysis and thrombocytopenia, and it promotes the synthesis of hyaluronan. Nerve growth factor production in osteocytes is inhibited by PPS, reducing bone pain in osteoarthritis and rheumatoid arthritis (OA/RA). PPS also removes fatty compounds from lipid-engorged subchondral blood vessels in OA/RA cartilage, reducing joint pain. PPS regulates cytokine and inflammatory mediator production and is also an anti-tumor agent that promotes the proliferation and differentiation of mesenchymal stem cells and the development of progenitor cell lineages that have proven to be useful in strategies designed to effect repair of the degenerate intervertebral disc (IVD) and OA cartilage. PPS stimulates proteoglycan synthesis by chondrocytes in the presence or absence of interleukin (IL)-1, and stimulates hyaluronan production by synoviocytes. PPS is thus a multifunctional tissue-protective molecule of potential therapeutic application for a diverse range of disease processes.

Pentosan Polysulfate-Associated Dysplasia in Patients with Inflammatory Bowel Disease: A Case Series

OBJECTIVES

This study evaluates the potential association of pentosan polysulfate (PPS) with inflammatory bowel disease (IBD) or dysplasia.

METHODS

We searched electronic medical records to identify patients with IBD using PPS.

RESULTS

10 of 30 identified patients (33.3%) had colonic dysplasia. Six of these (60%) underwent colectomy for endoscopically unresectable dysplasia. Three (10%) discontinued PPS, each with apparent benefit.

CONCLUSIONS

Patients with IBD at two institutions who had taken PPS had high rates of colonic dysplasia leading to surgery. Patients who stopped PPS showed improvement in their colitis. PPS may play a causal role in the development of colitis and dysplasia.

Oral pharmacological treatments for chronic prostatitis/chronic pelvic pain syndrome: A systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Pharmacological treatments for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are empirically used. However, the quantitative comparative effectiveness and safety of multiple pharmacological treatments is lacking.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to March 22, 2022. Randomised controlled trials comparing two or more oral pharmacological treatments for patients with CP/CPPS were included. Title, abstract, and full-text screening were independently screened by four reviewers. Primary outcomes were efficacy (the National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI] total score, pain score, urinary score, and quality of life score [QoL]) and safety (adverse events). This study was registered with PROSPERO, CRD42020184106.

FINDINGS

25 studies (3514 patients) assessed 26 treatments. Low to very low quality evidence indicated that doxazosin (Mean difference [MD], -11.4, 95% Credible interval [CrI], -17.5 to -5.1) and the doxazosin, ibuprofen, and thiocolchicoside combination (MD, -11.6, CrI, -18.1 to -5.3) were significantly more effective than placebo in the NIH-CPSI total score. Other NIH-CPSI relative outcomes (pain, urinary, and QoL scores) showed a similar pattern. Low and very low quality evidence suggested that combination treatment including doxazosin, ibuprofen, and thiocolchicoside (odds ratios [OR], 3.2, CrI, 0.5 to 19.3) and the tamsulosin and dapoxetine combination (OR, 6.0, CrI, 0.7 to 67.3) caused more adverse events. In half of all comparisons regarding NIH-CPSI pain scores and quality of life scores, heterogeneity was minimal or low. Heterogeneity was high in both NIH-CPSI total symptom scores (I²  = 78.0%) and pain scores (I²  = 87. 0%) for tamsulosin versus placebo. There was also high heterogeneity in NIH-CPSI urine scores for the combination of tamsulosin and ciprofloxacin versus tamsulosin (I²  = 66.8%), tamsulosin and levofloxacin versus tamsulosin (I²  = 93.3%), and tamsulosin versus placebo (I²  = 83%).

INTERPRETATION

Pharmacological treatments have little evidence supporting efficacy in CP/CPPS. Future studies could personalise therapy for individuals according to specific symptoms and identify non-pharmacological targets for CP/CPPS.

FUNDING

Dr Jiani Wu received funding for this project from the China Association for Science and Technology (2017QNRC001), the China Academy of Chinese Medical Sciences (ZZ13-YQ-027), and the National Natural Science Foundation of China (82105037).

Efficacy and safety of oral pharmacological and supplementary therapies in bladder pain syndrome: a systematic review

Treatment goals in bladder pain syndrome (BPS) or interstitial cystitis (IC) focusing on relieving symptoms to improve quality of life and avoiding adverse events (AEs) since curative treatment for BPS/IC is not available. The readily available pharmacologic options for BPS/IC including oral, intravesical, and transdermal therapy. The purpose of this study is to review randomized trial studies over the last 15 years examining the efficacy and safety of oral pharmacological and supplementary therapies for BPS/IC. A systematic search was conducted in PubMed and Medline Library. Only randomized-controlled trials and randomized comparative trials published between 2005 and 2020 on the efficacy and safety of oral therapies for BPS/IC were included. The keywords used were “bladder pain syndrome”, or “interstitial cystitis”, and “random” or “trial”. From 629 articles, nine were included in this review. Oral therapies included consist of cyclosporine A (CyA), amitriptyline, amitriptyline plus alpha lipoic acid (ALA) and omega-3 fatty acids (n-3 PUFA), PD-0299685, sildenafil, pentosan polysulfate sodium (PPS), AQX-1125, and hydrogen-rich water. Among retrieved trials, amitriptyline in combination with ALA and n-3 PUFA, sildenafil, and cyclosporine A proved their efficacy for BPS/IC. Sildenafil was generally well tolerated, while amitriptyline and CyA must be used with caution, the supplementation of ALA/n-3 PUFAs possibly lower dosage of amitriptyline, subsequently reduce its AEs. CyA was superior to PPS but possessed greater AEs. Further studies focusing on etiopathology and phenotype differentiation of this syndrome will greatly contribute to the development of effective therapy.

A systematic review and meta-analysis of placebo effect in clinical trials on chronic prostatitis/chronic pelvic pain syndrome

BACKGROUND

It is a common practice to control efficacy of pharmacological treatment with a placebo group. However, placebo itself may affect subjective and even objective results. The purpose of this study was to evaluate the placebo effect on symptoms of CP/CPPS to improve future clinical trials.

METHODS

A search at three databases (Scopus, MEDLINE, and Web of Science) was conducted to identify double-blind placebo-controlled clinical trials on the treatment of CP/CPPS published until April 2021. The primary outcome - National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score.

SECONDARY OUTCOMES

Qmax, PVR, IPSS, and prostate volume.

