Role of alpha1-blockers in chronic prostatitis syndromes

Category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most commonly diagnosed prostatitis syndrome. CP/CPPS is characterized by lower urinary tract symptoms (LUTS) of which pain (particularly perineal pain and pain on ejaculation) and dysfunctional voiding cause the greatest morbidity and poor quality of life. There is no standard treatment for CP/CPPS. Patients report only transient relief of symptoms from currently available therapies and are frequently required to change treatments. The origin of LUTS and possibly the pelvic pain (e.g. on ejaculation) is thought to be prolonged smooth muscle contraction in the bladder and prostate, caused by alpha(1)-adrenoceptor activation. alpha(1)-Blockers are not indicated in the treatment of CP/CPPS but clinical experience suggests that they might be of benefit, possibly by promoting smooth muscle relaxation. Encouraging results of three phase II, randomized, placebo-controlled trials evaluating (using a validated instrument) the efficacy of alfuzosin, tamsulosin and terazosin in alpha(1)-blocker-na?ve patients with CP/CPPS, support this hypothesis. The National Institute of Health and the National Institute of Diabetes and Digestive and Kidney Diseases are currently conducting a large phase III trial in 272 newly diagnosed and alpha(1)-blocker-na?ve CP/CPPS patients randomized to received alfuzosin 10 mg once daily or placebo for 12 weeks.     

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

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

UPOINT:一种新的慢性前列腺炎/慢性盆腔疼痛综合征表型分类系统

慢性前列腺炎/慢性盆腔疼痛综合征(CP/CPPS)是一种严重困扰广大泌尿外科医师及患者的常见疾病。现已认识到CP/CPPS是一种异质性疾病,即它是一种具有不同病因、不同疾病进程且对治疗反应不一的临床综合征。基于对CP/CPPS病因的深入认识以及对CP/CPPS临床研究的重新评估,国外研究者目前制定了能够对CP/CPPS进行分类并指导临床个性化治疗的表型分类系统——UPOINT。UPOINT由6个独立的因子组成,分别为排尿症状(U)、社会心理的(P)、器官特异性的(O)、感染(I)、神经/系统性的(N)及盆底肌疼痛(T)。本文系统综述了UPOINT提出的理论基础、各因子的临床特征以及基于该系统的治疗策略。     

细胞因子及热休克蛋白在慢性前列腺炎患者精浆中的含量及其临床意义

目的:探讨慢性细菌性前列腺炎以及慢性前列腺炎/慢性骨盆疼痛综合症(CP/CPPS)患者精浆中肿瘤坏死因子α(TNF-α)、白细胞介素1β(IL-1β)以及热休克蛋白70(HSP70)的含量及临床意义。方法:采用酶联免疫吸附测定法(ELISA)对36例慢性细菌性前列腺炎(Ⅱ型)、43例炎症型慢性非细菌性前列腺炎即炎症型慢性骨盆疼痛综合征(ⅢA型)、46例非炎症型慢性非细菌性前列腺炎即非炎症型慢性骨盆疼痛综合征(ⅢB型)患者及25例健康志愿者精浆中TNF-α、IL-1β以及HSP70含量进行测定分析,并将HSP70的表达与慢性前列腺炎症状评分进行相关性分析。结果:慢性细菌性前列腺炎患者精浆中细胞因子(TNF-α、IL-1β)以及HSP70含量明显高于CP/CPPS患者及正常对照组。CP/CPPSⅢA型患者精浆中IL-1β的含量明显高于CP/CPPSⅢB型患者及正常对照组。CP/CPPS患者精浆中HSP70的含量明显低于正常对照组。慢性细菌性前列腺炎患者精浆中HSP70的含量与CPSI评分呈显著负相关。结论:精浆中HSP70的含量能够作为评价慢性细菌性前列腺炎病情程度的分子生物学指标。IL-1β能够作为CP/CPPS分型诊断指标。对于慢性细菌性前列腺炎患者,HSP70具有细胞保护功能。CP/CPPS患者精浆中HSP70表达的抑制可能与T细胞功能受损有关。     

