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Yu XW, Wang CS, Yu XH. A systematic review and meta-analysis of moxibustion for chronic prostatitis. Medicine (Baltimore) 2023; 102:e36742. [PMID: 38115243 PMCID: PMC10727555 DOI: 10.1097/md.0000000000036742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Chronic prostatitis (CP) is a common condition that affects many individuals. Previous clinical trials have explored the use of moxibustion as a potential treatment for CP. However, the evidence on the effectiveness of moxibustion for CP remains limited. Therefore, this study aimed to comprehensively assess the effects of moxibustion for CP. METHODS In order to gather relevant and up-to-date information, we conducted a systematic literature search of databases including Cochrane Library, PUBMED, EMBASE, CNKI, and Wangfang from inception until June 30, 2023. Only randomized clinical trials (RCTs) that investigated the use of moxibustion for CP were included in this study. The primary outcomes of interest were the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) scores and the overall response rate. To evaluate the quality of the included studies, we used the Cochrane risk-of-bias tool. RESULTS After analyzing the data from 8 RCTs involving a total of 664 patients, we found significant differences in NIH-CPSI scores between moxibustion and other treatment modalities. Specifically, when compared with herbal medicine, moxibustion was associated with a mean difference (MD) of -1.78 in NIH-CPSI scores (95% confidence interval [CI] [-2.78, -0.78], P < .001), and when compared with western medicine, moxibustion was associated with a MD of -5.24 in NIH-CPSI scores (95% CI [-7.80, -2.67], P < .08). In terms of the overall response rate, moxibustion was found to be superior to herbal medicine, with a MD of 2.36 (95% [19, 4.67], P = .01). Additionally, when moxibustion was combined with herbal medicine, it yielded a higher overall response rate with a MD of 4.07 (95% CI [1.54, 10.74], P = .005) compared to herbal medicine alone. Moxibustion also outperformed western medicine in terms of the overall response rate, with a MD of 4.56 (95% CI [2.24, 9.26], P < .001). CONCLUSION Based on the findings of this study, moxibustion appears to be a potentially efficacious treatment for CP. The results suggest that moxibustion can improve NIH-CPSI scores and overall response rate in patients with CP. However, further high-quality studies are needed to validate these results and establish the long-term effects of moxibustion as a treatment for CP.
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Affiliation(s)
- Xi-wen Yu
- Department of Acupuncture and Moxibustion, Baicheng Medical College, Baicheng, China
| | - Cheng-si Wang
- College of Mathematical Sciences, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-hong Yu
- Second Ward of Cardiology Department, First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, China
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Zhou X, Lv Z, Hong S, Hu H, Tian Y, Wu S, Wang K, Wei Z, Lv L. Effectiveness and safety of acupuncture and moxibustion for chronic prostatitis: A protocol for an overview of systematic reviews and meta-analysis. Medicine (Baltimore) 2022; 101:e26116. [PMID: 36254055 PMCID: PMC9575744 DOI: 10.1097/md.0000000000026116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Chronic prostatitis (CP) refers to a disease characterized by local pain and discomfort, urination discomfort, and quality of life. Acupuncture (ACU) and moxibustion are widely used in the treatment of CP, and the curative effect is satisfactory. Several systematic reviews (SRs) and meta-analyzes have reported the effectiveness of ACU and moxibustion in treating patients with CP. However, the evidence is not systematically integrated. This overview aims to integrate and evaluate the reliability of these SRs and the evidence generated from the ACU and moxibustion for CP meta-analysis. METHODS We will make a comprehensive retrieval in seven databases as following: Embase, Cochrane Library, Pubmed, Chinese databases SinoMed (previously called the Chinese Biomedical Database), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), and Wanfang Data (WF). The time is limited from the construction of the library to May 2021. We will use the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool to evaluate methodological quality. Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P) will be used in the report checklist to assess the quality of reports in the study. The GRADE will be used to evaluate the included SRs and meta-analysis. Our reviewers will conduct SRs, qualification evaluation, data extraction, methodological quality and evidence quality screening in pairs. The outcomes of interest include: NIH-Chronic Prostatitis Symptom Index (NIH-CPSI), effective rate, other CP symptom scales, EPS-WBC, and adverse events. Evidence will be combined based on patient subgroups and results where appropriate. RESULTS The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER INPLASY202150018. CONCLUSION This overview will provide comprehensive evidence of ACU and moxibustion for patients with CP.
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Affiliation(s)
- Xingchen Zhou
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhizhen Lv
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shuangwei Hong
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Huijie Hu
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yu Tian
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shuang Wu
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Kaizheng Wang
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zicheng Wei
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Lijiang Lv
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- * Correspondence: Lijiang Lv, The Third Clinical Medical College of Zhejiang Chinese Medical University, No. 548, Binwen Road, Hangzhou, 310053, China (e-mail: )
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Majzoub A, Mahdi M, Adnan I, Saeedi AA, Rumaihi KA. Clinical phenotyping and multimodal treatment of men with chronic prostatitis/ chronic pelvic pain syndrome from the Middle East and North Africa: determining treatment outcomes and predictors of clinical improvement. Urology 2022; 167:179-184. [DOI: 10.1016/j.urology.2022.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
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Zhu K, Shen Y, Zhu Y, Li L, You Y. Effect of acupoint therapies on prostatitis: A systematic review protocol. Medicine (Baltimore) 2020; 99:e18967. [PMID: 32028405 PMCID: PMC7015636 DOI: 10.1097/md.0000000000018967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Prostatitis is a common urinary infectious disease. Acupoint therapies, including massage, acupuncture, acupoints injection, acupressure, and moxibustion, showed clinical and long-lasting benefits for prostatitis, but the efficiency of acupoint therapies was poorly evaluated. The current review is attempted to evaluate the efficacy and safety of the different acupoint-based therapies for prostatitis. METHODS Randomized controlled trials (RCTs) assessing acupoint therapies for prostatitis are included in the following databases: Web of Science, PubMed, Science Direct, Wan Fang Data Knowledge Service Platform, Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP database), China National Knowledge Infrastructure (CNKI), and EMBASE. All RCTs on acupoint or related interventions will be included we will also conduct unpublished academic research data. Databases will be searched from inception to Dec 2019. Study inclusion, data extraction, and quality assessment will be performed independently by 2 reviewers. Assessment of risk of bias and data synthesis will be performed by RevMan 5.3 software. Cochrane criteria for risk-of-bias will be used to assess the methodological quality of the trials. RESULTS According to the data of effective rate, quality of life, the cure rate, the recurrent rate, and the complications rate, this study will provide an evidence-based review of acupoint therapies for prostatitis. CONCLUSION This systematic review will evaluate the efficacy, and safety of the different acupoint-based therapies for prostatitis, we will recommend which acupoint therapies may be considered as the effective treatment for prostatitis, and show how it might work. PROSPERO REGISTRATION NUMBER DOI 10.17605/OSF.IO/H7KQJ.
