CPPS

Many men diagnosed with prostatitis and CPPS are confused about what the doctor is saying is wrong with them. As we have written about extensively on our website, in our book, A Headache in the Pelvis and in our published research, most men diagnosed with prostatitis and CPPS have no prostate infection or inflammation responsible for their symptoms. Yet most men given the diagnosis don’t understand this and suffer silently when medicines aimed at the prostate fail to help. This is an essay featuring the writing of a renounced physician and expert in prostatitis/chronic pelvic pain syndrome who speaks strongly to doctors to clarify their misunderstandings about prostatitis. In his admonitions to the doctors who treat pelvic pain, he clarifies the issues than many patients are confused about.

Men are typically diagnosed with prostatitis and CPPS and are given antibiotics without any evidence of infection in the prostate.

Today, when a man comes into the physician’s office and complains about the following issues, the doctor often treats the patient as if the cause of the problem is an infected or inflamed prostate gland and routinely gives antibiotics:

Pain: pelvic, urinary, rectal, or genital
Urinary symptoms such as: frequency, urgency, dysuria (pain during urination), sitting pain, or ejaculatory discomfort

However, there is no evidence of structural disease if one types in ‘prostatitis and CPPS’. If you search these terms on the internet, this misinformation, unfortunately, comes right up from a large number of sources.

Prostatitis, meaning an infection or inflammation of the prostate gland, is often diagnosed without the doctor doing any tests to establish the validity of such a diagnosis. We have seen men who have been given multiple rounds of antibiotics who have had no evidence of infection in the prostate. We do not consider it a good practice without verifying the presence of infection.

Antibiotics are not effective for symptoms diagnosed as prostatitis when the source of symptoms is pelvic muscle dysfunction.

Antibiotic treatment of bacterial prostatitis is an achievement of modern medicine. If you have bacterial prostatitis, antibiotics are a very good treatment—certainly the only treatment. Viewing all conditions of pelvic pain and dysfunction in men, however, as acute or chronic bacterial prostatitis is an error in therapeutic judgment, diagnosis, and treatment. Despite the clear scientific evidence to the contrary, it is shocking that giving antibiotics routinely for nonbacterial prostatitis is common. This is very important to understand, particularly if you have been diagnosed with prostatitis and it has not been determined whether infection or inflammation is present.

Below, Daniel Shoskes, MD, a urologist and expert in the research and treatment of prostatitis, understands this confusion particularly from the physician’s viewpoint. He writes an excellent article that also explains how prostatitis is typically misdiagnosed and treated.

He uses the analogy of Martin Luther who nailed 95 ‘theses’ on the door of a Church in the 16th century protesting the ‘selling of salvation from sins’ where a priest would grant you absolution by giving you a piece of paper called an indulgence if you paid the priest. Luther’s protest was to protest and stop this behavior of the Catholic priests at the time.

If you have been diagnosed with prostatitis, you and your physician can learn from the article below written to physicians.

What is Chronic Pain?

Since the beginning of our work at Stanford, we have held the idea that the prostate gland is not the problem in a very large proportion of men who are diagnosed with prostatitis. Like Martin Luther, Shoskes ‘protests’ against the common confused treatment of prostatitis. If you are a patient, you can learn from his instruction to physicians. If you are physician his article is sure to be enormously instructive. Here is a summary of the theses or points he makes to doctors who treat what is commonly called prostatitis/chronic pelvic pain syndrome. At the bottom of this article is Shoskes article in full. Here are excerpts of Dr. Shoskes advice to physicians diagnosing prostatitis:

Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients chronic pain relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis and CPPS, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

Stop telling everyone that they have prostatitis and CPPS as though it is one disease.
You should not tell a man with pain in between his nipples and knees that he has prostatitis and CPPS without doing a proper history and physical examination.
Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post-massage urine sample instead.
Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
Not everyone with prostatitis and CPPS needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (e.g., tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6]
Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteri in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement
Do not forget to tell men about simple and often effective supportive measures
Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at http://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
Learn and use simple and effective therapies for the different clinical domains
Patients with longstanding chronic pain can get depression and feel helpless or hopeless.
Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
Take new symptoms seriously.
In patients without UTI, do not treat an elevated prostate specific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
Assemble a good referral team.