生物反馈和电刺激联合治疗慢性前列腺炎/慢性骨盆疼痛综合征

目的:通过临床试验的方法,探讨生物反馈和电刺激联合治疗慢性前列腺炎/慢性骨盆疼痛综合征(CP/CPPS)的效果。方法:收集湘雅医院门诊诊断为CP/CPPS符合研究标准患者140例。将患者随机分为对照组、生物反馈组、电刺激组和生物反馈加电刺激组;对照组20例,生物反馈组、电刺激组和生物反馈加电刺激组各40例。采用Laborie-Urostym生物反馈电刺激治疗仪,生物反馈组行生物反馈治疗,电刺激组行电刺激治疗,生物反馈加电刺激组行生物反馈电刺激治疗;每周5次,连续2周;对照组不予上述治疗,随诊1个月。治疗前后进行NIH-CPSI评分以及尿流率检查。结果:生物反馈组、电刺激组和生物反馈加电刺激组治疗后NIH-CPSI疼痛与不适评分、NIH-CPSI排尿症状评分、NIH-CPSI生活质量评分、NIH-CPSI总评分、最大尿流率较治疗前均有显著改善(P<0.05);治疗前各组积分及最大尿流率比较无显著差异(P>0.05);治疗后上述参数生物反馈组、电刺激组比较没有显著差异(P>0.05),生物反馈加电刺激组与生物反馈组、电刺激组比较有显著差异(P<0.05)。而对照组治疗前后的以上各组评分及最大尿流率比较无显著差异(P>0.05)。结论:生物反馈和电刺激治疗能明显改善CP/CPPS患者疼痛与不适症状,排尿症状,提高生活质量,以及提高最大尿流率。生物反馈和电刺激联合治疗CP/CPPS有协同作用。     

Economic impact of chronic prostatitis

There are four types of prostatitis, including type I (acute bacterial prostatitis), type II (chronic bacterial prostatitis), type III (chronic prostatitis/chronic pelvic pain syndrome, or CP/CPPS), and type IV (asymptomatic inflammatory prostatitis). These prostatitis conditions account for approximately 2 million office visits each year to primary care physicians and urologists. The annual cost to treat prostatitis is approximately $84 million. Compared with control subjects, men with prostatitis incur significantly greater costs, predominantly due to increased outpatient visits and pharmacy expenses. CP/CPPS is the most common type of prostatitis. The condition is characterized by chronic, idiopathic pelviperineal pain. Due to the lack of effective treatments for CP/CPPS, the per-person costs associated with the condition are substantial and are similar to those reported for peripheral neuropathy, low back pain, fibromyalgia, and rheumatoid arthritis. Costs appear to be higher in men with more severe symptoms. Indirect costs (eg, work and productivity loss) are incurred by many patients with CP/CPPS. Identification of effective treatments for CP/CPPS would be expected to substantially reduce the costs associated with the condition.     

坦索罗辛治疗非细菌性慢性前列腺炎临床分析

目的 :评价选择性α1A 肾上腺素能受体阻滞剂坦索罗辛 (tamsulosin)治疗慢性非细菌性前列腺炎 /慢性盆腔痛综合征 (CPPS)的临床疗效。　方法 :4 3例CPPS病人给予坦索罗辛 0 .2mg口服 ,1次 /d ,治疗 4周 ,比较治疗前后慢性前列腺炎症状评分及尿流率的变化。　结果 :治疗后 ,32例 (74 .4 % )病人评分明显降低 ;最大尿流率(MFR)偏低者 ,MFR和平均尿流率 (AFR)分别提高了 30 .4 %和 6 5 .4 % (P <0 .0 5 ) ;无严重副作用发生。　结论 :选择性α1A 肾上腺素能受体阻滞剂坦索罗辛是治疗CPPS的有效药物     

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

Introduction

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

Methods

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

Results

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

Conclusions

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

M受体阻滞剂联合抗组胺药物治疗CP/CPPS的近期疗效分析

目的:评估联合应用M受体拮抗剂(酒石酸托特罗定缓释片)和抗组胺药物(盐酸氯雷他定片)联合治疗α1受体阻滞剂(哈乐)无效的慢性前列腺炎/慢性盆底疼痛综合征(CP/CPPS)近期疗效与安全性。方法:2011年9月~2013年5月,排除包茎、尿道炎、前列腺增生和尿道狭窄等病例,我院泌尿外科门诊诊治α1受体阻滞剂(哈乐)治疗无效的ⅢB CP/CPPS患者75例,随机分为3组,分别给予抗组胺药物(盐酸氯雷他定片)、M受体阻滞剂(酒石酸托特罗定缓释片)和联合治疗组(盐酸氯雷他定片+酒石酸托特罗定缓释片),持续治疗6周后门诊复查。记录治疗期间药物的不良反应,对比观察治疗前后前列腺按摩液白细胞计数和NIH-CPSI评分,评估治疗的有效性。结果:3组患者治疗前一般情况无显著差异。治疗6周后,联合治疗组患者的NIH-CPSI评分和前列腺按摩液白细胞计数均较治疗前显著下降,与其他两组比较差异有统计学意义(P0.05)。χ2检验结果表明,联合治疗组的治疗有效率明显优于单一抗组胺组和单一M受体阻滞剂组(P0.05)。治疗期间3组患者均未发现明显药物不良反应。结论:抗组胺药物联合M受体阻滞剂治疗能够显著地改善α1受体阻滞剂无效CP/CPPS的临床症状,减少前列腺按摩液白细胞计数。相对于单一抗组胺药物或单一M受体阻滞剂,联合治疗近期疗效更佳,可在临床推广。     

Alternative Therapies for the Treatment of Chronic Prostatitis

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a prevalent disease for which there is no standardized therapy. Traditional treatments have included antibiotics, α-blockers, and anti-inflammatories, but those have not proven to be efficacious therapies through many clinical trials. Alternative therapies, such as phytotherapy, acupuncture, and pelvic floor physical therapy, have grown in popularity for the treatment of CP/CPPS. As clinicians continue to explore these alternative therapies, there is an accumulation of strong evidence demonstrating the success of these alternative therapies.     