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Affiliation(s)
- Kun Zhu
- Hospital of Chengdu University of Traditional Chinese Medicine
- Chengdu University of Traditional Chinese Medicine, PR China
| | - Yifeng Shen
- Hospital of Chengdu University of Traditional Chinese Medicine
| | - Yi Zhu
- Chengdu University of Traditional Chinese Medicine, PR China
| | - Lan Li
- Chengdu University of Traditional Chinese Medicine, PR China
| | - Yaodong You
- Hospital of Chengdu University of Traditional Chinese Medicine
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Appiya Santharam M, Khan FU, Naveed M, Ali U, Ahsan MZ, Khongorzul P, Shoaib RM, Ihsan AU. Interventions to chronic prostatitis/Chronic pelvic pain syndrome treatment. Where are we standing and what's next? Eur J Pharmacol 2019; 857:172429. [PMID: 31170381 DOI: 10.1016/j.ejphar.2019.172429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 12/29/2022]
Abstract
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 Tregs expressing chimeric receptors may improve the treatment outcomes by inducing immune tolerance and controlling expression of pro-inflammatory cytokines.
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Affiliation(s)
- Madanraj Appiya Santharam
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester LE1 9HN, United Kingdom
| | - Farhan Ullah Khan
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Jiangsu Province, Nanjing, 211198, PR China; Shanghai Jiao Tong University, School of Pharmacy, 800 Dongchuan Road, Shanghai, 200240, China
| | - Muhammad Naveed
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Jiangsu Province, Nanjing, 211166, PR China
| | - Usman Ali
- Shanghai Jiao Tong University, School of Pharmacy, 800 Dongchuan Road, Shanghai, 200240, China
| | - Muhammad Zaeem Ahsan
- Shanghai Jiao Tong University, School of Pharmacy, 800 Dongchuan Road, Shanghai, 200240, China
| | - Puregmaa Khongorzul
- State Key Laboratory of Natural Medicines, School of Life Science & Technology, China Pharmaceutical University, Nanjing, China
| | - Rana Muhammad Shoaib
- Shanghai Jiao Tong University, School of Pharmacy, 800 Dongchuan Road, Shanghai, 200240, China
| | - Awais Ullah Ihsan
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Jiangsu Province, Nanjing, 211198, PR China.
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Farmer T, Johnston M, Milica A, Hindley R, Emara A. Chronic Prostatitis/Chronic Pelvic Pain Syndrome: a Literature Review of NIH III Prostatitis. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00508-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Roy H, Offiah I, Dua A. Neuromodulation for Pelvic and Urogenital Pain. Brain Sci 2018; 8:brainsci8100180. [PMID: 30274287 PMCID: PMC6209873 DOI: 10.3390/brainsci8100180] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/21/2022] Open
Abstract
Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. In cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. However, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. The aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. Our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. However, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.
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Affiliation(s)
- Holly Roy
- Neurosurgery Department, University Hospitals Plymouth, Plymouth PL6 8DH, UK.
| | - Ifeoma Offiah
- Department of Obstetrics and Gynaecology, University Hospitals Plymouth, Plymouth PL6 8DH, UK.
| | - Anu Dua
- Department of Obstetrics and Gynaecology, University Hospitals Plymouth, Plymouth PL6 8DH, UK.
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Abstract
BACKGROUND Chronic prostatitis (CP) is a prevalent genitourinary condition. Considering its safety profile, acupuncture can be an option treating CP symptoms. The aim of this review is to undertake a systematic review to estimate the effectiveness and safety of acupuncture on CP. METHODS We will search all randomized controlled trials for CP in August 2018 in the databases of MEDLINE, Cochrane Library, Web of Science, EMBASE, Springer, WHO International Clinical Trials Registry Platform (ICTRP), China National Knowledge Infrastructure (CNKI), Wan fang, Chinese Biomedical Literature Database (CBM), PsycInfo, Chinese Scientific Journal Database (VIP), and other available resources. Languages are limited as English and Chinese. Search terms used are will "acupuncture," and "chronic prostatitis," "non-bacterial prostatitis," "abacterial prostatitis." And duplicates will be screened. The primary outcomes consisted of improvement rate and pain relief evaluated by The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) index. Secondary outcomes include the recurrence rate and side effects, such as pneumothorax, discomforts, and infection. RESULTS This study will demonstrate an evidence-based review of acupuncture for chronic prostatitis. CONCLUSION The study will provide clear evidence to assess the effectiveness and side effects of acupuncture for chronic prostatitis. ETHICS AND DISSEMINATION There is no requirement of ethical approval and it will be in print or disseminated by electronic copies. PROSPERO REGISTRATION NUMBER CRD42018088834.
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Affiliation(s)
- Tianzhong Peng
- Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi Province
| | - Ying Cheng
- Yunnan University of Traditional Chinese Medicine, Kunming, Yunnan Province, China
| | - Yuhao Jin
- Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi Province
| | - Na Xu
- Nanchang Hongdu Hospital of Traditional Chinese Medicine, Nanchang, Jiangxi Province
| | - Taipin Guo
- Yunnan University of Traditional Chinese Medicine, Kunming, Yunnan Province, China
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9
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Chronic Prostate Inflammation Predicts Symptom Progression in Patients with Chronic Prostatitis/Chronic Pelvic Pain. J Urol 2017; 198:122-128. [PMID: 28089730 DOI: 10.1016/j.juro.2017.01.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 01/27/2023]
Abstract
PURPOSE We examined the 4-year longitudinal association between histological prostate inflammation and chronic prostatitis/chronic pelvic pain syndrome. We also studied the development of new and progressing existing chronic prostatitis/chronic pelvic pain syndrome in men randomized to placebo in the REDUCE (REduction by DUtasteride of prostate Cancer Events) population. MATERIALS AND METHODS At multiple time points during 4 years univariable and multivariable analyses were performed between acute and chronic inflammation detected on baseline biopsies and the incidence of chronic pelvic pain syndrome-like symptoms, defined as a positive response to CPSI (Chronic Prostatitis Symptom Index) question 1a-perineal pain and/or question 2b-ejaculatory pain and a total pain subscore of at least 4, and progression of chronic prostatitis/chronic pelvic pain syndrome, defined as a 4-point or greater increase from baseline in total CPSI score, in patients with a baseline categorization of chronic prostatitis/chronic pelvic pain syndrome. RESULTS Of the 4,109 men in the study acute and chronic inflammation was detected in 641 (15.6%) and 3,216 (78.3%), respectively. Chronic prostatitis/chronic pelvic pain syndrome symptom status was available for 2,816 at baseline. Chronic prostatitis/chronic pelvic pain syndrome-like symptoms developed in 317 of 2,150 men without the condition at baseline who had followup data. Acute and chronic inflammation was not associated with the incidence of the symptoms (p >0.1). At a median followup of 12.0 months 109 of 145 men with baseline chronic prostatitis/chronic pelvic pain syndrome and followup data showed symptomatic progression. Chronic but not acute inflammation was significantly associated with shorter time to progression on univariable and multivariable analyses (p = 0.029 and 0.018, respectively). CONCLUSIONS Inflammation is not associated with an increased risk of chronic prostatitis/chronic pelvic pain syndrome. However, chronic inflammation predicts the risk of symptomatic progression in men in whom chronic prostatitis/chronic pelvic pain syndrome symptoms have been identified.
