Drs Jon Rees and Alison Cooper explain how prostatitis can have a wide range of clinical presentations and that an individualised, symptom-based approach is needed
- CBP and CP/CPPS show a range of clinical manifestations, mainly as urogenital pain, LUTS (voiding or storage symptoms), psychological issues, or sexual dysfunction
- Initial assessment in primary care should include physical examination and testing for STI and PSA
- A symptom-based approach to treatment is recommended, but repeated use of antibiotics should be avoided if there is no evidence of benefit
- In patients with early-stage CBP and CP/CPPS who present with pain symptoms, the use of opioids for pain relief should be avoided, due to the risk of opioid dependency
- Patients with CBP or CP/CPPS should be managed according to their individual symptom pattern
- Early use of antineuropathic pain medication should be considered for all patients with CBP and CP/CPPS who are refractory to initial treatments. If neuropathic pain is suspected, ensure a quick referral to the MDT, which includes pain specialists
- Early referral to specialist services, ideally to a clinician with an interest in the management of CBP and/or CP/CPPS, but not necessarily a urologist, should be considered when patients fail to respond to initial measures
- An MDT approach should be implemented and made available to all patients with CBP and CP/CPPS
- Patients should be fully informed about the possible underlying causes of and treatment options for CBP and CP/CPPS. The MDT responsible for the management of these patient groups should be able to explain the chronic pain cycle and other relevant information to improve patient understanding of the conditions.
CBP=chronic bacterial prostatitis; CP/CPPS= chronic prostatitis/chronic pelvic pain syndrome; LUTS=lower urinary tract symptoms; STI=sexually transmitted infection; PSA=prostate specific antigen; MDT=multidisciplinary team
P rostatitis is a common condition, with 35%–50% of men reported to be affected by symptoms suggesting prostatitis during their lifetime.1 Based on a population of over 10,600 participants, a systematic review found an 8.2% prevalence of prostatitis symptoms.2 The condition affects men of all ages, although it is most prevalent among those aged 36–50 years.3
The symptomatic, chronic forms of prostatitis, as defined by the US National Institutes of Health (NIH; for further information, see here), are: 4
- chronic bacterial prostatitis (CBP; NIH category II)
- chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS; NIH category III).
The classification system highlights an important point: that although the description ‘prostatitis’ suggests the presence of infection and inflammation, this is not always the case.
There are a wide range of clinical presentations of CBP and CP/CPPS, arising from the variety of possible underlying aetiologies (e.g. bacterial infection and/or inflammation and/or neurological damage), which can vary between patients and fluctuate over time.
The main four symptom domains of CBP and CP/CPPS are:5
- urogenital pain
- lower urinary tract symptoms (LUTS)
- psychological issues
- sexual dysfunction.
While some of the symptoms experienced by men with CP/CPPS do originate from the prostate, pain symptoms are often generated by other structures (e.g. muscles, nerves, and bony structures) within the pelvis, abdomen, and spine, or by neuropathic mechanisms.6–8
The need for a guideline
CBP and CP/CPPS have a significant impact on patients’ quality of life9 and present diagnostic and therapeutic challenges for physicians. Since CP is poorly understood, underdiagnosed, and difficult to treat, there is a lack of robust published evidence and guidance on how to recognise and manage the condition, particularly for practitioners working in primary care.1 A guideline to address these issues was therefore published by Prostate Cancer UK in September 2014: Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline (this can be accessed at: prostatecanceruk.org/prostatitisguideline).8
Remit of the guideline
The guideline population was men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months).8
A Prostatitis Expert Reference Group (PERG) was convened by Prostate Cancer UK, with members from primary care, urology (medical and nurse specialists), pain, physiotherapy and psychology specialties, as well as patient representatives, to develop a consensus guideline with three main goals:8
- to provide guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non-specialist and specialist settings
- to improve awareness and recognition of these conditions among non-specialists and patients
- to promote efficient referral of care between non-specialists and specialists and the involvement of the multidisciplinary team.
Because of the limited number of published Randomised Controlled Trials (RCTs) in CBP and CP/CPPS, the PERG concluded that the guideline would benefit from a supporting web-based Delphi panel to gather individual opinions from experts to form consensus recommendations in areas where high quality, published evidence was lacking.8
Box 1: Typical presentation of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome
- Urogenital pain—typically pain in the perineum, but also lower abdomen, groin, low back, testes, tip of penis. Pain is often neuropathic; it is suggested it may start with an episode of infection or inflammation, but continues after resolution owing to pain sensitisation
- Urinary symptoms—CBP and CP/CPPS is often associated with LUTS:
- voiding (hesitancy and weak stream)
- storage (urgency and frequency)
- sometimes dysuria or urethral burning independent of micturition
- Sexual dysfunction—erectile dysfunction, ejaculatory dysfunction (particularly pain or discomfort), and loss of libido are common
- Psychosocial symptoms—anxiety and depression are common, with severe impact on quality of life.