RESULTS

A total of 3502 studies were identified. Placebo arms of 42 articles (5512 patients, median 31 patients) were included in the systematic review. Systematic review identified positive changes in the primary endpoint, meta-analysis of 10 articles found that NIH-CPSI total score results were significantly influenced by placebo, mean difference -4.2 (95% confidence interval [CI]: -6.31, -2.09). Mean difference of NIH-CPSI pain domain was -2.31 (95% CI: -3.4, -1.21), urinary domain -1.12 (95% CI: -1.62, -0.62), quality of life domain -1.67 (95% CI: -2.38, -0.96); p < 0.001 for all. In case of the objective indicator - Qmax, there were three articles included in the meta-analysis. Qmax mean change from baseline was 0.68 (95% CI: -0.85, 2.22, p = 0.38). Systematic review showed no significant changes in pain, measured by VAS or other scores, IPSS and PVR.

CONCLUSIONS

Placebo significantly affected the subjective parameters (NIH-CPSI) and limitedly affected various other measurements of pain (visual analog scale, McGill pain questionnaire). There was no long-term effect on IPSS and objective measurements (Qmax, PVR). This study can be used in further clinical trials to develop general rules of CPPS treatment assessment.

Therapeutic interventions to urologic chronic pelvic pain syndrome and UPOINT system for clinical phenotyping: How far are we?

The assessment and management of urologic chronic pelvic pain syndrome (UCPPS), is controversial. It is classified by voiding symptoms, pelvic pain, and bladder pain, which is weekly treated, weekly understood, and bothersome. In the aspect of clinical efforts and research to help people with this syndrome have been hampered by the deficiency of a widely reliable, accepted, and a valuable tool to evaluate the patient symptoms and quality of life (QoL) impact. However, the etiology comes into sight is multifactorial, and available treatment options have been imprecise considerably in present years. We compiled the published literature on the assessment of the syndrome, a tentative role of pharmacological and non-pharmacological (conservative, alternative, and invasive therapy) interventions in eradicating the disease as well as improving symptoms. The previously published literature on animal models has established the association of immune systems in the etiology, pathogenesis, and progression of the disease. The UPOINT system for clinical phenotyping of UCPPS patients has six predefined domains that direct multimodal therapy, which would lead to significant symptom improvement in the medical field. The narrative review aims to scrutinize the fluctuating scientist's views on the evaluation of patient and multimodal treatment of the UPOINT system.

Poria cocos polysaccharides attenuate chronic nonbacterial prostatitis by targeting the gut microbiota: Comparative study of Poria cocos polysaccharides and finasteride in treating chronic prostatitis

Finasteride is an antiandrogenic drug used for the clinical treatment of chronic nonbacterial prostatitis (CNP). Recently, we reported the anti-CNP activity of Poria cocos polysaccharides (PPs) in a rat model. In this study, we compared the differences between PPs and finasteride in treating CNP, especially their effects on the gut microbiota. Results showed that both PPs and finasteride significantly reduced the prostate weight and prostate index of CNP rats, and improved the histological damages in the inflamed prostate. Moreover, PPs and finasteride inhibited the production of pro-inflammatory cytokines (TNF-α, IL-2 and IL-8) and androgens (dihydrotestosterone and testosterone). By 16S rDNA sequencing, PPs and finasteride were found to reprogram the gut microbiota into distinct profiles. Further analysis presented that PPs but not finasteride recovered CNP-induced changes in the gut microbiota, including Ruminococcaceae NK4A214 group, uncultured bacterium f Ruminococcaceae, Ruminiclostridium 9, Phascolarctobacterium, Coriobacteriaceae UCG-002 and Oribacterium. LDA effect size (LEfSe) analysis revealed that PPs recovered the gut microbiota by targeting Ruminococcaceae NK4A214 group. Our results suggested that PPs alleviated CNP via different mechanisms from finasteride, especially by regulating the gut microbiota, which offers therapeutic target for the treatment of CNP.

Diagnostic and Management Strategies for Patients with Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common and often heterogenous condition that can have severe consequences on patient quality of life. In this review, we describe the pathophysiology, diagnostic work-up, and treatment of patients with CP/CPPS incorporating the most recent literature. Studies have demonstrated that CP/CPPS involves a complex pathophysiology, including infectious, immunologic, neurologic, endocrinologic, and psychologic etiologies, with frequent intersections between the different entities. Despite robust research assessing a variety of therapeutics targeting these etiologies, clinical trials have failed to identify an empiric treatment strategy applicable specifically to older adult male patients with CP/CPPS. As such, it can be challenging to manage older male patients with this condition. The advent of clinical phenotyping of patients with CP/CPPS has led to advances in tailored management strategies. Monomodal therapy has been largely unsuccessful because of the unclear and complex etiology of CPPS. As a result, CP/CPPS therapy has transitioned to a multimodal approach, including both pharmacologic and non-pharmacologic therapies. The best studied pharmacologic therapies include antibiotics, alpha-blockers, anti-inflammatory and immunomodulatory agents, phytotherapies, phosphodiesterase inhibitors, hormonal agents, neuromodulatory agents, and antidepressants. The best studied non-pharmacological therapies include pelvic floor physical therapy, myofascial trigger point release, acupuncture and electroacupuncture, psychological support and biofeedback, and electrocorporeal shockwave therapy and local thermotherapy.

Results of purified micronized flavonoid fraction in the treatment of categorized type III chronic pelvic pain syndrome: a randomized controlled trial

OBJECTIVES

The management of chronic pelvic pain syndrome (CPPS) is controversial because of the unclear pathogenesis of this disease. In one theory, prostatitis has been proposed to be associated with pelvic venous diseases such as varicocele and hemorrhoids, dilatation of the Santorini plexus. In this study, we investigated the effect of micronized flavonoid fraction (an agent used in venous insufficiency) in the treatment of type III CPPS.

METHODS

Patients diagnosed with type III chronic prostatitis were randomized and divided into 3 groups. Group 1 consisted of patients using antibiotics + anti-inflammatory + alpha-blocker (n = 47), Group 2 consisted of patients using antibiotics + anti-inflammatory + purified micronized flavonoid fraction (n = 45), and Group 3 consisted of patients using only purified micronized flavonoid fraction (n = 35).

RESULTS

The mean age of the patients was 32.93 ± 4.70 (range; 23-44) years. There was a statistically significant difference between the groups in terms of the 6th month NIH-CPSI (National Institute of Health Chronic Prostatitis Symptom Index) total scores (p = .000). Also, it was found that NIH-CPSI total scores at month 12 in Group 3 were significantly higher than those in Group 1 and 2 (p¹ = .000, p² = .002). NIH-CPSI total scores at month 12 in Group 2 were significantly higher than those in Group 1 (p = .000).