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Sahin S, Bicer M, Eren GA, Tas S, Tugcu V, Tasci AI, Cek M. Acupuncture relieves symptoms in chronic prostatitis/chronic pelvic pain syndrome: a randomized, sham-controlled trial. Prostate Cancer Prostatic Dis 2015; 18:249-54. [PMID: 25939517 DOI: 10.1038/pcan.2015.13] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 01/12/2015] [Accepted: 02/06/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are multiple approaches to the management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); and lately the data suggesting the ability of acupuncture treatment to decrease pain, positively impact quality of life and potentially modulate inflammation has suggested it as a potential therapeutic option for men with CP/CPPS. We conducted this study to determine whether acupuncture is really an effective therapeutic modality for CP/CPPS in terms of >50% decrease in total National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score from baseline compared with sham. METHODS One hundred patients with CP/CPPS (category III B) in an outpatient urology clinic were randomized to receive acupuncture at either seven acupoints bilaterally or sham points adjacent to these points. NIH-CPSI was completed by each patient before and 6, 8, 16, 24 weeks after the treatment. Mean values of total CPSI score and subscores after the treatment and on follow-up following the treatment were compared. RESULTS Of the acupuncture participants, 92% were NIH-CPSI responders (>50% decrease in total NIH-CPSI score from baseline) compared with 48% of sham participants, 8 weeks after the end of the therapy. Both groups experienced significant decrease in CPSI subscores throughout the whole follow-up period; however, the decline remained significantly greater in the active acupuncture group as compared with the sham group. CONCLUSIONS Our results show that the use of acupuncture in treatment of men with CP/CPPS symptoms resulted in a significant decrease in total NIH-CPSI scores.
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Affiliation(s)
- S Sahin
- Department of Urology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - M Bicer
- Department of Physical Treatment and Rehabilitation, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - G A Eren
- Department of Anesthesiology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - S Tas
- Department of Urology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - V Tugcu
- Department of Urology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - A I Tasci
- Department of Urology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - M Cek
- Department of Urology, Trakya University, Edirne, Turkey
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Khan A, Murphy AB. Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome. World J Pharmacol 2015; 4:1-16. [DOI: 10.5497/wjp.v4.i1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/03/2014] [Accepted: 01/20/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Zhao Y, Zhao W, Lang G, Chen Y, Liu J, Wang G, Ma X, Gong M, Xu D, Xia S. Circumcision plus antibiotic, anti-inflammatory, and α-blocker therapy for the treatment for chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, multicenter trial. World J Urol 2014; 33:617-22. [DOI: 10.1007/s00345-014-1350-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 06/16/2014] [Indexed: 12/14/2022] Open
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13
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Sung YH, Jung JH, Ryang SH, Kim SJ, Kim KJ. Clinical significance of national institutes of health classification in patients with chronic prostatitis/chronic pelvic pain syndrome. Korean J Urol 2014; 55:276-80. [PMID: 24741418 PMCID: PMC3988440 DOI: 10.4111/kju.2014.55.4.276] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/21/2013] [Indexed: 12/16/2022] Open
Abstract
Purpose We determined the effects of alpha-blockers and quinolone in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) classified by National Institute of Health (NIH) consensus group. Materials and Methods Data from a total of 111 patients who were diagnosed with CP/CPPS between June 2010 and June 2012 were analyzed retrospectively. The patients were classified into group 1 (category IIIA, n=40) and group 2 (category IIIB, n=71). Treatment using alfuzosin and levofloxacin was given to both groups for 6 weeks. International Prostate Symptom Score (IPSS) and NIH Chronic Prostatitis Symptom Index were measured before and after therapy. Results Group 1 had a significant decrease in total IPSS score, CPSI pain score, CPSI quality of life (QoL) score, and total CPSI score (p=0.043, p=0.006, p=0.015, and p=0.006, respectively). Group 2 had a significant decrease in IPSS voiding symptom score, IPSS storage symptom score, total IPSS, CPSI pain score, CPSI voiding score, CPSI QoL score, and total CPSI score (p=0.002, p=0.004, p=0.001, p=0.001, p=0.006, p=0.001, and p=0.001, respectively). The CPSI score was reduced by 6 points or more in 50.0% of patients (n=18) in group 1 and in 51.6% of patients (n=32) in group 2. However, there was no statistically significant difference between the changes in IPSS and CPSI scores across the 2 groups. Conclusions Although combination treatment reduced the CPSI score in both groups, there was no significant difference between the groups after combination treatment. We suggest that factors other than inflammation also contribute to symptoms associated with CP/CPPS.
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Affiliation(s)
- Yun Hsien Sung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung Hoon Ryang
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Jin Kim
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kwang Jin Kim
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea
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Koh JS, Ko HJ, Wang SM, Cho KJ, Kim JC, Lee SJ, Pae CU. The impact of depression and somatic symptoms on treatment outcomes in patients with chronic prostatitis/chronic pelvic pain syndrome: a preliminary study in a naturalistic treatment setting. Int J Clin Pract 2014; 68:478-85. [PMID: 24471930 DOI: 10.1111/ijcp.12340] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
AIM The aim of this study was to evaluate the impact of depression and somatic symptoms on treatment outcomes in Korean male patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) attending a routine clinical practice. METHODS This was a 12-week prospective observational study (n = 80). The Korean version of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) to measure the severity of CP/CPPS, the Korean version of the Patient Health Questionnaire-9 (PHQ-9) to assess depression, the Korean version of the Patient Health Questionnaire-15 (PHQ-15) to evaluate somatisation and the Korean version of the EuroQol Questionnaire-5 Dimensions (EQ-5D), specifically the EQ-5D utility index and the EQ-5D visual analogue scale (EQ-5D VAS), to assess quality of life, were utilised and given at baseline and week 12. The primary and secondary end-points in this study were changes in the NIH-CPSI total score from baseline to week 12 according to depression and somatisation. RESULTS The change in NIH-CPSI total score was significantly higher in those without depression than in those with depression (p = 0.003), with a magnitude of difference of 2.8. The responder rate (a ≥ 4 point decrease in NIH-CPSI total score from baseline) was significantly higher in those without depression (42.9%) than in those with depression (17.2%, p = 0.023). However, significant differences were not observed between the two groups in the other outcome measures or in all study outcomes between subjects with or without somatisation. A logistic regression analysis revealed that the presence or absence of depression may be a principal predictor of response to treatment. CONCLUSION These preliminary results indicate that depression may have a negative impact on treatment outcome and is a likely predictor of response to treatment in patients with CP/CPPS. However, additional studies with adequate power and improved design are necessary to further support the present findings.