- CBP=chronic bacterial prostatitis; CP/CPPS=chronic prostatitis/chronic pelvic pain syndrome; LUTS=lower urinary tract symptoms
Assessment and diagnosis
History-taking should focus on the symptoms listed in Box 1 (above). As an aid to the clinical assessment of CBP and CP/CPPS, both in terms of initial evaluation and during therapeutic monitoring, validated symptom-scoring instruments are available, including:
- Urinary, Psychosocial, Organ-specific, Infection, Neurological/systemic and Tenderness (UPOINT) scale10
- NIH-Chronic Prostatitis Symptom Index (CPSI)11
- International Prostate Symptom Score (IPSS)8
- International Index of Erectile Function (IIEF-5)8
- Sexual Health Inventory for Men (SHIM)8
- Patient Health Questionnaire-9 (PHQ-9)8
- Generalised Anxiety Disorder-7 (GAD-7).8
A summary of the investigations and physical examinations that should be considered during clinical assessment, including whether they are considered core or optional, and in which setting they are typically completed (specialist or non-specialist), are detailed in Table 1 (below).8 To establish the diagnosis of CBP or CP/CPPS, the patient should have a history of persistent or recurrent symptoms, with the absence of other urogenital pathology, for a minimum of 3 out of the past 6 months. However, some men have fluctuating symptoms and, in practice, the diagnosis is often suspected after a shorter symptom duration.
|Examinations and investigationsa||Setting||Rating|
Digital rectal examination
Including assessment of external genitalia and pelvic floor muscle dysfunction
To exclude other causes of abdominal pain
|Urine dipstick and/or MSU for culture/microscopy||✓||✓||✓|
|Four-glass or two-glass test:b
|Tests to rule out differential diagnoses:c
PSA testing to exclude prostate cancer
|STI screen (eg. via NAATs)||✓||✓||✓|
|Uroflowmetry, retorgrade urethrography or cystoscopy (to exclude BOO, urethral stricture or bladder neck stenosis)||✓||✓|
|Prostate biopsy (only if prostate cancer is suspected on basis of PSA and/or DRE results||✓||✓|
|Transrectal ultrasound (only in refractory patients in whom a prostatic abscess or other pathology is suspected)||✓||✓|
|Diagnostic cystoscopy if bladder cancer is suspected||✓||✓|
|Urethral swab and culture if urethritis is suspected||✓||✓|
|MRI if prostatic abscess suspected||✓||✓|
See Figure 1, below, for a treatment algorithm to guide the management of patients with suspected or confirmed CBP or CP/CPPS in primary care.8
A symptom-based approach to treatment is recommended at an early stage. As outlined in Figure 1, the guideline8 recommends an initial course of an antibiotic for all patients (e.g. ciprofloxacin 500 Morning twice daily for 4–6 weeks), with an alpha- adrenergic antagonist (e.g. tamsulosin 400 μg once daily) if voiding lower urinary tract symptoms are present and simple analgesics/non-steroidal anti-inflammatories if pain is present. Repeated use of antibiotics should be avoided if there is no obvious benefit from infection control or cultures do not support an infectious cause.
For patients who do not respond to initial measures and in whom pain is considered to be neuropathic, early treatment with a gabapentanoid (e.g. gabapentin 100 mg–300 mg at night), a tricyclic antidepressant (amitriptyline 10 mg in the evening), or a serotonin-noradrenaline reuptake inhibitor (duloxetine 30 mg in the evening) should be considered (as recommended in NICE CG173 for the management of neuropathic pain).12 In patients with early-stage CBP and CP/CPPS presenting with pain symptoms, the use of opioids for pain relief should be avoided, due to the risk of opioid dependency.8
When to refer
Early referral to specialist services is suggested for men with severe symptoms or where there is diagnostic uncertainty. This may be to a urologist with an interest in the field, a pain physician, or a sexual health clinic. Patients should be fully informed about the possible underlying causes and treatment options to help improve patient understanding of the condition. This may include an explanation of the chronic pain cycle,13 the routes of pain (neuropathic versus nociceptive) and the basic anatomy of the pelvic region (e.g. position of the pelvic floor muscle).
A multidisciplinary team (MDT) approach should be implemented and made available to patients with CBP and CP/CPPS. The MDT should include urologists, pain specialists, nurse specialists, specialist physiotherapists, GPs, cognitive behavioural therapists/ psychologists, and sexual health specialists. Patients should be fully informed about the possible underlying causes of and treatment options for CBP and CP/CPPS. The MDT responsible for the management of these patient groups should be able to explain the chronic pain cycle and other relevant information to improve patient understanding of the conditions.
Key priorities in primary care
The key priorities for implementation of the guideline in primary care are shown in Box 2, below.