CONCLUSION

The use of purified micronized flavonoid will decrease prostatic inflammation occurring due to increased perineal venous return.it can also be preferred as part of multimodal therapy because of its profile with relatively less side effects and being more affordable compared with alpha-blockers.

The role of glycosaminoglycans in the management of chronic pelvic pain: a systematic review

INTRODUCTION

Glycosaminoglycans (GAGs) are involved in the pathogenesis of several urologic chronic diseases. Thus, GAGs replenishment therapy is widely reported as a therapeutic tool for chronic pelvic pain (CPP) conditions such as interstitial cystitis/bladder pain syndrome (IC/BPS) and prostate pain syndrome/chronic prostatitis. In this article we reviewed the current status of evidence on the clinic applications of glycosaminoglycans (GAGs) in the CPP.

EVIDENCE ACQUISITION

A literature search from inception was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement to identify clinical trials, randomized controlled trials, meta-analyses, and guidelines.

EVIDENCE SYNTHESIS

A total of 29 papers were identified regarding the use of GAGs in CPP.

CONCLUSIONS

GAGs replenishment therapy results are encouraging in chronic forms of pelvic pain even though well-powered randomized clinical trials are needed to better comprehend the exact role of this treatment.

Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disorder in which the two main clinical features are pelvic pain and lower urinary tract symptoms. There are currently many approaches for its management, using both pharmacological and non-pharmacological interventions. The National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) score is a validated measure commonly used to measure CP/CPPS symptoms. We considered a 25% decrease of NIH-CPSI baseline score or a six-point reduction as MCID.

OBJECTIVES

To assess the effects of pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome.

SEARCH METHODS

We performed a comprehensive search using CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, trial registries, grey literature and conference proceedings, with no restrictions on the language of publication or publication status. The date of the latest search of all databases was July 2019.

SELECTION CRITERIA

We included randomised controlled trials. Inclusion criteria were men with a diagnosis of CP/CPPS. We included all available pharmacological interventions compared to placebo or in head-to-head comparisons.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed the risks of bias of included studies. We assessed the quality of the evidence (QoE) using the GRADE approach.

MAIN RESULTS

We included 99 unique studies in 9119 men with CP/CPPS, with assessments of 16 types of pharmacological interventions. Unless stated otherwise, our comparisons were based on short-term follow-up (less than 12 months). Most studies did not specify their funding sources; 21 studies reported funding from pharmaceutical companies.1. Alpha blockers: (24 studies, 2061 participants). We are uncertain about the effects of these drugs on prostatitis symptoms when compared to placebo at short-term follow-up (mean difference (MD) in total NIH-CPSI score -5.01, 95% confidence interval (CI) -7.41 to -2.61; 18 studies, 1524 participants, very low QoE) and at long-term follow-up (MD -5.60, 95% CI -10.89 to -0.32; 4 studies, 235 participants, very low QoE). Alpha blockers may be associated with an increased incidence of adverse events, such as dizziness and postural hypotension (risk ratio (RR) 1.60, 95% CI 1.09 to 2.34; 19 studies, 1588 participants; low QoE). Alpha blockers probably result in little to no difference in sexual dysfunction, quality of life and anxiety and depression (moderate to low QoE).2. 5-alpha reductase inhibitors (5-ARI): (2 studies, 177 participants). Finasteride probably reduces prostatitis symptoms compared to placebo (NIH-CPSI score MD -4.60, 95% CI -5.43 to -3.77; 1 study, 64 participants; moderate QoE) and may not be associated with an increased incidence of adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.3. Antibiotics: (6 studies, 693 participants). Antibiotics (quinolones) may reduce prostatitis symptoms compared to placebo (NIH-CPSI score MD -2.43, 95% CI -4.72 to -0.15; 5 studies, 372 participants; low QoE) and are probably not associated with an increased incidence in adverse events (moderate QoE). Antibiotics probably result in little to no difference in sexual dysfunction and quality of life (moderate QoE). There was no information on anxiety or depression.4. Anti-inflammatories: (7 studies, 585 participants). Anti-inflammatories may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -2.50, 95% CI -3.74 to -1.26; 7 studies, 585 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.5. Phytotherapy: (7 studies, 551 participants). Phytotherapy may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -5.02, 95% CI -6.81 to -3.23; 5 studies, 320 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). Phytotherapy may not improve sexual dysfunction (low QoE). There was no information on quality of life or anxiety and depression.6. Botulinum toxin A (BTA): Intraprostatic BTA injection (1 study, 60 participants) may cause a large reduction in prostatitis symptom (NIH-CPSI scores MD -25.80, 95% CI -30.15 to -21.45), whereas pelvic floor muscle BTA injection (1 study, 29 participants) may not reduce prostatitis symptoms (low QoE). Both comparisons used a placebo injection. These interventions may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.7. Allopurinol: (2 studies, 110 participants). Allopurinol may result in little to no difference in prostatitis symptoms and adverse events when compared to placebo (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.8. Traditional Chinese medicine (TCM): (7 studies, 835 participants); TCM may reduce prostatitis symptoms (NIH-CPSI score, MD -3.13, 95% CI -4.99 to -1.28; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). TCM probably does not improve sexual dysfunction (moderate QoE) and may not improve symptoms of anxiety and depression (low QoE). There was no information on quality of life.The most frequent reasons for downgrading the QoE were study limitations, inconsistency and imprecision. We found few trials with active comparators.

AUTHORS' CONCLUSIONS

We found low- to very low-quality evidence that alpha blockers, antibiotics, 5-ARI, anti-inflammatories, phytotherapy, intraprostatic BTA injection, and traditional Chinese medicine may cause a reduction in prostatitis symptoms without an increased incidence of adverse events in the short term, except for alpha blockers which may be associated with an increase in mild adverse events. We found few trials with active comparators and little evidence of the effects of these drugs on sexual dysfunction, quality of life or anxiety and depression. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient-important outcomes, including potential treatment-related adverse events, and appropriate sample sizes.

Interventions to chronic prostatitis/Chronic pelvic pain syndrome treatment. Where are we standing and what's next?

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a frustrating syndrome. The pathogenesis and state of the art treatment of CP/CPPS are not known. A wide variety of therapies including anti-inflammatories, antibiotics, alpha-blockers, neuropathic pain modulators, and 5α-reductase inhibitors are in practice. These treatment strategies focus on alleviating symptoms in specific domains without treating root-cause and therapeutic outcome is far from satisfactory. We review the literature on current pharmacological treatments for CP/CPPS in detail and suggest future perspectives to modify the treatment strategies. We suggest that introducing novel treatment strategies such as gene editing, and T_regs expressing chimeric receptors may improve the treatment outcomes by inducing immune tolerance and controlling expression of pro-inflammatory cytokines.

