-
Update on Prostatitis and TreatmentsBAUN Benign Study
Day14/03/2012Mr Richard CettiSpecialist Registrar Urology, QA
Portsmouth
-
Prostatitis an Important Problem!
Prevalence 2.2-13.8%Quality of lifeEconomic Costs
-
Prostatitis an Important Problem!
Pain management is a necessity in the work of each physician. F.
Sauerbruch, 1936
-
IntroductionPainClassification/TerminologyPresentationInvestigationTreatment-
historical, contemporary and the evidenceThe Future
-
Pain-an unpleasant sensory and emotional experience Hypogastric
NervePelvic NervesPudendal NerveSkinViscusConvergence Projection
Theory (Ruch)
-
Chronic PainCombination of:NeuroplasticityCentral processing
alteredTrophic changes in subcutaneous tissue and muscleAll site
normal sensations become painful (allodynia).At site painful
stimuli become more painful (hyperalgesia).Zone affected adjacent
tissue (secondary hyperalgesia).
-
Aetiology of Chronic ProstatitisPoorly understoodMultiple
factors within and between patientsHypotheses:Presence of
antibiotic resistant non-culturable micro-organismsChemical
irritationIntra-ductal reflux and obstructionDysfunctional high
pressure voidingNeuropathic painPudendal nerve
entrapmentAutoimmune
-
Classification
-
Classification- NIH/EAUCat IAcute bacterial prostatitisCat
IIChronic bacterial prostatitisCat IIIProstate Pain Syndrome
(CPPS)Cat IVAsymptomatic inflammatory prostatitis
-
Classification- NIH/EAUCat IAcute bacterial prostatitisCat
IIChronic bacterial prostatitisCat IIIProstate Pain Syndrome
(CPPS)Discomfort or pain in the pelvic region for at least 3 months
with variable voiding and sexual symptoms, no demonstrable
infection.IIIa- inflammatory PPS- white cells in semen/eps/post eps
urineIIIb- non-inflammatoryCat IV
-
Evaluation3 main factors:
SymptomsWBCsBacteria
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
EvaluationChronic Prostatitis Symptom IndexIPSS
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
EvaluationMeares-Stamey 4 Glass Test1st 10-15ml of voided urine
VB1MSU 10-15ml urine VB2Prostate Massage- EPS1st 10-15ml voided
urine post massage VB3Modified: VB1 and VB3
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
EvaluationHistoryFocused ExaminationCondition Specific
QuestionnairesUrinalysis and CultureSemen cultureOptional: PSA,
Urinary Cytology, US, Cystoscopy, Urodynamics, Psychosocial
evaluation
-
Evaluation
Diagnosis of exclusion
-
Treatment- Organcentric vs. Snowflake
-
Traditional Organcentric ModelPathogenesis simple
-
Traditional Organcentric ModelPathogenesis
simpleInfectionitisInflammationPAIN!
-
Traditional Organcentric ModelPathogenesis
simpleAntibioticsAnti-inflammatoriesAlpha blockersTreatment
simple?InfectionitisInflammationPAIN!
-
AntibioticsCiprofloxacin, ofloxacin, levofloxacin~10% patients
will have culturable bacteria.J Urol. 2001 May;165(5):1539-44.
Predictors of patient response to antibiotic therapy for the
chronic prostatitis/chronic pelvic pain syndrome: a prospective
multicenter clinical trial. Nickel JC et al.However, 57% of
patients on ofloxacin saw improvementTrial 2 weeks and continue for
6 if benefit.
-
Alpha-blockersAlfuzosin, Terazosin, TamsulosinN Engl J Med. 2008
Dec 18;359(25):2663-73. Alfuzosin and symptoms of chronic
prostatitis-chronic pelvic pain syndrome Nickel JC et
al.Multicenter, randomized, double-blind, placebo-controlled trial
of alfuzosin.272 men were randomly assigned to treatment for 12
weeks with either 10 mg of alfuzosin/day or placebo.The primary
outcome was a reduction of at least 4 points in the CPSI score.
-
Anti-inflammatoriesCelecoxib, rofecoxibJ Urol. 2003
Apr;169(4):1401-5. A randomized, placebo controlled, multicenter
study to evaluate the safety and efficacy of rofecoxib in the
treatment of chronic nonbacterial prostatitis. Nickel JC et
al.Multicenter, randomized, double-blind, placebo-controlled trial
of rofecoxib.161 men were randomly assigned to treatment with
either 25-50 mg of rofecoxib/day or placebo.Of the patients, 79% on
50 mg rofecoxib versus 59% on placebo reported no or mild pain. But
not statistically significant.
-
Neuropathic PainkillersAmitriptylline, PregabalinArch Intern
Med. 2010 Sep 27;170(17):1586-93. Pregabalin for the treatment of
men with chronic prostatitis/chronic pelvic pain syndrome: a
randomized controlled trial. Pontari MA et al.Multicenter,
randomized, double-blind, placebo-controlled trial of
pregabalin.218 men were randomly assigned to treatment for 6 weeks
with either 150-600 mg of pregabalin/day or placebo.The primary
outcome was a reduction of at least 6 points in the CPSI score.
-
So are we getting desperate?Laparoscopic prostatectomy for
chronic prostatitis
This study is currently recruiting participants.Verified by the
Krongrad Institute Oct 2008.ClinicalTrials.gov identifier:
NCT00775515
-
UPOINTUrinaryPsychosocialOrgancentricInfectionNeurogenic/SystemicTenderness
-
UPOINTRetrospective study of 90 CPPS patients seen by one
Urologist over 12 months
-
The Future: Patient-centric treatment. Phenotyping
-
Novel TherapiesCerniltonEur Urol. 2009 Sep;56(3):544-51. A
pollen extract (Cernilton) in patients with inflammatory chronic
prostatitis-chronic pelvic pain syndrome: a multicentre,
randomised, prospective, double-blind, placebo-controlled phase 3
study. Wagenlehner FM et al.Multicentre, prospective, randomised,
double-blind, placebo-controlled trial in men with CP/CPPS (NIH
IIIA)Primary end-point, defined as a decrease of the CPSI total
score by at least 25% or at least 6 points.
-
Take Home PointsPoorly understood
aetiology/pathogenesis.Heterogenous disease.Established treatments
perform poorly in RCTs.Phenotyping patient and treatment.
Active exclusion, Active Inclusion
-
Active exclusion, Active Inclusion
-
Active exclusion, Active Inclusion
Convergence Projection Theory (Ruch)