Full Article

Commentary on Chronic Prostatitis and CPPS: The Status Quo Is Not Good Enough (But It Can Be)

Daniel Shoskes

Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA

Submitted March 5, 2010 – Accepted for Publication April 5, 2010

www.urotodayinternationaljournal.com

Volume 3 – June 2010

COMMENTARY

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness. Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

Stop telling everyone that they have prostatitis as though it is one disease. The National Institutes of Health (NIH) classification may not be perfect, but it is a start and simple to use [1]. Category I is an acute febrile urinary tract infection (UTI). Category II is recurrent UTI with the same bacteria that is recovered from the prostate between acute bladder infections. Category III is persistent pain with or without lower urinary tract symptoms (LUTS) in men without UTI who have no other demonstrable cause. Category IV is asymptomatic and found during semen analysis or prostate biopsy. Stop telling everyone that they have the same condition and treating them all the same.
You should not tell a man with pain between his nipples and knees that he has prostatitis without doing a proper history and physical examination.
Nobody has to do a full Meares-Stamey 4-glass test. Who cares if there is Escherichia coli in VB1 vs VB2? It makes no difference. You should test at least a midstream sample of urine and then obtain a culture of either prostate fluid or post massage urine [2]. Unless you want false negatives, do Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post massage urine sample instead.
Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
Not everyone with prostatitis needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (eg, tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6].
Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteria in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement (eg, severe refractory frequency; pain that worsens with bladder filling and improves with emptying) [9].
Do not forget to tell men about simple and often effective supportive measures such as sitting on a donut-shaped cushion and avoiding caffeine and spicy foods.
Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at http://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
Learn and use simple and effective therapies for the different clinical domains: Urinary symptoms: alpha blockers or antimuscarinics. Prostate pain or inflammation: quercetin [11] and cernilton [12]. Systemic neurologic symptoms: pregabalin or amitriptyline [13]. Pelvic floor spasm: pelvic floor physiotherapy myofascial release, NOT Kegel’s) [4].
Patients with longstanding chronic pain can get depression and feel helpless or hopeless. This reaction is called catastrophizing [14]. Find out if they are feeling these emotions with a few simple questions and refer those with symptoms to other professionals for chronic pain treatment or chronic pain medication.
Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
Take new symptoms seriously. Patients with prostatitis also can develop kidney stones and genitourinary (GU) cancers.
In patients without UTI, do not treat an elevated prostatespecific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
Assemble a good referral team. Urologists cannot be expected to treat the parts of these conditions that do not pertain to the GU system. Team members may include physical therapists who know myofascial release therapy, pain management specialists, and psychologists who have experience with catastrophizing, chronic pain, or stress.

Conflict of Interest: Dr. Shoskes is a paid consultant to Farr

[1] Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236-237.

[2] Nickel JC, Shoskes D, Wang Y, et al. How does the pre massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119-124.

[3] Shoskes DA, Berger R, Elmi A, et al. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008;179(2):556-560.

[4] Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-160.

[5] Bjerklund Johansen TE, Gruneberg RN, Guibert J, et al. The role of antibiotics in the treatment of chronic prostatitis: a consensus statement. Eur Urol. 1998;34(6):457-466.

[6] Gleckman R, Alvarez S, Joubert DW. Drug therapy reviews: nitrofurantoin. Am J Hosp Pharm. 1979;36(3):342-351.

[7] Dalhoff A, Shalit I. Immunomodulatory effects of quinolones. Lancet Infect Dis. 2003;3(6):359-371.

[8] Nickel JC, Alexander RB, Schaeffer AJ, et al. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol. 2003;170(3):818-822.

[9] Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: enigmas and opportunities. Urology. 2007;69(Suppl 4):60-63.

[10] Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009;73(3):538-543.

[11] Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology. 1999;54(6):960-963.

[12] Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brahler E, Weidner W. 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. Eur Urol. 2009;56(3):544-551.

[13] O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med. 2009;122(Suppl 10):S22-S32.

[14] Nickel JC, Tripp DA, Chuai S, et al. Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome. BJU Int.2008;101(1):59-64.

[15] Shtricker A, Shefi S, Ringel A, Gillon G. PSA levels of 4.0 – 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy. Int Braz J Urol. 2009;35(5):551-558.

[16] Propert KJ, Litwin MS, Wang Y, et al. Responsiveness of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). Qual Life Res. 2006;15(2):299-305.

http://www.urotodayinternationaljournal.com

ISSN 1944-5792 (print), ISSN 1944-5784 (online)

Abbreviations and Acronyms

GU = genitourinary

LUTS = lower urinary tract symptoms

NIH = National Institutes of Health

PSA = prostate-specific antigen

UTI = urinary tract infection

ABSTRACT

CORRESPONDENCE: Daniel Shoskes, MD, Department of Urology, Cleveland

Clinic, 9500 Euclid Ave, Desk Q10-1, Cleveland, Ohio, 44195, USA (dshoskes@mac.com).

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.12

Facts About Prostatitis and CPPS: How Prostatitis is Often Misdiagnosed