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Affiliation(s)
- J S Koh
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
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Penna G, Fibbi B, Maggi M, Adorini L. Prostate autoimmunity: from experimental models to clinical counterparts. Expert Rev Clin Immunol 2014; 5:577-86. [DOI: 10.1586/eci.09.37] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Kim TH, Han DH, Cho WJ, Lee HS, You HW, Park CM, Ryu DS, Lee KS. The efficacy of extracorporeal magnetic stimulation for treatment of chronic prostatitis/chronic pelvic pain syndrome patients who do not respond to pharmacotherapy. Urology 2013; 82:894-8. [PMID: 23958510 DOI: 10.1016/j.urology.2013.06.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/18/2013] [Accepted: 06/21/2013] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the effect of extracorporeal magnetic stimulation (EMS) on symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men who did not respond to pharmacotherapy. METHODS Patients with chronic pelvic pain and/or voiding symptoms in the absence of urinary tract infection for at least 3 months in spite of medication were included in this study. All patients underwent EMS for 6 weeks for a total of 12 sessions. The primary endpoint was the changes in total and pain scores of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) at 24 weeks after treatment. Patients were also evaluated by International Prostate Symptom Score (IPSS), voiding diary, Benefit Satisfaction and Willingness (BSW) questionnaire, and patient perception of symptom improvement (PPSI). RESULTS A total of 46 men were included, and data from 37 patients who completed this study were analyzed. The baseline vs 24 weeks mean NIH-CPSI score was total score 25.0 ± 6.9 vs 15.6 ± 7.7, pain score 11.8 ± 3.7 vs 6.9 ± 4.7 (all P <.05). Total and subdomain sums of IPSS improved significantly after treatment, and the improvements were maintained until 24 weeks. Patient voiding diaries demonstrated a tendency toward a decrease in all subdomains after treatment. In BSW, >70% of patients reported positive answers to each domain at 24 weeks after treatment. PPSI measured by the visual analog scale was maintained from immediately after treatment until 24 weeks. CONCLUSION EMS offers a new treatment option for patients with CP/CPPS who do not respond to pharmacotherapy.
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Affiliation(s)
- Tae Heon Kim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Thakkinstian A, Attia J, Anothaisintawee T, Nickel JC. α-blockers, antibiotics and anti-inflammatories have a role in the management of chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2012; 110:1014-22. [PMID: 22471591 DOI: 10.1111/j.1464-410x.2012.11088.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Nickel JC, Shoskes DA. Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2010; 106:1252-63. [PMID: 20946349 DOI: 10.1111/j.1464-410x.2010.09701.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
• 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.
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Tugcu V, Tas S, Eren G, Bedirhan B, Karadag S, Tasci A. Effectiveness of acupuncture in patients with category IIIB chronic pelvic pain syndrome: a report of 97 patients. PAIN MEDICINE 2010; 11:518-23. [PMID: 20113410 DOI: 10.1111/j.1526-4637.2009.00794.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is of significant interest in urology and unfortunately, the therapy modalities recommended are not fully effective. Therefore, we undertook a pilot study to determine whether acupuncture improves the pain, voiding symptoms, and quality of life in men with category IIIB CP/CPPS. DESIGN Prospective, one-group trial, cohort study. SETTING Outpatient urology clinic. PATIENTS AND INTERVENTIONS Ninety-seven CP/CPPS patients received six sessions of acupuncture to the BL-33 acupoints once a week. The National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was completed by each patient before and after the treatment and on 12th and 24th weeks following the treatment. OUTCOME MEASURES Mean values of total CPSI score, pain subscore, urinary subscore, and quality of life subscore after the treatment and on follow-up after the treatment were compared with the baseline values. RESULTS There was a statistically significant decrease in all of the subscores evaluated at all periods compared with the baseline. Eighty-six patients out of 93 (92.47%) were NIH-CPSI responders (more than 50% decrease in total NIH-CPSI score from baseline) at the end of the treatment. CONCLUSIONS The results of this study suggest that acupuncture appears to be a safe and potentially effective treatment in improving the symptoms and quality of life of men clinically diagnosed with CP/CPPS.
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Affiliation(s)
- Volkan Tugcu
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Nickel JC, Krieger JN, McNaughton-Collins M, Anderson RU, Pontari M, Shoskes DA, Litwin MS, Alexander RB, White PC, Berger R, Nadler R, O'Leary M, Liong ML, Zeitlin S, Chuai S, Landis JR, Kusek JW, Nyberg LM, Schaeffer AJ. Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome. N Engl J Med 2008; 359:2663-73. [PMID: 19092152 PMCID: PMC2815340 DOI: 10.1056/nejmoa0803240] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In men with chronic prostatitis-chronic pelvic pain syndrome, treatment with alpha-adrenergic receptor blockers early in the course of the disorder has been reported to be effective in some, but not all, relatively small randomized trials. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate the efficacy of alfuzosin, an alpha-adrenergic receptor blocker, in reducing symptoms in men with chronic prostatitis-chronic pelvic pain syndrome. Participation in the study required diagnosis of the condition within the preceding 2 years and no previous treatment with an alpha-adrenergic receptor blocker. Men were randomly assigned to treatment for 12 weeks with either 10 mg of alfuzosin per day or placebo. The primary outcome was a reduction of at least 4 points (from baseline to 12 weeks) in the score on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) (range, 0 to 43; higher scores indicate more severe symptoms). A 4-point decrease is the minimal clinically significant difference in the score. RESULTS A total of 272 eligible participants underwent randomization, and in both study groups, 49.3% of participants had a decrease of at least 4 points in their total NIH-CPSI score (rate difference associated with alfuzosin, 0.1%; 95% confidence interval, -11.2 to 11.0; P=0.99). In addition, a global response assessment showed similar response rates at 12 weeks: 33.6% in the placebo group and 34.8% in the alfuzosin group (P=0.90). The rates of adverse events in the two groups were also similar. CONCLUSIONS Our findings do not support the use of alfuzosin to reduce the symptoms of chronic prostatitis-chronic pelvic pain syndrome in men who have not received prior treatment with an alpha-blocker. (ClinicalTrials.gov number, NCT00103402.)
