Book Review

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

N Engl J Med 2008; 359:2506-2507December 4, 2008

Article

Chronic Prostatitis/Chronic Pelvic Pain Syndrome
(Current Clinical Urology.) Edited by Daniel A. Shoskes. 278 pp., illustrated. Totowa, NJ, Humana Press, 2008. $99.50. ISBN: 978-1-934115-27-5

Approximately 10% of men are affected by the enigmatic condition known as chronic prostatitis–chronic pelvic pain syndrome. Traditionally, the prostate has been implicated, but emerging evidence implicates other organs and sites within the pelvis that can contribute to the pain and voiding dysfunction that are typical in patients with this condition. This book is a timely review of the topic, and its authors present plausible diagnostic and therapeutic strategies.

The book's editor, Daniel Shoskes, emphasizes accurate documentation of symptoms, using the new National Institutes of Health (NIH) Chronic Prostatitis Symptom Index to objectively summarize symptoms and assess responses to therapy. The importance of identifying or excluding conditions that mimic chronic prostatitis–chronic pelvic pain syndrome before initiating treatment is highlighted. The syndrome is generally not thought to be an infectious disease, and so the chapters on acute and chronic bacterial prostatitis — written by Kurt Naber, Florian Wagenlehner, and Wolfgang Weidner — may seem unnecessary. However, about 10% of patients with a diagnosis of prostatitis can have a bacterial infection. Recognition of the characteristics of both acute and chronic bacterial prostatitis is important because this condition can be treated with relatively high cure rates through the use of the clear approaches outlined in these chapters.

The economic and social effects of chronic prostatitis–chronic pelvic pain syndrome are substantial, but the choices for effective therapies are limited. In chapter 6, Russell Egerdie clearly summarizes the attractiveness of antimicrobial therapy, but he appropriately points out that it has minimal, if any, potential benefit in the treatment of the syndrome. However, because many of the trials were conducted in groups of patients for whom antimicrobial therapy had already failed, Egerdie asserts that for newly diagnosed patients, a limited course (4 to 6 weeks) of antimicrobial therapy might be beneficial.

Two robust studies that were recently conducted by the NIH Chronic Prostatitis Collaborative Research Network failed to demonstrate the efficacy of alpha-blocker therapy. Phytotherapy with saw palmetto, pollen extracts, or quercetin to quell symptoms and inflammation in the prostate appeared promising in several small trials, but large, well-controlled follow-up studies have not been conducted.

In chapter 9, Michel Pontari focuses on the treatment of neuropathic pain in men with chronic prostatitis–chronic pelvic pain syndrome. A variety of drugs, including tricyclic antidepressants and pregabalin, have been used with success in the treatment of other chronic pain syndromes, including interstitial cystitis and fibromyalgia. Chronic pelvic pain can also lead to pelvic muscle spasms that potentiate the symptoms. In chapter 11, Jeannette Potts summarizes and introduces evidence to suggest that biofeedback and myofascial trigger-point release can be applied successfully in the treatment of chronic pelvic pain. The use of invasive techniques to reduce muscle spasm, including neuromodulation and heat therapy, has not been met with enthusiasm and can lead to substantial side effects. In the next chapter, Dean Tripp addresses the psychosocial aspects of chronic prostatitis–chronic pelvic pain syndrome, starting with the observation that it is strongly associated with intrapersonal and interpersonal difficulties such as pain, disability, problems in relationships, and reduced overall quality of life.

Patients frequently ask whether chronic prostatitis–chronic pelvic pain syndrome will affect fertility and sexual function. The answer is no, with the caveat, as Lawrence Hakim points out in chapter 14, that in rare instances a patient may have ejaculatory pain that can mimic the pain associated with the syndrome but is actually caused by obstruction of the ejaculatory ducts. Because of the overlap in symptomology between interstitial cystitis, painful bladder syndrome, and chronic prostatitis–chronic pelvic pain syndrome — as discussed by Jonathan Kaye and Robert Moldwin in chapter 15 — if small voiding capacity and pain with bladder distention are present, therapy should be directed toward interstitial cystitis. In chapter 17, Jeffrey Jones, Neva Ciftcioglu, and David McKay point out that prostate inflammation can elevate prostate-specific antigen. If antiinflammatory therapy reduces prostate-specific antigen, prostate cancer is thought to be less likely and prostate biopsy can be deferred.

The variety of factors that contribute to chronic prostatitis–chronic pelvic pain syndrome, the paucity of well-conducted trials, and ineffective therapies make the management of this condition very difficult. Recognition of subsets of patients with treatable conditions and avoidance of ineffective therapies that could cause harm are important first steps. Goal-directed empirical therapy, with the NIH symptom index as a marker for response, is a reasonable approach for individual patients in the effort to reduce the significant burden of this condition.

Anthony J. Schaeffer, M.D.
Northwestern University Feinberg School of Medicine, Chicago, IL 60611