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

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

Use of Acupuncture as a Treatment Method for Chronic Prostatitis/Chronic Pelvic Pain Syndromes

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common category of clinical prostatitis. The etiologic factors of CP/CPPS still remain unknown, and standard therapies often fail to achieve sustainable amelioration of symptoms; therefore, various treatment therapies have been approached. Recently, there is increasing evidence that acupuncture could be a safe and effective treatment in managing CP/CPPS. However, acupuncture therapy still is ranked as low-priority treatment, which results from the fact that the studies, mostly reported in nontraditional medical journals, had not employed standard definitions of the condition or validated-outcome parameters, and that the mechanism of acupuncture effects on CP/CPPS remains to be elucidated. In this article, we review the recent clinical research using acupuncture to reveal its clinical utility for CP/CPPS and the possible mechanisms of action. This article could encourage health care providers and urologists to apply acupuncture for managing pains of CP/CPPS with standard treatment.     

Sexual dysfunction in chronic prostatitis/chronic pelvic pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), or NIH category III prostatitis, is a common clinical syndrome characterized by genital/pelvic pain and lower urinary tract symptoms in the absence of urinary tract infection. There is also growing recognition of the association of sexual dysfunction with CP/CPPS including erectile dysfunction, ejaculatory pain, and premature ejaculation. In this review, we discuss the association between CP/CPPS and sexual dysfunction, potential mechanisms for sexual dysfunction, and treatment strategies for erectile dysfunction in CP/CPPS.     

Herbal nutraceutical treatment of chronic prostatitis–chronic pelvic pain syndrome: a literature review

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most frequent form of prostatitis, and has a serious impact on patients’ quality of life, and causes severe symptoms. The pain in the pelvic, perineal and penile areas, lower abdominal pain, and pain during urination or ejaculation are the main complaints of CP/CPPS. The underlying complex and unknown pathophysiology of this syndrome have made the management of CP/CPPS and the availability of monotherapy challenging. To identify an effective monotherapy, a plethora of clinical trials failed due to its puzzling etiology. Antibiotics, anti-inflammatory, and a-blockers have been commonly used for the treatment of CP/CPPS, but the desired and complete effects have not been gotten yet. The patients and clinicians are attracted to alternative therapies because of their multi-targeted effects. Attention toward natural compounds effectiveness and safety, supporting the development of a new nutraceutical science. In the alternative remedies for the treatment of prostatic diseases, medicinal herbs, in the form of herb parts or extracts, are getting attention due to their positive effects on prostatic diseases. At present, there is no available detailed literature review about the efficacy of medicinal herbs in the treatment of CP/CPPS. This review aimed to explore the useful medicinal herbs in the treatment of CP/CPPS from different perspectives and their possible mechanism of action in managing CP/CPPS.

     

The Estonian version of the National Institutes of Health chronic prostatitis symptom index

Our aim was to establish the Estonian version of the National Institutes of Health chronic prostatitis symptom index (NIH-CPSI), and to examine its validity and applicability in chronic prostatitis patients as well as in community-based study. The questionnaire was tested in 54 category III prostatitis patients. In addition, 452 men were enrolled into a community-based study that resulted in 83 completed questionnaires. The discriminatory power, psychometric properties and internal correlations of the questionnaire were tested. The questionnaire demonstrated good internal consistency, with Cronbach's alpha coefficient 0.82. The pain and quality of life domains demonstrated high correlations with each other and with the entire questionnaire. The total score and the scores of pain and quality of life domains of the Estonian NIH-CPSI differed significantly between the chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients and the men without CP/CPPS, and so the index proved a good discriminant validity. We can conclude that the Estonian NIH-CPSI is easily understood and reflects accurately the clinical symptoms and the quality of life in patients with chronic prostatitis. The similarity of the psychometric properties of the English and Estonian versions of the NIH-CPSI supports their measurement equivalence.     