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Affiliation(s)
- J Curtis Nickel
- Department of Urology, Queen's University, Kingston, ON, Canada.
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St Sauver JL, Jacobson DJ, McGree ME, Girman CJ, Lieber MM, Jacobsen SJ. Longitudinal association between prostatitis and development of benign prostatic hyperplasia. Urology 2008; 71:475-9; discussion 479. [PMID: 18342190 DOI: 10.1016/j.urology.2007.11.155] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Revised: 10/30/2007] [Accepted: 11/12/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To determine whether physician-diagnosed prostatitis was associated with later development of benign prostatic hyperplasia (BPH)-associated events in a longitudinal, population-based sample of 2447 men residing in Olmsted County, Minnesota. METHODS Medical records were reviewed for physician diagnosis of prostatitis and subsequent diagnoses of BPH, enlarged prostate, prostatism, and acute urinary retention. Records were also reviewed for medical or surgical treatments for BPH. Odds ratios were calculated to assess the associations between physician-diagnosed prostatitis and later development of development of BPH-associated events. RESULTS Physician-diagnosed prostatitis was associated with a 2.4-fold increased odds of receiving a later diagnosis of prostatism, enlarged prostate, or BPH (OR: 2.44, 95% CI: 1.48, 4.01). Prostatitis was also associated with a 70% increased odds of requiring later treatment for BPH (OR: 1.69, 95% CI: 1.28, 2.22), and a non-significant increased odds of acute urinary retention (OR: 1.33, 95% CI: 0.89, 1.99). CONCLUSIONS Physician-diagnosed prostatitis was associated with an increased risk of later onset of several BPH-associated events. Physician-diagnosed prostatitis may therefore be an early marker or a risk factor for development of later prostatic or urologic problems.
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22
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Dimitrakov J, Joffe HV, Soldin SJ, Bolus R, Buffington CAT, Nickel JC. Adrenocortical hormone abnormalities in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 2008; 71:261-6. [PMID: 18308097 DOI: 10.1016/j.urology.2007.09.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 07/03/2007] [Accepted: 09/16/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify adrenocortical hormone abnormalities as indicators of endocrine dysfunction in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS We simultaneously measured the serum concentrations of 12 steroids in patients with CP/CPPS and controls, using isotope dilution liquid chromatography, followed by atmospheric pressure photospray ionization and tandem mass spectrometry. RESULTS We evaluated 27 patients with CP/CPPS and 29 age-matched asymptomatic healthy controls. In the mineralocorticoid pathway, progesterone was significantly greater, and the corticosterone and aldosterone concentrations were significantly lower, in the patients with CP/CPPS than in the controls. In the glucocorticoid pathway, 11-deoxycortisol was significantly lower and the cortisol concentrations were not different between the patients and controls. In the sex steroid pathway, the androstenedione and testosterone concentrations were significantly greater in those with CP/CPPS than in the controls. The estradiol, dehydroepiandrosterone, and dehydroepiandrosterone sulfate concentrations were not different between the patients and controls. The National Institutes of Health-Chronic Prostatitis Symptom Index total and pain domain scores correlated positively with the 17-hydroxyprogesterone and aldosterone (P <0.001) and negatively with the cortisol (P <0.001) concentrations. CONCLUSIONS Our results suggest reduced activity of CYP21A2 (P450c21), the enzyme that converts progesterone to corticosterone and 17-hydroxyprogesterone to 11-deoxycortisol. Furthermore, these results provide insights into the biologic basis of CP/CPPS. Follow-up studies should explore the possibility that patients with CP/CPPS meet the diagnostic criteria for nonclassic congenital adrenal hyperplasia and whether the hormonal findings improve or worsen in parallel with symptom severity.
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Affiliation(s)
- Jordan Dimitrakov
- Harvard Urological Diseases Research Center, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Youn CW, Son KC, Choi HS, Kwon DD, Park K, Ryu SB. Comparison of the Efficacy of Antibiotic Monotherapy and Antibiotic Plus Alpha-blocker Combination Therapy for Patients with Inflammatory Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Korean J Urol 2008. [DOI: 10.4111/kju.2008.49.1.72] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Chul Woong Youn
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Kyung-Chul Son
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyang-Sik Choi
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Deuk Kwon
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Kwangsung Park
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Soo Bang Ryu
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
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Nickel JC. Treatment of chronic prostatitis/chronic pelvic pain syndrome. Int J Antimicrob Agents 2007; 31 Suppl 1:S112-6. [PMID: 17954024 DOI: 10.1016/j.ijantimicag.2007.07.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 07/12/2007] [Indexed: 12/24/2022]
Abstract
Acceptance of the National Institutes of Health definition of Category III Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) and the development and validation of the Chronic Prostatitis Symptom Index has stimulated significant research into treatment of this condition. Evidence-based suggestions for treatment include the following. (i) Antimicrobials cannot be recommended for men with longstanding, previously treated CP/CPPS. (ii) Alpha-blockers can be recommended as first-line medical therapy, particularly in alpha-blocker-naïve men with moderately severe symptoms who have relatively recent onset of symptoms. (iii) Alpha-blockers cannot be recommended in men with longstanding CP/CPPS who have tried and failed alpha-blockers in the past. And (iv) anti-inflammatory therapy, finasteride and pentosan polysulfate are not recommended as primary treatment; however, they may have a useful adjunctive role in a multimodal therapeutic regimen. Early data on herbal therapies, particularly quercetin and cernilton, are intriguing, but larger multicentre, randomised, placebo-controlled trials are required before a high level of evidence recommendation can be made on its use. At this time, surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.
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Affiliation(s)
- J Curtis Nickel
- Department of Urology, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada.