Box 2: Key priorities for primary care
- Not all men with CP/CPPS present with the classic picture of persistent perineal pain:
- recognising the condition in its many different forms is a vital step to successful management
- Complex investigations are not required for the majority of patients with CP/CPPS:
- a digital rectal examination, urine tests to exclude UTI and STI, plus consideration of PSA testing are the core tests
- Many men with CP/CPPS are given recurrent courses of antibiotics; these may have some effect, but this may be largely a placebo response. A symptom-based management strategy, including neuropathic medication, can be far more effective
- Referral to secondary care, when required, should ideally be to a clinician with a specialist interest in prostatitis: this may be a urologist, pain physician, or sexual health consultant.
- CP/CPPS=chronic prostatitis/chronic pelvic pain syndrome; UTI=urinary tract infection; STI=sexually transmitted infection.
Chronic bacterial prostatitis (CBP) and CP/CPPS can present with a wide variety of signs and symptoms. For primary care practitioners who are treating or advising patients, this guideline will make an important contribution to improving confidence and consistency in assessment and diagnosis of CBP and CP/CPPS as well as ensuring that an individualised, symptom-based treatment approach is followed.
Prostate Cancer UK is grateful to the following PERG members for giving their time and expertise to develop this guideline: Mark Abrahams; Victor Abu; Trevor Allan; Alison Cooper; Andrew Doble; Kirsty Haves; Jenny Lee; Sarah Mee; Theresa Neale; Penny Nixon; Jon Rees (Chair), and Maxwell Saxty.
The authors also thank all Delphi panel members who participated in the process. Fiona Carter, of South West Training Surgical Network, provided consultancy services during the Delphi panel process. Hayward Medical Communications provided writing and editorial support.
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
- Chronic prostatitis and chronic pelvic pain syndrome are surprisingly common conditions in patients presenting to GPs
- GPs are often concerned about missing a diagnosis of prostate cancer, which is not always easy to exclude confidently, so the algorithm (see Figure 1) will be useful to support them in making the correct diagnosis and allowing specific treatment
- Clinical commissioning groups:
- should review local formularies to cover the use of quinolines for prostatitis as these drugs are currently often excluded, or have very few indications due to the risk of Clostridium difficile infection
- could consider specific educational events to cover this condition and LUTS symptoms in men to help increase confidence and potentially reduce unnecessary referrals while stimulating appropriate ones
Tariff costs for urology outpatients: £127 (new); £70 (follow up)a
LUTS=lower urinary tract symptoms
- Pavone-Macaluso M. Chronic prostatitis syndrome: A common, but poorly understood condition. Part I. EAU-EBU Update Ser 2007; 5 (1): 1–15.
- Krieger J, Lee S, Jeon J et al. Epidemiology of prostatitis. Int J Antimicrob Agents 2008; 31 (Suppl 1): S85–90.
- Schaeffer A. Epidemiology and evaluation of chronic pelvic pain syndrome in men. Int J Antimicrob Agents 2008; 31 (Suppl 1): S108–111.
- Nyberg L, Krieger J, Nickel J. National Institutes of Health classification of chronic prostatitis. In: Nickel J, editor. Textbook of Prostatitis. London: CRC Press, 1999.
- Murphy A, Macejko A, Taylor A, Nadler R. Chronic prostatitis: management strategies. Drugs 2009; 69 (1): 71–84.
- Aboumarzouk O, Nelson R. Pregabalin for chronic prostatitis. Cochrane Database Syst Rev 2012; 15 (8): CD009063.
- Pontari M, Krieger J, Litwin M, et al. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome. Arch Intern Med 2010: 170 (17): 1586–1593.
- Prostate Cancer UK. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. Prostate Cancer UK, 2014. Available at: prostatecanceruk.org/prostatitisguideline (accessed 26 November 2014).
- McNaughton Collins M, Pontari M, O’Leary M et al. Quality of life is impaired in men with chronic prostatitis. J Gen Intern Med 2001; 16 (10): 656–662.
- Shoskes D, Nickel J, Rackley R, Pontari M. Clinical phenotyping in chronic prostatitis/ chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis 2009; 12: 177–183.
- Litwin M, McNaughton-Collins M, Fowler F Jr. et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999; 162: 369–375.
- NICE. Neuropathic pain—pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings. Clinical Guideline 173. NICE, 2013. Available at: www.nice.org.uk/guidance/CG173 (accessed 26 November 2014).
- Main C, Spanswick C. Pain management: an interdisciplinary approach. Edinburgh/New York: Churchill Livingstone, 2000.
- NHS Choices website. Map of Medicine. Prostatitis—primary care. International view. London: Map of Medicine: 2014 (Issue 1). Available at: healthguides.mapofmedicine. com/choices/map/prostatitis1.html (accessed 26 November 2014).
- NHS Choices website. Map of Medicine. Prostatitis—secondary care. 2014. London: Map of Medicine, 2014 (Issue 1). Available from: www.nhs.uk/conditions/prostatitis/pages/mapofmedicine.aspxhealthguides.mapofmedicine.com/choices/map/prostatitis2.html (accessed 26 November 2014).
- Nickel J, Downey J, Clark J et al. Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo- controlled multicenter trial. Urology 2003; 62 (4): 614–617.