Male CP/CPPS: where do we stand?

INTRODUCTION

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), commonly encountered in urologic practice, carries with it a stigma of poor understanding, ineffective treatment, and significant financial and quality of life burden.

MATERIALS AND METHODS

This clinically practical review is based on the authors' personal clinical experience in interpretation and application of currently available evidence.

RESULTS

Significant progress has been made in terms of classification and evaluation of the disease, leading to encouraging improvements in treatment outcomes. The Chronic Prostatitis Symptom Index (CPSI) is a helpful tool in clinical evaluation and has proven invaluable for research purposes, while UPOINT has demonstrated the heterogeneity of the disease and provides physicians with a uniquely patient-centered approach to treatment. The importance of the microbiome in the evaluation of CP/CPPS patients has yet to be fully appreciated. While personalized, multi-modal therapy appears to be the key to treatment, the addition of pelvic floor physiotherapy (PFPT) with injection of trigger points, and psychosocial therapies to the multi-modal approach armamentarium are promising advances. Innovative interventional approaches are encouraging but require study.

CONCLUSIONS

While encouraging therapies have been added to personalized, multi-modal treatment strategies, newer innovative therapies appear promising for improved treatment of CP/CPPS patients.

Current best practice in the management of cystitis and pelvic pain

Bladder pain syndrome (BPS) is a difficult disorder to diagnose and subsequently manage despite having been recognized for more than 200 years according to references in medical literature. There are currently three widely accepted guidelines on BPS: the American Urological Association Guidelines; the Royal College of Obstetricians and Gynaecologists in conjunction with the British Society of Urogynaecologists Guidelines; and the European Association of Urology Guidelines. These guidelines have similarities to each other but also significant differences. This leaves clinicians still confused about this condition and how to appropriately manage the 'real' patient. We review the current guidelines and appropriate literature and put forward a clinically usable management strategy.

Comprehensive overview of prostatitis

Prostatitis is a common urinary tract syndrome that many doctors find problematic to treat effectively. It is the third most commonly found urinary tract disease in men after prostate cancer and Benign Prostate Hyperplasia (BPH). Prostatitis may account for 25% of all office visits made to the urological clinics complaining about the genital and urinary systems all over the world. In the present study, we classified prostatitis and comprehensively elaborated the etiology, pathogenesis, diagnosis, and treatment of acute bacterial prostatitis (category I), chronic bacterial prostatitis (category II), chronic pelvic pain syndrome (CPPS) (category III), and asymptomatic prostatitis (category IV). In addition, we also tried to get some insights about other types of prostatitis-like fungal, viral and gonococcal prostatitis. The aim of this review is to present the detail current perspective of prostatitis in a single review. To the best of our knowledge currently, there is not a single comprehensive review, which can completely elaborate this important topic in an effective way. Furthermore, this review will provide a solid platform to conduct future studies on different aspects such as risk factors, mechanism of pathogenesis, proper diagnosis, and rational treatment plans for fungal, viral, and gonococcal prostatitis.

Immunological Mechanisms Underlying Chronic Pelvic Pain and Prostate Inflammation in Chronic Pelvic Pain Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common urologic morbidity in men younger than 50 years and is characterized by a diverse range of pain and inflammatory symptoms, both in type and severity, that involve the region of the pelvis, perineum, scrotum, rectum, testes, penis, and lower back. In most patients, pain is accompanied by inflammation in the absence of an invading infectious agent. Since CP/CPPS etiology is still not well established, available therapeutic options for patients are far from satisfactory for either physicians or patients. During the past two decades, chronic inflammation has been deeply explored as the cause of CP/CPPS. In this review article, we summarize the current knowledge regarding immunological mechanisms underlying chronic pelvic pain and prostate inflammation in CP/CPPS. Cumulative evidence obtained from both human disease and animal models indicate that several factors may trigger chronic inflammation in the form of autoimmunity against prostate, fostering chronic prostate recruitment of Th1 cells, and different other leukocytes, including mast cells, which might be the main actors in the consequent development of chronic pelvic pain. Thus, the local inflammatory milieu and the secretion of inflammatory mediators may induce neural sensitization leading to chronic pelvic pain development. Although scientific advances are encouraging, additional studies are urgently needed to establish the relationship between prostatitis development, mast cell recruitment to the prostate, and the precise mechanisms by which they would induce pelvic pain.

Contemporary Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome

CONTEXT

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common condition that causes severe symptoms, bother, and quality-of-life impact in the 8.2% of men who are believed to be affected. Research suggests a complex pathophysiology underlying this syndrome that is mirrored by its heterogeneous clinical presentation. Management of patients diagnosed with CP/CPPS has always been a formidable task in clinical practice. Due to its enigmatic etiology, a plethora of clinical trials failed to identify an efficient monotherapy.

OBJECTIVE

A comprehensive review of published randomized controlled trials (RCTs) on the treatment of CP/CPPS and practical best evidence recommendations for management.

EVIDENCE ACQUISITION

Medline and the Cochrane database were screened for RCTs on the treatment of CP/CPPS from 1998 to December 2014, using the National Institutes of Health Chronic Prostatitis Symptom Index as an objective outcome measure. Published data in concert with expert opinion were used to formulate a practical best evidence statement for the management of CP/CPPS.

EVIDENCE SYNTHESIS

Twenty-eight RCTs identified were eligible for this review and presented. Trials evaluating antibiotics, α-blockers, anti-inflammatory and immune-modulating substances, hormonal agents, phytotherapeutics, neuromodulatory drugs, agents that modify bladder function, and physical treatment options failed to reveal a clear therapeutic benefit. With its multifactorial pathophysiology and its various clinical presentations, the management of CP/CPPS demands a phenotypic-directed approach addressing the individual clinical profile of each patient. Different categorization algorithms have been proposed. First studies applying the UPOINTs classification system provided promising results. Introducing three index patients with CP/CPPS, we present practical best evidence recommendations for management.

CONCLUSIONS

Our current understanding of the pathophysiology underlying CP/CPPS resulting in this highly variable syndrome does not speak in favor of a monotherapy for management. No efficient monotherapeutic option is available. The best evidence-based management of CP/CPPS strongly suggests a multimodal therapeutic approach addressing the individual clinical phenotypic profile.

PATIENT SUMMARY

Chronic prostatitis/chronic pelvic pain syndrome presents a variable syndrome. Successful management of this condition is challenging. It appears that a tailored treatment strategy addressing individual patient characteristics is more effective than one single therapy.

Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome

Prostatitis comprises of a group of syndromes that affect almost 50% of men at least once in their lifetime and makeup the majority of visits to the Urology Clinics. After much debate, it has been divided into four distinct categories by National Institutes of Health namely (1) acute bacterial prostatitis; (2) chronic bacterial prostatitis; (3) chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) which is further divided into inflammatory and non-inflammatory CP/CPPS; and (4) asymptomatic inflammatory prostatitis. CP/CPPS has been a cause of great concern for both patients and physicians because of the lack of presence of thorough information about the etiological factors along with the difficult-to-treat nature of the syndrome. For the presented manuscript an extensive search on PubMed was conducted for CP/CPPS aimed to present an updated review on the evaluation and treatment options available for patients with CP/CPPS. Several diagnostic criteria’s have been established to diagnose CP/CPPS, with prostatic/pelvic pain for at least 3 mo being the major classifying symptom along with the presence of lower urinary tract symptoms and/or ejaculatory pain. Diagnostic tests can help differentiate CP/CPPS from other syndromes that come under the heading of prostatitis by ruling out active urinary tract infection and/or prostatic infection with uropathogen by performing urine cultures, Meares-Stamey Four Glass Test, Pre- and Post-Massage Two Glass Test. Asymptomatic inflammatory prostatitis is confirmed through prostate biopsy done for elevated serum prostate-specific antigen levels or abnormal digital rectal examination. Researchers have been unable to link a single etiological factor to the pathogenesis of CP/CPPS, instead a cluster of potential etiologies including atypical bacterial or nanobacterial infection, autoimmunity, neurological dysfunction and pelvic floor muscle dysfunction are most commonly implicated. Initially monotherapy with anti-biotics and alpha adrenergic-blockers can be tried, but its success has only been observed in treatment naïve population. Other pharmacotherapies including phytotherapy, neuromodulatory drugs and anti-inflammatories achieved limited success in trials. Complementary and interventional therapies including acupuncture, myofascial trigger point release and pelvic floor biofeedback have been employed. This review points towards the fact that treatment should be tailored individually for patients based on their symptoms. Patients can be stratified phenotypically based on the UPOINT system constituting of Urinary, Psychosocial, Organ-specific, Infectious, Neurologic/Systemic and symptoms of muscular Tenderness and the treatment algorithm should be proposed accordingly. Treatment of CP/CPPS should be aimed towards treating local as well as central factors causing the symptoms. Surgical intervention can cause significant morbidity and should only be reserved for treatment-refractory patients that have previously failed to respond to multiple drug therapies.

Assessing psychological factors, social aspects and psychiatric co-morbidity associated with Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) in men -- a systematic review

OBJECTIVE

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a chronic pain disease with high prevalence rates and substantial health care costs. An interdisciplinary classification system is commonly used (UPOINT) which includes psychosocial factors. Nevertheless, psychosocial influences on CP/CPPS only recently became a research focus. Therefore, we aimed to synthesize the existing data and to identify further research topics. Then, based on our results, diagnosis and treatment can be improved.

METHODS

In a systematic review conducted according to the PRISMA reporting guidelines we searched different databases (MEDLINE, EMBASE, PsychINFO) using the broad search terms "chronic pelvic pain syndrome AND men". Two raters independently screened the literature and assessed the risk of bias.

RESULTS

We included 69 original research articles which considered psychosocial variables. We found studies investigating different psychosocial factors (pain catastrophizing, stress, personality factors, social aspects), co-morbid psychiatric disorders (depression, anxiety and trauma-related disorders, somatization disorder, substance abuse) and Quality of Life (QoL). In addition, there is a high risk of bias in most studies e.g. concerning the study design or the measures.

CONCLUSIONS

There is evidence suggesting that psychological factors are important in understanding CP/CPPS. However, research concentrated on a few aspects while the others were not covered adequately. We found evidence of a higher number of psychosocial factors and psychiatric co-morbidities than is currently included in the UPOINT system. More high quality research is needed to understand the interplay of psychosocial factors in CP/CPPS. Furthermore, these factors should be incorporated into treatment approaches.

Chronic pelvic pain syndrome: a clinical enigma

Chronic nonbacterial prostatitis is an ill-defined, painful clinical condition that is characterized by various nonspecific symptoms, some of which are related to urination or the male reproductive organs. Urologists diagnose this particular condition when the symptoms are not associated with urinary bacterial growth before and after transrectal prostate massage. In this review, we describe the recommended and optional tests that can be performed in these cases. There is significant overlap between chronic nonbacterial prostatitis and other unexplained pain conditions, raising the question as to whether the prostate is the culprit. The sources and mediators of pain and the psychological aspects of this complex condition are discussed. Treatments consist of traditional antibiotics and α-blockers. Because the pain relief is often temporary, patients seek other solutions. Various therapeutics have been introduced to satisfy the expectations of patients and physicians. We discuss other pain medications, as well as intraprostatic drug injections and shockwave therapy. Importantly, however, not all of these suggestions have been widely accepted by urologists or pain clinics.

Clinical phenotyping of urologic pain patients

PURPOSE OF REVIEW

Urologic pain conditions such as chronic prostatitis/chronic pelvic pain syndrome, interstitial cystitis/bladder pain syndrome and chronic orchialgia are common, yet diagnosis and treatment are challenging. Current therapies often fail to show efficacy in randomized controlled studies. Lack of efficacy may be due to multifactorial causes and heterogeneity of patient presentation. Efforts have been made to map different phenotypes in patients with urologic pain conditions to tailor more effective therapies. This review will look at current literature on phenotype classification in urologic pain patients and their use in providing effective therapy.

RECENT FINDINGS

There has been validation of the 'UPOINT' system (urinary symptoms, psychosocial dysfunction, organ specific findings, infection, neurologic/systemic and tenderness of muscle) to better categorize male chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/bladder pain syndrome. Refinement of domain systems and recent cluster analysis has suggested possible central processes involved in urologic pain conditions similar to systemic pain syndromes such as fibromyalgia, chronic fatigue and irritable bowel syndrome.

SUMMARY

Domain characterization of urologic pain conditions via phenotype mapping can be used to better understand causes of chronic pain and hopefully provide more effective, targeted and multimodal therapy.