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Abstract
The prostate is one of the main male sex accessory glands and the target of many pathological conditions affecting men of all ages. Pathological conditions of the prostate gland range from infections, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) of a still unknown aetiology to benign hyperplasia and cancer. CP/CPPS is one of the most prevalent diseases in the urologic clinic and affects men younger than 50 years old. A significant advance in the understanding of CP/CPPS was made when an autoimmune response against prostate antigens was revealed in a considerable number of patients. During the last 30 years, extensive work has been done regarding the development and characterization of different rodent models of experimental autoimmune prostatitis (EAP). It has been demonstrated that tolerance to prostate antigens can be disrupted in some strains of rats and mice and cellular and humoral responses to prostate antigens are elicited. A Th1 pattern has been described and the cellular response seems to be the major pathogenic mechanism involved. Immune cells infiltrate the gland and induce prostate lesions. The genetic background and hormonal imbalance are factors that could contribute to the onset of the disease in susceptible young males. Moreover, spontaneous autoimmune prostatitis could also occur with advanced age in susceptible strains. In this review, we summarize the current knowledge regarding rodent models of EAP and the immunological alterations present in CP/CPPS patients. We also discuss the reliability of these experimental approaches as genuine tools for the study of human disease.
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Affiliation(s)
- R D Motrich
- Departamento de Bioquímica Clínica, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Haya de la Torre y Medina Allende, Ciudad Universitaria, Córdoba, Argentina
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Nickel JC, Roehrborn CG, O'leary MP, Bostwick DG, Somerville MC, Rittmaster RS. Examination of the relationship between symptoms of prostatitis and histological inflammation: baseline data from the REDUCE chemoprevention trial. J Urol 2007; 178:896-900; discussion 900-1. [PMID: 17632164 DOI: 10.1016/j.juro.2007.05.041] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE Symptoms of abacterial chronic prostatitis/chronic pelvic pain syndrome are considered to be associated with prostate inflammation. The ongoing Reduction by Dutasteride of Prostate Cancer Events trial is a 4-year, phase III, placebo controlled study to determine whether 0.5 mg dutasteride daily decreases the risk of biopsy detectable prostate cancer. All men underwent biopsy before study entry, allowing review of the relationship between histological prostate inflammation and prostatitis symptoms. MATERIALS AND METHODS Eligible men were 50 to 75 years old with serum prostate specific antigen 2.5 ng/ml or greater and 10 ng/ml or less (ages 50 to 60 years), or 3.0 ng/ml or greater and 10 ng/ml or less (older than 60 years), and an International Prostate Symptom Score of less than 25 (or less than 20 if already on alpha-blocker therapy). Acute prostatitis was an exclusion criterion. The National Institutes of Health Chronic Prostatitis Symptom Index was used to assess prostatitis-like symptoms. Spearman rank correlations were used to assess the relationship between acute and chronic inflammation, and Chronic Prostatitis Symptom Index scores for the pain, urinary symptoms and quality of life domains as well as average pain, total score and prostatitis-like symptoms. RESULTS Data were available on 5,597 patients. The distribution of inflammation status was similar for those with and without chronic prostatitis-like symptoms. Significant correlations were found between average chronic inflammation, and total Chronic Prostatitis Symptom Index score and subscores for urinary symptoms and quality of life but the magnitude of these correlations was small. CONCLUSIONS A lack of clinically meaningful association was found between prostatitis-like pain symptoms and histological inflammation in the Reduction by Dutasteride of Prostate Cancer Events population, suggesting that the view that symptoms of chronic prostatitis/chronic pelvic pain syndrome and prostate inflammation are associated needs further scrutiny.
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Affiliation(s)
- J Curtis Nickel
- Department of Urology, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada.
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Magri V, Trinchieri A, Pozzi G, Restelli A, Garlaschi MC, Torresani E, Zirpoli P, Marras E, Perletti G. Efficacy of repeated cycles of combination therapy for the eradication of infecting organisms in chronic bacterial prostatitis. Int J Antimicrob Agents 2007; 29:549-56. [PMID: 17336504 DOI: 10.1016/j.ijantimicag.2006.09.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Revised: 09/15/2006] [Accepted: 09/16/2006] [Indexed: 11/21/2022]
Abstract
A total of 137 patients with a diagnosis of chronic bacterial prostatitis (CBP) were subjected to combination pharmacological therapy with antibacterial agents (ciprofloxacin/azithromycin), alpha-blockers (alfuzosin) and Serenoa repens extracts. Of those, 88 patients (64.2%) showed microbiological eradication at the completion of a 6-week cycle of therapy. Of the remaining 49 patients showing persistence of the causative organism(s) or reinfection at the end of treatment, 36 completed a second cycle of combination therapy for 6 weeks: 27 patients (75%) showed eradication of the causative organism, whereas in nine cases persistence or reinfection was observed. The cumulative eradication rate of the present study - calculated on a total of 137 enrolled patients - is 83.9%. Clinical examination showed a marked improvement of signs and symptoms linked to prostatitis. Remarkably, combination therapy could attenuate CBP symptoms prior to microbiological eradication, thus rapidly decreasing the impact of the disease on the quality of life of patients. Clinical remission was extended throughout a follow-up period of 30 months for 94% of patients, whereas seven patients showed relapse of the disease. In summary, our results indicate that about 20% of patients enrolled in this study, who were refractory to a protocol of 6-week combination therapy, could be 'rescued' by a second cycle of treatment. Clinical follow-up data show that combination therapy could ensure extended relief from CBP symptoms, and a general improvement in quality of life.
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Affiliation(s)
- Vittorio Magri
- Urology and Sonography Outpatient Clinic, Istituti Clinici di Perfezionamento, Milan, Italy
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Lee SWH, Liong ML, Yuen KH, Liong YV, Krieger JN. Chronic prostatitis/chronic pelvic pain syndrome: role of alpha blocker therapy. Urol Int 2007; 78:97-105. [PMID: 17293646 DOI: 10.1159/000098064] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This article reviews the rationale and data supporting alpha blocker therapy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), the most common and difficult prostatitis syndrome. METHODS Systematic review identified ten clinical trials evaluating alpha blocker therapy for patients with CP/CPPS, including five open-label or small prospective studies and five double-blinded and placebo-controlled clinical trials. RESULTS Encouraging results in uncontrolled and small clinical trials led to the development of reasonably powered, double-blinded, placebo-controlled, randomized clinical trials evaluating terazosin, doxazosin, tamsulosin, and alfuzosin. CONCLUSIONS Current data suggest that treatment-naïve and/or newly diagnosed patients appear more likely to respond than long-term, chronic refractory patients. Longer courses of treatment (12 weeks to 6 months) appear superior to shorter courses, and less selective agents appear superior to more selective alpha1 blockers. These observations outline important questions that must be answered to define optimal treatment strategies for patients with CP/CPPS.