Interleukin 8 and anti-chlamydia trachomatis mucosal IgA as urogenital immunologic markers in patients with C. trachomatis prostatic infection

OBJECTIVE: This study evaluates the role of interleukin 8 (IL-8) and anti-Chlamydia trachomatis (CT) immunoglobulin A (IgA) in total ejaculate (TE) of patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) as potential markers in prostatic CT infection. METHODS: Seventy-eight consecutive patients with a diagnosis of CP/CPPS and CT infection were enrolled; 20 healthy volunteers represented the control group. All subjects underwent microbiologic analysis for common bacteria, yeasts, and viruses in TE, expressed prostatic secretion, and urine samples and molecular analysis for CT identification, anti-CT species-specific IgA, and IL-8 levels. Questionnaires regarding symptoms were given to each subject to determine correlations between clinical and laboratory data. RESULTS: Thirty-five patients were positive for CT plasmid DNA, but none of the controls were positive. Mucosal IgA was detected in 69.2% of patients and significant levels of IL-8 were detected in 75.6% of them. Significant correlations between IL-8 and mucosal IgA (p<0.001) and between IL-8 levels and symptom score results (p<0.001) were found. IL-8 values strongly correlated with CP/CPPS (p<0.001). Moreover, the patients with higher levels of IL-8 and higher positivity for IgA reported the worst symptoms. CONCLUSIONS: Our results clearly highlight the role of immune system activation in the pathophysiology of CP/CPPS and that seminal IL-8 and mucosal IgA levels specific to CT antigens appear to be the best immunologic markers of chronic chlamydial prostatitis status.     

Acute bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: andrological implications

There is a consensus on the diagnostic management of bacterial prostatitis (acute and chronic). In chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) the diagnostic approach remains unclear, because inflammatory and noninflammatory CP/CPPS might be one entity with varying findings over time. The WHO definition of male accessory gland infection does not differentiate between prostatitis, epididymitis, and other inflammatory alterations of the urethral compartment. The definition therefore cannot be further accepted as a rational tool for the diagnosis of prostatitis and related diseases in urological andrology. Therapy in infectious prostatitis is standardised and antibiotics are the primary agents. Andrological implications are well defined, side-effects are minimal. CP/CPPS therapy has the goal to reduce pelvic pain. However, treatment regimens are not as standardised. Andrological side-effects are well defined and mainly due to the functional background of these agents.     

Acupuncture for chronic prostatitis/ chronic pelvic pain syndrome

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.     

Failure of a monotherapy strategy for difficult chronic prostatitis/chronic pelvic pain syndrome

PURPOSE: We determined the effect of a best evidence based monotherapeutic strategy for patients diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) referred to a specialized prostatitis clinic. MATERIALS AND METHODS: Patients with CP/CPPS referred by urologists after failure of prescribed therapy for evaluation and treatment at Queen's University prostatitis research clinic were extensively evaluated, aggressively treated following a standardized treatment algorithm and followed for 1 year using a validated prostatitis specific symptom and quality of life instrument, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). All patients underwent a standardized protocol for CP/CPPS including a history, physical examination, standard 4-glass test, plus urethral swab and semen for microscopy and culture, uroflowmetry and residual urine determination. Treatment followed a best evidence based strategy with a standardized monotherapy based algorithm. RESULTS: A total of 100 consecutive patients with CP/CPPS (average age 42.2 years, range 20 to 70 and average symptom duration 6.5 years, range 0.5 to 39) had 1-year followup after initial evaluation. Patients were prescribed treatment based on documentation of "failed," "successful" and "never tried" therapies based on a standardized treatment algorithm. Patients treated successfully were continued on the prescribed therapy, while therapy was discontinued and new therapy instituted (based on algorithm) in those in whom the initially prescribed therapy failed. At 1 year there was a statistically significant decrease in total NIH-CPSI (23.3 to 19.5, p = 0.0004), pain (11.0 to 9.4, p = 0.03) and quality of life (7.7 to 6.1, p <0.001), but not voiding (4.6 to 4.0, p = 0.12). A perceptible 25% decrease in total NIH-CPSI symptom score was noted in 37% and the greatest improvement was in the quality of life domain (43% of patients had greater than 25% improvement in quality of life). Of the patients 35% had a significant decrease of greater than 6 points in total NIH-CPSI. A clear, clinically significant improvement in total NIH-CPSI (greater than 50% decrease) was noted in 19%. CONCLUSIONS: Approximately a third of patients with treatment refractory CP/CPPS undergoing extensive evaluation and therapy based on a sequential monotherapy treatment strategy in a specialized prostatitis clinic had at least modest improvement in symptoms during 1 year. This study confirms that a treatment strategy based on the sequential application of monotherapies for patients with a long history of severe CP/CPPS remains relatively poor.     

Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men

PURPOSE: A perspective on the neurobehavioral component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT). MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with a pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom Index. Patient reported perceptions of overall effects of therapy were documented on a global response assessment questionnaire. RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptom scores, as assessed by the PPSS. In those at the 50% or greater improvement level median scores decreased 69% and 80% for pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy. CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy.