Urology Textbook
Clinical Essentials
By Dirk Manski, MD

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Treatment and Prognosis of Chronic Pelvic Pain Syndrome

Therapy

The classification according to UPOINT(S) domains enables structured multimodal treatment; see Table UPOINT(S) domains.

Therapy concepts for functional somatic symptoms:

See the S3 guideline on functional somatic symptoms (DGPM, 2018).

Physical medicine:

Aerobic exercise therapy, pelvic floor biofeedback relaxation therapy, pelvic floor electromagnetic therapy, myofascial trigger-point therapy, microwave heat therapy, massage, stretching, and yoga.

Complementary medicine:

Osteopathy, acupuncture, homeopathy, and hypnosis.

Antibiotics:

Despite the absence of evidence for bacterial infection, randomized trials have shown response rates in early disease. This justifies one treatment trial for 4–6 weeks.

Alpha blockers:

Randomized trials have demonstrated the efficacy of alpha blockers in chronic prostatitis or CPPS. Effectiveness is approximately 40–60 %. For pharmacology and dosages, see alpha blockers.

5α-reductase inhibitors:

These agents improve bladder outlet obstruction, shrink prostatic tissue, and thereby reduce intraprostatic reflux. They are a treatment option for older patients with an enlarged prostate.

Phytotherapeutics:

A randomized trial demonstrated the efficacy of quercetin, a plant flavonoid with antioxidant activity, compared with placebo; dosage 500 mg 1-0-1. In a randomized trial, the pollen extract Pollstimol was also effective (70 vs. 50 % improvement) at a dosage of 2-2-2 capsules per day. Saw palmetto extracts were inferior to finasteride in direct comparison and showed no efficacy.

Analgesics:

NSAIDs or COX-2 inhibitors may be used for symptomatic treatment, but only about half of patients respond. Adverse effects of long-term administration are problematic. Do not prescribe opioids for functional disorders such as CPPS.

Treatment of bladder pain syndrome:

Pentosan polysulfate (PPS) and intravesical instillations may be used; see interstitial cystitis.

Treatment of pudendal pain syndrome:

Injections of local anesthetics and steroids at sites of nerve entrapment; if effective, consider surgical decompression.

Treatment of testicular pain syndrome:

Injections of local anesthetics and steroids into the spermatic cord; if effective, consider surgical denervation through an inguinal approach. Vasovasostomy may help in postvasectomy pain syndrome.

Botulinum toxin injections:

Intraprostatic injection of botulinum toxin A showed some efficacy in prospective studies but is not approved for CPPS outside clinical trials.

Transcutaneous electrical nerve stimulation:

TENS is a minimally invasive option with response rates of up to 50 %.

Extracorporeal shock wave therapy:

Perineal low-intensity extracorporeal shock wave therapy (Li-ESWT) improved pain, quality of life, and voiding symptoms in randomized trials. Treatment consists of 4–6 weekly sessions with 2000–3000 impulses. Depending on the symptoms, treatment targets painful trigger points or the prostate.

Invasive treatment:

Surgical treatment of BPH (TURP, endoscopic or open surgical enucleation) is indicated only in the presence of obstruction. No convincing long-term studies have demonstrated improvement of the pain syndrome. Sacral nerve stimulation is a treatment option within clinical trials.

Prognosis

Prognosis after initial presentation:

Approximately 60 % of patients become symptom-free within six months, 20 % have a variable course, and 20 % develop persistent symptoms and chronicity. Factors associated with a poor prognosis are severe polysymptomatic complaints, passive or overactive behavior, psychiatric comorbidity (depression, anxiety, substance use disorder, posttraumatic symptoms, suicidality), social withdrawal, and inability to work.






Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

EAU guidelines: Chronic pelvic pain

Krieger u.a. 1999 KRIEGER, J. N. ; NYBERG, Jr. ; NICKEL, J. C.: NIH consensus definition and classification of prostatitis.
In: Jama
282 (1999), Nr. 3, S. 236–7

Nickel 2003 NICKEL, J. C.: Recommendations for the evaluation of patients with prostatitis.
In: World J Urol
21 (2003), Nr. 2, S. 75–81

Schaeffer u.a. 2002 SCHAEFFER, A. J. ; DATTA, N. S. ; FOWLER, Jr. ; KRIEGER, J. N. ; LITWIN, M. S. ; NADLER, R. B. ; NICKEL, J. C. ; PONTARI, M. A. ; SHOSKES, D. A. ; ZEITLIN, S. I. ; HART, C.: Overview summary statement. Diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
In: Urology
60 (2002), Nr. 6 Suppl, S. 1–4



  Deutsche Version: Therapie der chronischen Prostatitis

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