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Affiliation(s)
- Shaun Wen Huey Lee
- Department of Urology, University of Washington School of Medicine, Seattle, Wash. 98195, USA
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Forrest JB, Nickel JC, Moldwin RM. Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Male Interstitial Cystitis: Enigmas and Opportunities. Urology 2007; 69:60-3. [PMID: 17462482 DOI: 10.1016/j.urology.2006.08.1106] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Revised: 05/22/2006] [Accepted: 08/14/2006] [Indexed: 11/21/2022]
Abstract
Recently, it has been recognized that interstitial cystitis (IC) in males is a more common clinical entity than was previously thought. Further, increasing evidence suggests clinical and pathogenetic similarities between male IC and chronic nonbacterial prostatitis (CP)/chronic pelvic pain syndrome. In this article, we highlight the similarities and differences between male IC and CP and review the presentation, diagnosis, and treatment of IC in men, with particular attention to those who have received an initial diagnosis of CP.
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Affiliation(s)
- John B Forrest
- University of Oklahoma Health Science Center-Tulsa, Tulsa, Oklahoma, USA.
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Capodice JL, Jin Z, Bemis DL, Samadi D, Stone BA, Kapan S, Katz AE. A pilot study on acupuncture for lower urinary tract symptoms related to chronic prostatitis/chronic pelvic pain. Chin Med 2007; 2:1. [PMID: 17284322 PMCID: PMC1800847 DOI: 10.1186/1749-8546-2-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Accepted: 02/06/2007] [Indexed: 11/19/2022] Open
Abstract
Background The etiology and treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) remain poorly understood. Pain, lower urinary tract voiding symptoms and negative impact on quality of life (QOL) are the most common complaints. Acupuncture, which has been widely used to treat painful and chronic conditions, may be a potential treatment to alleviate the constellation of symptoms experienced by men with CP/CPPS. The purpose of our study was to assess the impact of standardized full body and auricular acupuncture in men refractory to conventional therapies and collect pilot data to warrant further randomized trials. Methods Ten men diagnosed with category IIIA or IIIB CP/CPPS >6 months, refractory to at least 1 conventional therapy (antibiotics, anti-inflammatory agents, 5-α reductase inhibitors, α-1 blockers) and scoring >4 on the pain subset of the NIH-CPSI were prospectively analyzed in an Institutional Review Board (IRB) approved, single-center clinical trial (Columbia University Medical Center IRB#AAAA-7460). Standardized full body and auricular acupuncture treatment was given twice weekly for 6 weeks. The primary endpoints were total score of the NIH-CPSI and assessment of serious adverse events. The secondary endpoints were individual scores of the NIH-CPSI and QOL questionnaire scores of the short-form 36 (SF-36). Results The median age of the subjects was 36 years (range 29–63). Decreases in total NIH-CPSI scores (mean ± SD) after 3 and 6 weeks from baseline (25.1 ± 6.6) were 17.6 ± 5.7 (P < 0.006) and 8.8 ± 6.2 (P < 0.006) respectively and remained significant after an additional 6 weeks of follow-up (P < 0.006). Symptom and QOL/NIH-CPSI sub-scores were also significant (P < 0.002 and P < 0.002 respectively). Significance in 6 of 8 categories of the SF-36 including bodily pain (P < 0.002) was achieved. One regression in the SF-36 vitality category was observed after follow-up. There were no adverse events. Conclusion The preliminary findings, although limited, suggest the potential therapeutic role of acupuncture in the treatment of CP/CPPS. Data from this and previous studies warrant randomized trials of acupuncture for CP/CPPS and particular attention towards acupuncture point selection, treatment intervention, and durability of acupuncture.
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Affiliation(s)
- Jillian L Capodice
- Department of Urology, Columbia University Medical Center, New York, NY 10032, USA
| | - Zhezhen Jin
- Department of Biostatistics, Columbia University Medical Center, New York, NY, 10032, USA
| | - Debra L Bemis
- Department of Urology, Columbia University Medical Center, New York, NY 10032, USA
| | - David Samadi
- Department of Urology, Columbia University Medical Center, New York, NY 10032, USA
| | - Brian A Stone
- Department of Urology, Columbia University Medical Center, New York, NY 10032, USA
| | - Steven Kapan
- Department of Urology, Weill Cornell Medical College, New York, NY, 10022, USA
| | - Aaron E Katz
- Department of Urology, Columbia University Medical Center, New York, NY 10032, USA
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Vykhovanets EV, Resnick MI, MacLennan GT, Gupta S. Experimental rodent models of prostatitis: limitations and potential. Prostate Cancer Prostatic Dis 2007; 10:15-29. [PMID: 17199136 DOI: 10.1038/sj.pcan.4500930] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Prostatitis is a polyetiological inflammation of the prostate gland in men characterized by pelvic pain, irritative voiding symptoms, and sexual dysfunction. Histologically prostatitis is characterized by poly- and mononuclear cell infiltrates (neutrophils, lymphocytes, macrophages and plasma cells) in the stromal connective tissue around the acini or ducts. Prostatitis is an important worldwide health problem in men. The pathogenesis and diagnostic criteria for the condition are obscure, with the result that the development of management programs for this condition has been hindered. Animal model(s) might be useful in elucidating mechanisms involved in the molecular pathogenesis of chronic nonbacterial prostatitis and chronic pelvic pain syndrome. Given that prostatitis might have a multifactorial etiology, several animal models with unique features may prove helpful. This review examines a number of experimental rodent models of prostatitis and evaluates their advantages and limitations.
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Affiliation(s)
- E V Vykhovanets
- Department of Urology, Case Western Reserve University & University Hospitals of Cleveland, Cleveland, OH 44106, USA
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Abstract
Prostatic disease continues to present clinicians with challenges. Although giant strides have been made in the medical and surgical management of benign prostatic hyperplasia, many fundamental questions about its pathogenesis, progression, and treatment efficacy remain unanswered. Prostate cancer also continues to be an area in which progress is needed despite major recent advancements. Numerous debates that include the value of prostate-specific antigen screening and appropriate roles for each of the numerous therapeutic modalities await resolution. For millions of patients who suffer from prostatitis, a major breakthrough is yet to come. Current treatment regimens for prostatitis remain ineffective at best. Contemporary approaches to the pathogenesis, diagnosis, and treatment of benign prostatic hyperplasia, prostate cancer, and prostatitis are discussed in this review.
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Affiliation(s)
- Alexander Kutikov
- Division of Urology, Department of Surgery, University of Pennsylvania Medical Center, 9 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Abstract
Prostatitis is a common urologic diagnosis. Although treatment algorithms are available for this poorly understood entity, several adaptations must be made in order to accommodate the therapeutic needs of HIV-positive patients. The most important consideration when treating HIV-infected patients for prostatitis is their current immune status, whether they are immunocompromised or not (non-progressive disease or reconstituted with highly active antiretroviral therapy). A treatment algorithm for those with chronic bacterial prostatitis (Category II), chronic nonbacterial prostatitis (Category IIIA), and prostatodynia (Category IIIB) is presented in this article. In the HIV-positive patient population, there is a greater likelihood for atypical pathogens including fungi, tuberculosis, anaerobes, and viruses. Because the HIV-infected patient is at increased risk for the development of prostatic abscess and urosepsis than the general population, increased monitoring and evaluation and longer-term appropriately directed antimicrobial therapy are required.