Prostatitis and chronic prostatitis/chronic pelvic pain syndrome

The prevalence of prostatitis is extremely high, with up to 16% of men diagnosed with prostatitis at some point throughout their lifetime. However, the etiology appears to be multifactorial and standard treatment regimens have been altered significantly in recent years. The purpose of this review is to examine the changing scientific views on the causes and treatment of prostatitis, chronic prostaitis and chronic pelvic pain syndrome. We review the infectious and noninfectious etiology of the disease, examining the role of antimicrobial treatment in eradicating infection as well as ameliorating symptoms. Current NIH classifications, which stratify prostatitis into four categories, are discussed, as is the NIH Chronic Prostatitis Symptom Index, the primary tool used to assess symptomatology. Diagnostic examinations are studying the need for the four-glass test and its practical replacement by the two-glass test. Multimodal treatment therapy is then discussed, including recent data on biofeedback and evaluation of the role of pelvic floor dysfunction in prostatitis.

Classification and treatment of men with chronic prostatitis/chronic pelvic pain syndrome using the UPOINT system

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common condition; however, many of the traditional therapies used in clinical practice fail to show efficacy when subjected to large randomized placebo-controlled trials. This may be because CP/CPPS is a heterogeneous syndrome rather than a specific disease which would explain the failure of "one size fits all" therapy. In order to direct appropriate therapy, we have developed a six-point clinical phenotyping system to evaluate patients with chronic urologic pelvic pain. The clinical domains are urinary symptoms, psychosocial dysfunction, organ-specific findings, infection, neurologic/systemic, and tenderness of muscles, which produces the acronym UPOINT. Each domain is diagnosed clinically and is associated with specific therapies. This approach is simple and has proven effective in our hands for patients even after many years of failed therapies.

Management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): the studies, the evidence, and the impact

INTRODUCTION

The development of an accepted clinical definition, classification system and validated outcome questionnaire for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has led to a flurry of clinical trial activity over the last 15 years.

METHODS

Twenty-four of these studies enrolled a homogeneous population of CP/CPPS patients, were prospective randomized placebo or sham controlled, and employed the National Institutes of Health chronic prostatitis symptom index (CPSI) as an outcome parameter.

RESULTS

This review of the evidence and clinical impact from these studies suggests that physician's strict adherence to a rigid evidence-based approach for the treatment of a CP/CPPS patient will result in disappointed patients as well as disappointed physicians.

CONCLUSIONS

There is no one particular treatment that shows significant clinical efficacy to be recommended as a mono-therapy for CP/CPPS. Therefore, the physician must adapt his knowledge and interpretation of the evidence from randomized placebo- and sham-controlled trials to determine what therapy or therapies are best indicated for each individual patient.

Therapeutic intervention for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a systematic review and meta-analysis

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has been treated with several different interventions with limited success. This meta-analysis aims to review all trials reporting on therapeutic intervention for CP/CPPS using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI).

METHODS

We searched Medline, PubMed, the Cochrane Pain, Palliative & Supportive Care Trials, the Cochrane Register of Controlled Trials, CINAHL, ClinicalTrials.gov, and the NIDDK website between 1947 and December 31, 2011 without language or study type restrictions. All RCTs for CP/CPPS lasting at least 6 weeks, with a minimum of 10 participants per arm, and using the NIH-CPSI score, the criterion standard for CP/CPPS, as an outcome measure were included. Data was extracted from each study by two independent reviewers. Gillbraith and I-squared plots were used for heterogeneity testing and Eggers and Peters methods for publication bias. Quality was assessed using a component approach and meta-regression was used to analyze sources of heterogeneity.

RESULTS

Mepartricin, percutaneous tibial nerve stimulation (PTNS), and triple therapy comprised of doxazosin + ibuprofen + thiocolchicoside (DIT) resulted in clinically and statistically significant reduction in NIH-CPSI total score. The same agents and aerobic exercise resulted in clinically and statistically significant NIH-CPSI pain domain score reduction. Acupuncture, DIT, and PTNS were found to produce statistically and clinically significant reductions in the NIH-CPSI voiding domain. A statistically significant placebo effect was found for all outcomes and time analysis showed that efficacy of all treatments increased over time. Alpha-blockers, antibiotics, and combinations of the two failed to show statistically or clinically significant NIH-CPSI reductions.

CONCLUSION

Results from this meta-analysis reflect our current inability to effectively manage CP/CPPS. Clinicians and researchers must consider placebo effect and treatment efficacy over time and design studies creatively so we can more fully elucidate the etiology and role of therapeutic intervention in CP/CPPS.

α-blockers, antibiotics and anti-inflammatories have a role in the management of chronic prostatitis/chronic pelvic pain syndrome

Study Type - Therapy (systematic review) Level of Evidence 1a. What's known on the subject? and What does the study add? Individual clinical trials evaluating antibiotics, anti-inflammatories and α-blockers for the treatment of chronic prostatitis/chronic pelvic pain syndrome have shown only modest or even no benefits for patients compared with placebo, yet we continue to use these agents in selected patients with some success in clinical practice. This network meta-analysis of current evidence from all available randomized placebo-controlled trials with similar inclusion criteria and outcome measures shows that these '3-As' of chronic prostatitis/chronic pelvic pain syndrome treatment (antibiotics, anti-inflammatories and α-blockers) do offer benefits to some patients, particularly if we use them strategically in selected individuals.

OBJECTIVES

To provide an updated network meta-analysis mapping α-blockers, antibiotics and anti-inflammatories (the 3-As) in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). • To use the results of this meta-analysis to comment on the role of the 3-As in clinical practice.

PATIENTS AND METHODS

We updated a previous review including only randomized controlled studies employing the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) as one of the outcomes to compare treatment effects in CP/CPPS patients. • A longitudinal mixed regression model (network meta-analysis) was applied to indirectly assess multiple treatment comparisons (i.e. α-blockers, antibiotics, anti-inflammatory/immune modulation therapies, α-blockers plus antibiotics, and placebo).

RESULTS

Nineteen studies (1669 subjects) were eligible for analysis. • α-blockers, antibiotics and anti-inflammatory/immune modulation therapies were associated with significant improvement in symptoms when compared with placebo, with mean differences of total CPSI of -10.8 (95% CI -13.2 to -8.3; P < 0.001), -9.7 (95% CI -14.2 to -5.3; P < 0.001) and -1.7 (95% CI -3.2 to -0.2; P= 0.032) respectively, while α-blockers plus antibiotics resulted in the greatest CPSI difference (-13.6, 95% CI -16.7 to -10.6; P < 0.001). • With respect to responder analysis compared with placebo, anti-inflammatories showed the greatest response rates (risk ratio 1.7, 95% CI 1.4-2.1; P < 0.001) followed by α-blockers (risk ratio 1.4, 95% CI 1.1-1.8; P= 0.013) and antibiotics (risk ratio 1.2, 95% CI 0.7-1.9; P= 0.527).

