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Obscure diagnosis - chronic prostatitis

Dr Jon Rees, GPSI in urology, on recognising and managing this relatively common condition

Chronic prostatitis (CP) is a condition with a huge impact on the quality of life of many men but it is poorly understood, significantly underdiagnosed and often difficult to treat. As a result, there is a lack of good evidence and guidance, for primary care in particular, on how to recognise the condition and carry out effective management in the community. However, consensus guidelines aimed at a primary care audience were published in 2015 and provide a framework for the recognition and management of prostatitis in general practice.2,3

Definition

The symptomatic, chronic forms 
of prostatitis, as defined by the US National Institutes of Health, are:

  • 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.

To establish the diagnosis of CP/CPPS the patient should have a history of persistent or recurrent symptoms, with the absence of other urogenital pathology, for a minimum of three out of the past six months (although the diagnosis can often be suspected after a shorter time period).

Prevalence

The condition affects men of all ages, although it is most prevalent among those aged 36–50 years. Prostatitis is a relatively common condition, with 35%–50% of men reported to be affected by symptoms suggesting prostatitis during their lifetime. Based on a population of over 10,600 participants, a systematic review found an 8.2% prevalence of prostatitis symptoms.1 But the proportion of men formally diagnosed with this condition is significantly lower than these studies would suggest.

Clinical features

CP/CPPS typically presents with a range of symptoms:

  • Urogenital pain
    • Typically pain is felt in the perineum but can also be in the lower abdomen, groin, lower back, testes or tip of the penis. Pain is often neuropathic in nature – it is suggested that pain may start with an original episode of infection or inflammation, but continues after resolution of this initial insult due to pain sensitisation.
  • Urinary symptoms
    • CP/CPPS is often associated with lower urinary tract symptoms such as voiding (e.g. hesitancy and weak stream), storage (e.g. urgency and frequency), and sometimes dysuria or urethral burning independent of micturition.
  • Sexual dysfunction
    • Erectile dysfunction, ejaculatory dysfunction (particularly ejaculatory pain or discomfort) and loss of libido are commo
  • Psychosocial symptoms
    • Anxiety and depression frequently affect these men, with cognitive and behavioural consequences severely impacting quality of life.

Physical examination of the patient is simple. The abdomen and external genitalia should be examined and a digital rectal examination performed – often palpation of the prostate reproduces the pain of prostatitis. Basic investigations are also required, with a urine dip (with or without microscopy) being essential, and consideration of an STI screen to exclude chlamydia in particular also being important. PSA testing should be considered, but it is vital to be aware that during an infective or inflammatory flare of symptoms this can be temporarily elevated, and testing should ideally be delayed until 4-6 weeks after symptoms have settled, or treatment for infection has been completed. Physical examinations/investigations are outlined in table 1.

cp

Table 1: Summary of physical examination / investigations2, 3

Differential diagnosis

A number of other conditions can have symptoms that overlap with CP/CPPS. Benign prostatic enlargement, overactive bladder and urethral strictures can cause lower urinary tract symptoms. Rectal cancer and prostate cancer can cause perineal/rectal pain, and need to be considered with DRE and PSA testing. Urinary tract infection and sexually transmitted infections also need to be excluded.

How can GPs diagnose it with certainty?

Diagnosis is based on clinical presentation, and exclusion, of other conditions. The cardinal feature of CP is the presence of persistent or relapsing urogenital pain/discomfort, with or without the urinary, sexual and psychosocial symptoms outlined above. Provided appropriate investigations, as detailed, are carried out, management can begin in primary care.

Treatment

Despite the wide use of antibiotics in the treatment of patients with CP/CPPS, the evidence base for their use in these populations is relatively weak.3 However, antimicrobial therapy may have a moderate effect on pain, urinary symptoms and quality of life in CP/CPPS and should be considered as an initial treatment option. For early-stage CBP and CP/CPPS patients, offer a quinolone (e.g. ciprofloxacin) for four to six weeks as first-line therapy – but aim to avoid further repeated courses of antibiotics unless there is microbiological evidence of infection, or a strong history of response to antibiotic therapy. Alpha blockers such as tamsulosin can have an effect not just on urinary symptoms, but also on overall pain and quality of life in men with CP/CPPS. For men with voiding LUTS and CP, alpha blockers should be initiated early in the treatment pathway.

For analgesia, use simple analgesics such as paracetamol, avoiding opiates if at all possible. NSAIDs appear to work best in the early stages of the condition and during subsequent inflammatory flares, so should be used intermittently in short courses rather than as continuous long-term therapy.

The mainstay of long-term treatment for persistent pelvic pain is the use of antineuropathic agents such as tricyclic drugs (amitriptyline), gabapentinoids (gabapentin/pregabalin) or SNRIs (duloxetine) – guidelines suggest early use of these agents.

When to refer

If symptoms are severe, atypical or fail to respond to the measures above, onward referral for specialist assessment is advisable, however this need not always mean a referral to a urologist. Sometimes this may involve pain physicians, genitourinary medicine or pelvic physiotherapists and referral pathways will differ from area to area depending on local expertise. 

Dr Jon Rees is GPSI in urology at Tyntesfield Medical Group, Nailsea, North Somerset and chair of the Primary Care Urology Society

References

  1. Krieger JN, Lee SW, Jeon J, et al. Epidemiology of prostatitis. Int J Antimicrob Agents 2008; 31(Suppl 1):S85–90.
  2. UK guidelines on the assessment & management of chronic prostatitis / chronic pelvic pain syndrome; Rees J, Doble A et al on behalf of the Prostatitis Expert Reference Group, Prostate Cancer UK, 2015. http://prostatecanceruk.org/prostatitisguideline
  3. ‘Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis / chronic pelvic pain syndrome’. Rees J, Doble A, Abrahams M, Cooper A. BJU International 2015; 116 (4): 509-525.

 

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