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Affiliation(s)
- Vincent M Santillo
- Columbia University, College of Physicians and Surgeons, Department of Urology, St. Luke's-Roosevelt Hospital, 425 W 59th Street, #3A, New York, NY 10019, USA
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Nickel JC, Elhilali M, Emberton M, Vallancien G. The beneficial effect of alfuzosin 10 mg once daily in 'real-life' practice on lower urinary tract symptoms (LUTS), quality of life and sexual dysfunction in men with LUTS and painful ejaculation. BJU Int 2006; 97:1242-6. [PMID: 16686719 DOI: 10.1111/j.1464-410x.2006.06171.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of the selective alpha(1)-blocker alfuzosin in men with lower urinary tract symptoms (LUTS) and painful ejaculation, compared with those with LUTS only, as painful ejaculation is one of the most prevalent, differentiating and bothersome symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. PATIENTS AND METHODS In all, 4857 sexually active men with LUTS had an evaluable answer to the Danish Prostate Symptom Score for Sexual Symptoms question related to pain/discomfort on ejaculation at enrolment in a 6-month open-label study with alfuzosin 10 mg once daily. Efficacy was analysed at the endpoint in the intent-to-treat population. RESULTS Of the 4857 men, 997 (20.5%) had pain/discomfort on ejaculation and 889/997 (89.2%) considered it was a problem. At inclusion, men with painful ejaculation had more severe LUTS and bother than men with LUTS only. Erectile dysfunction (ED) and reduced ejaculation were more prevalent (74.5% and 71.9%, respectively) and bothersome in men with painful ejaculation than in those with no pain (59.6% and 57.4%, respectively). Under alfuzosin treatment, all variables in both groups significantly improved from baseline; men with painful ejaculation compared to LUTS-only had similar improvements in weighted scores for LUTS (-7.8 vs -7.7), bother (-1.7 vs -1.7), and reduced ejaculate (-0.5 vs -0.4) but greater improvements in ED (-0.6 vs -0.4; P < 0.001). The weighted score for painful ejaculation decreased from 2.2 to 0.8 (P < 0.001). Alfuzosin was well tolerated in both groups. CONCLUSIONS This 6-month open-label study suggests that alfuzosin 10 mg once daily significantly improves LUTS, quality of life and sexual function in men with prostatitis-like symptoms, and is well tolerated.
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Affiliation(s)
- J Curtis Nickel
- Department of Urology, Queen's University, Kingston, ON, Canada.
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Abstract
We review the diagnosis, categorization, and treatment of prostatitis/chronic pelvic pain syndrome based on the National Institutes of Health (NIH) classification. Prostatitis is an extremely common syndrome that afflicts 2%-10% of men. Formerly a purely clinical diagnosis, prostatitis is now classified within a complex series of syndromes (NIH category I-IV prostatitis) that vary widely in clinical presentation and response to treatment. Acute bacterial prostatitis (category I) and chronic bacterial prostatitis (category II) are characterized by uropathogenic infections of the prostate gland that respond well to antimicrobial treatment. In contrast, chronic prostatitis/chronic pelvic pain syndrome (category III), which accounts for 90%-95% of prostatitis cases, is of unknown etiology and is marked by a mixture of pain, urinary, and ejaculatory symptoms with no uniformly effective therapy. Asymptomatic inflammatory prostatitis (category IV) is an incidental finding of unknown clinical significance. This review describes the current status of prostatitis syndromes and explores the future prospects of new diagnostic tools and therapies.
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Affiliation(s)
- Geoffrey M Habermacher
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Abstract
PURPOSE OF REVIEW To investigate the relationship, diagnosis and treatment of the overlapping lower urinary tract symptoms experienced by men diagnosed with benign prostatic hyperplasia and prostatitis. RECENT FINDINGS Recent studies have clearly shown that men can suffer from both benign prostatic hyperplasia and prostatitis. Approximately 5-20% of men diagnosed with benign prostatic hyperplasia suffer from prostatitis-like symptoms, while over one third of men diagnosed with benign prostatic hyperplasia have had a diagnosis of prostatitis in the past. Differentiation between these two symptom-based medical conditions can be difficult because of overlapping symptoms, but pain clearly identifies those patients with chronic prostatitis. Treatment for men with co-occurring benign prostatic hyperplasia and prostatitis may include alpha-blockers, 5alpha-reductase inhibitors and phytotherapies (saw palmetto and bee pollen extract), with evidence clearly showing the benefits of alpha-blocker therapy. SUMMARY Benign prostatic hyperplasia and chronic prostatitis are a common cause of lower urinary tract symptoms and frequently co-occur in older men. The best treatment for men with lower urinary tract symptoms associated with both benign prostatic hyperplasia and prostatitis is alpha-blockers.
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Affiliation(s)
- J Curtis Nickel
- Department of Urology, Queen's University, Kingston, Ontario, Canada.
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Mo KI, Lee KS, Kim DG. Efficacy of Combination Therapy for Patients with Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Prospective Study. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.5.536] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Kyo Ik Mo
- Department of Urology, College of Medicine, Dongguk University, Gyeongju, Korea
| | - Kyung Seop Lee
- Department of Urology, College of Medicine, Dongguk University, Gyeongju, Korea
| | - Dae Gon Kim
- Department of Urology, College of Medicine, Dongguk University, Gyeongju, Korea
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Smith RD. The three As of chronic prostatitis therapy: antibiotics, alpha-blockers and anti-inflammatories. what is the evidence? BJU Int 2005; 95:1117. [PMID: 15839947 DOI: 10.1111/j.1464-410x.2005.5547_1.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is prevalent in urological practice and has a significant impact on quality of life. Standard therapies often fail to achieve sustainable amelioration of symptoms. This article attempts to show that neuromodulatory treatment in the form of electroacupuncture can be a minimally invasive and effective treatment for CP/CPPS that is refractory to standard therapies. This neuromodulatory therapy lends support to the hypothesis that the end stage of CP/CPPS may be a neuropathic pain syndrome.
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Affiliation(s)
- Richard C T Chen
- King Street Medical Arts Centre, 71 King Street, W. Suite 400, Mississauga, Ontario, L5B4A2, Canada
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