CONCLUSIONS

α-blockers, antibiotics and/or anti-inflammatory/immune modulation therapy appear to be beneficial for some patients with CP/CPPS. • The magnitude of effect and the disconnect between mean CPSI decrease and response rates compared with placebo suggest that directed multimodal therapy, rather than mono-therapy, with these agents should be considered for optimal management of CP/CPPS.

Chronic prostatitis: approaches for best management

Prostatitis is a prevalent condition that encompasses a large array of clinical symptoms with significant impacts on men's life. The diagnosis and treatment of this disorder presents numerous challenges for urologists, most notably, a lack of specific and effective diagnostic methods. Chronic bacterial prostatitis is successfully treated with appropriate antibiotics that penetrate the prostate and kill the causative organisms. Prostatitis category III (chronic pelvic pain syndrome) is common, very bothersome, and enigmatic. Symptoms are usually prolonged and, generally speaking, treatment results are unsatisfactory. During the last decade, research has focused on the distress caused by the condition, but although our knowledge has certainly increased, there have been no real breakthroughs; controversies and many unanswered questions remain. Furthermore, the optimal management of category III prostatitis is not known. Conventional prolonged courses of antibiotic therapy have not proven to be efficacious. Novel therapies providing some evidence for efficacy include alpha-blocker, anti-inflammatory phytotherapy, physiotherapy, neuroleptics, and others, each offering therapeutic mechanisms. A stepwise approach involving multimodal therapy is often successful for treating patients. The UPOINT technique has been used to clinically phenotype these patients and drive the appropriate selection of multimodal therapy.

Tamsulosin Monotherapy versus Combination Therapy with Antibiotics or Anti-Inflammatory Agents in the Treatment of Chronic Pelvic Pain Syndrome

Purpose

Chronic pelvic pain syndrome (CPPS) is treated by use of various protocols. We compared tamsulosin monotherapy with tamsulosin in combination with antibiotics or anti-inflammatory agents and evaluated the efficacy of these treatments in patients with CPPS.

Methods

Patients (n=107) who were younger than 55 years and diagnosed with CPPS were randomly assigned to treatment with tamsulosin at 0.2 mg (group A), tamsulosin at 0.2 mg plus anti-inflammatory drugs (group B) or tamsulosin at 0.2 mg plus antibiotics (group C) daily. We applied the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostate Symptom Score (IPSS) to evaluate 100 patients who were treated for 12 weeks (7 withdrew). Scores of the three groups were compared by analysis of variance and we also evaluated subscores, which included pain, voiding and quality of life (QoL).

Results

All three groups showed statistically significant decreases in NIH-CPSI score, IPSS and subscore scores (P<0.05). There were no statistically significant differences between the groups except for the QoL domain of the IPSS (group A vs. C; P<0.01).

Conclusions

Tamsulosin monotherapy for 12 weeks was effective for treating patients with CPPS, compared with combination therapy with antibiotics or anti-inflammatory drugs.

Pharmacotherapy of prostatitis

IMPORTANCE OF THE FIELD

Prostatitis is a prevalent and morbid condition with a significant impact on a patient's quality of life. The four distinct prostatitis syndromes have different pathophysiologies, therapy and prognosis. Acute and chronic bacterial prostatitis is best treated with appropriate antibiotics that penetrate the prostate and kill the causative organisms. The most challenging category to treat is category III or chronic prostatitis/chronic pelvic pain syndrome.

AREAS COVERED IN THE REVIEW

This review covers the categories of prostatitis and currently recommended therapies, as well as novel approaches on the horizon.

WHAT THE READER WILL GAIN

Knowledge of the current framework for the diagnosis and management of the diverse prostatitis spectrum.

TAKE HOME MESSAGE

Prostatitis is a diverse group of syndromes. Chronic prostatitis/chronic pelvic pain syndrome is a multifactorial syndrome that requires a multimodal approach to effectively treat the patient. The UPOINT technique is used to clinically phenotype these patients and drive the selection of multimodal therapy.

Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome

• Our traditional approach to managing the chronic prostatitis (CP) syndromes has not been very successful for many of our patients. • Our developing understanding of CP/chronic pelvic pain syndrome (CP/CPPS) as a heterogeneous syndrome rather than a homogenous disease has allowed us to develop treatment strategies based on individual patient characteristics. • By considering each patient as a unique individual and tailoring treatments to a specific patient's clinical 'phenotype' we improve our therapeutic outcomes.

[Specific treatments for chronic bacterial prostatitis and chronic pelvic pain syndrome]

OBJECTIVE

To review the treatment of chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

MATERIAL AND METHODS

A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either Medical subject heading (MeSH) keywords (antibacterial agents, pelvic pain, placebos, prostatitis, treatment) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time.

RESULTS

The treatment of chronic bacterial prostatitis is based on the use of antibiotics, primarily fluoroquinolones, for 4 to 6 weeks, but no consensus has been reached concerning the standard treatment of CP/CPPS. A review of the literature failed to identify any recognized and validated treatments for CP/CPPS, but several conclusions can be drawn: placebo gives satisfactory results in a considerable number of patients; antibiotics are not recommended; alpha-blocking agents may be effective in recently diagnosed, previously untreated patients, provided they are prescribed for 12 weeks to 6 months; invasive surgery of the prostate and bladder neck is not recommended.

CONCLUSION

Progress in the treatment of CP/CPPS will require more extensive basic and clinical research. Only randomized, placebo-controlled clinical trials including a large number of patients, and using the NIH-Chronic Prostatitis Symptom Index questionnaire (NIH-CPSI) as evaluation tool will be able to provide reliable conclusions. The use of patient subgroups selected according to the predominant symptoms could be contributive.

Pharmacotherapy strategies in chronic prostatitis/chronic pelvic pain syndrome management

IMPORTANCE OF THE FIELD

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is one of the most common diagnoses arising out of urologic office visits. It is a costly problem and sufferers compare the effect of this syndrome on quality of life as being similar to the effects of diabetes mellitus and myocardial infarction. The syndrome is variable in presentation and symptom management and efficacy will vary between inflicted men.

AREAS COVERED IN THIS REVIEW

CP/CPPS is not highly responsive to therapy. As such, it is often a waxing and waning illness with symptoms in multiple domains, including urinary symptoms, pain and ejaculatory dysfunction. The pharmacotherapeutic options and management strategies for CP/CPPS presented in this review are based on the published literature from September 1989 to January 2010. When available, randomized, placebo-controlled studies were reviewed to aid in making definitive recommendations for treatment strategies.

WHAT THE READER WILL GAIN

The reader will be familiarized with the commonly used classes of pharmaceutical and non-pharmaceutical therapies. Readers will then use the efficacy data to inform treatment decisions for patients with disparate symptomatology. This will be crystallized in the author's treatment algorithm and summary statement.

TAKE HOME MESSAGE

Many practitioners use antimicrobials as a first-line agent, particularly a fluoroquinolone, such as levofloxacin. Trimethoprim/sulfamethoxazole is another medication alternative, with comparable response rates. Many afflicted men will have significant improvement on a 4- to 6-week regimen of a fluoroquinolone antibiotic. Second-line pharmacotherapy includes alpha-blockers, 5-alpha reductase inhibitors and anti-inflammatories for men with urinary symptoms or pain as a predominant symptom domain. Other pharmacotherapy includes steroids, glycosaminoglycans and phytotherapy. Surgical options are generally not recommended for CP/CPPS. Despite the lack of curative therapies, effective symptom management can be achieved with knowledge of the classes of pharmacotherapy. Therapeutic decisions can be based on the symptoms of the patient. Pelvic floor physical therapy is a useful second-line therapy in the author's opinion, but randomized controlled trials and standardization of technique for CP/CPPS are needed before recommendations can be substantiated.

New treatments for chronic prostatitis/chronic pelvic pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common condition among men of a wide age range, with detrimental effects on quality of life. The etiology, pathogenesis, and optimal treatment of CP/CPPS remain unknown, although progress has been made in these domains in recent years. A wide variety of pharmacologic and nonpharmacologic therapies have been studied in clinical trials, but most have shown limited efficacy in symptom alleviation. CP/CPPS is increasingly viewed as a condition that involves variable degrees of neuropathic pain. Medications such as gabapentin, pregabalin, memantine, and tricyclic antidepressants are often used in other neuropathic pain conditions and, therefore, are considered potential treatments for CP/CPPS. Few studies of these agents in patients with CP/CPPS have been reported, but future clinical trials should help to determine their utility and to characterize the pathogenetic mechanisms of pain in CP/CPPS. Combining treatment trials with biomarker, genomic, and imaging studies, in addition to epidemiologic and symptom-based assessments, will maximize the ability to probe disease etiology and pathogenesis, as well as identify effective treatment.

Phenotypic approach to the management of chronic prostatitis/chronic pelvic pain syndrome

There is no one unifying etiological mechanism or specific curative therapy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). However, there is sufficient evidence to suggest that each of the proposed mechanisms may be important in some patients, and that many of our evaluated treatments do in fact work in subgroups of patients. We hypothesize that CP/CPPS patients are not a homogenous group suffering from a single disease entity. Rather, CP/CPPS patients are actually unique individuals with differing clinical phenotypes based on various etiological mechanisms with distinctive symptom complexes and progression trajectories. We call this the "Snow Flake Hypothesis." We propose the UPOINT (urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness domains) clinical phenotyping classification; we have validated the concept in a CP/CPPS cohort and have suggested that phenotypically directed therapy will improve our clinical treatment outcomes.

[Urethral syndrome in men--chronic pelvic pain syndrome]

INTRODUCTION

Chronic pelvic pain syndrome (CPPS) is defined as pelvis minor pain of nonmalignant nature repeating in different time intervals. Urethral syndrome (US) represents a most poorly defined entity within CPPS.

OBJECTIVE

The estimation of US influence on quality-of-life as well as the determination of the way of treatment and therapy optimal length.

MATERIAL AND METHODS

A prospective one-year study included 166 men with CPPS, median age of 54 years; they were monitored clinically. During the patient monitoring the NIH-CPSI questionnaire (National Institute of Health-Chronic Prostatis Symptom Index) was used. US was diagnosed in 79 patients (47%), and according to the most intensive pain localization they were divided into three groups. All the patients were treated with alpha adrenergic blockers and non-steroidal anti-inflammatory drugs, and the treatment of the patients with positive urethral smear also included antibiotherapy. The values of total NIH-CPSI, as well as of its individual components were analyzed after three and six months of treatment.

RESULTS AND DISCUSSION

The therapy application had a significant influence on the decrease of total NIH-CPSI--23.3% (p < 0.01), pain symptoms (p < 0.0) and urinary difficulties (p < 0.01), and the point values of quality-of-life score were diminished by 0.7 to 1.9 points depending on the group of those monitored (p < 0.01).

CONCLUSION

Our study indicated a significant influence of CPPS on quality-of-life and a necessity of a serious approach to patients and their treatment.

Chronic prostatitis: management strategies

The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this review involves a 4- to 6-week course of antibacterials, which may be repeated if the initial course provides relief. Pain and urinary symptoms can be ameliorated with anti-inflammatories and alpha-blockers. If the relief is not significant, then patients should be referred for biofeedback. Minimally invasive surgical options should be reserved for treatment-refractory patients.

Periodontal disease as reservoir for multi-resistant and hydrolytic enterobacterial species

AIMS

This investigation aimed to isolate enteric rods from subgingival sites of patients presenting chronic periodontitis lesions, and to assess antimicrobial resistance and expression of hydrolytic enzymes.

METHODS AND RESULTS

Enterobacteriaceae were isolated from 20% patients, and assayed for antimicrobial susceptibility and hydrolytic enzymes with specificity to different substrates. Isolates comprised seven Enterobacter cloacae (43.75%), five Serratia marcescens (31.25%), one Klebsiella pneumoniae (6.25%), one Enterobacter aerogenes (6.25%), one Pantoea agglomerans (6.25%), and one Citrobacter freundii (6.25%). Gelatinase activity was observed for 75% strains; caseinase and elastase was produced by six and two strains, respectively. DNase, lecithinase and lipase were expressed by S. marcescens. Most of strains were resistant to ampicillin (93.75%) and amoxicillin/clavulanic acid (81.25%). The majority of strains were susceptible to cephalosporins and aztreonam. Enterobacteria remained susceptible to imipenem, streptomycin and fluoroquinolones. Resistance to gentamicin, amikacin, sulfamethoxazole/thrimethoprim, tetracycline, and chloramphenicol were also observed. Eight strains presented multiple drug resistance.

CONCLUSIONS

Subgingival sites from periodontal diseases contain multi-resistant and hydrolytic enzyme-producing enterobacteria that may contribute to overall tissue destruction and spreading.

SIGNIFICANCE AND IMPACT OF THE STUDY

Enterobacteria isolated from patients generally considered as healthy individuals poses periodontal diseases as reservoir for systemic infections particularly in immunocompromised and hospitalized hosts.