Chronic prostatitis: A diagnosis of exclusion
Chronic prostatitis – does this disease really exist? This question can be answered with a clear yes, at least as far as the histological diagnosis is concerned. Chronic prostatitis is often found in the context of biopsy clarification of an elevated PSA level as differential diagnosis to prostate cancer, also specifically as chronic granulomatous prostatitis (image below).
The issue of the clinical disease is less clear. If you ask a medical layperson on the internet, you will find two main symptoms: pain and LUTS. Pain as pain in the pelvis and perineum, perineal foreign body sensation (“like a stone”), burning before, after and during micturition and ejaculation, also persistent over a longer period, changing pain localisation, sometimes difficult to localise. The pain is described as constant, diffuse, and triggered by a wide range of factors.
Another key symptom is LUTS, in the sense of according to pollakiuria, nocturia, dysuria and frequent urination frequency. In summary, the definition is: “long-term pelvic pain and lower urinary tract symptoms (LUTS) without evidence of a bacterial infection”. Approximately 2-6% of all men are affected. Real incidence is missing.
Avoid the term “Chronic prostatitis”
The term “chronic prostatitis” often triggers two thoughts in laypeople: it must be an inflammation and it must be chronic, so “I am seriously ill”. In this respect, the use of this term can only be warned against, and it should disappear from doctor patient communication.
This is also recommended by the EAU Guidelines on Chronic Pelvic Pain 2024. [1] This guideline advises the use of the term “Primary prostatic pain syndrome” (PPPS) as a pain syndrome that can be triggered regularly and recurrently, among other things, by palpation of the prostate. The syndrome is associated with negative cognitive, behavioural, sexual, and emotional consequences, often in conjunction with LUTS and erectile dysfunction.
The classification presented in the guideline shows a wide variation of causes and connections to other problems beyond the scope of this article. In essence, PPPS is a diagnosis of exclusion. Therefore, other curable causes such as bacterial infections, BPS or a tumour must be excluded during the diagnostic process. Cooperation with other disciplines, especially gastroenterology or neurology, may also be necessary to rule out other diseases in the environment.
What can we do?
First, it is important to take a detailed medical history. Questions about the extent of the pain, triggering factors, localisation and much more should be clarified. Furthermore, emotional, social and sexual changes and consequences of the complaints must be asked.
Symptoms of defined and causally treatable diseases should be clarified. The use of a life scoring instrument questionnaire (e.g. NIH-Chronic Prostatitis Symptom Index) is recommended to record the symptoms. The diagnostic process can
then be adapted to the individual patient. Further imaging, laboratory, microbiological and organ-specific diagnostics are then based on the UPOINT classification (Fig. 3). Here, all further diagnostic measures are presented in a systematic way and can be carried out in a patient-adapted and needs-orientated manner way.
A multimodal therapeutic approach is necessary. It is important to discuss the nature, possible causes and treatment options with the patient. The patient should be aware that this is a pain syndrome without cause root. In office and outpatient urology, we try to make the patient understand that the disease is not dangerous but extremely annoying and requires a lot of patience from all sides. The EAU guidelines recommend antibiotics for patients in the first year of the disease. Quinolones and tetracyclines are recommended for at least six weeks. However, side effects, especially of quinolones, should be considered. Alpha blockers are also recommended in the first year of the disease. There is also a weak recommendation for NSAIDs, again taking into account contraindications and side effects.
In significant psychological stress, psycho therapeutic treatment should also be considered. In the case of sexual dysfunction in particular, behavioural therapy may also be considered, possibly involving the partner. For further multimodal therapy, please refer to the EAU Guidelines 2024. [1]
A study at the National Institutes of Health (NIH) showed that phytotherapy with rye pollen extracts had significant effects on pain in patients with CPPS, particularly in the IIIa stage. However, it should be noted that patients with pollen allergies should not take this treatment.
Summary
The importance of talking to the patient should be emphasised again. Here, the term chronic prostatitis should be avoided. The main purpose of the diagnosis is to rule out causally treatable diseases. In the EAU guidelines, antibiotics and alpha blockers are only recommended for patients in the first year of the disease. Psychotherapy, behavioural therapy and phytotherapy are possible. Be patient… and talk to your patient.
Reference
EAU Guidelines on Chronic Pelvic Pain. Edn. presented at the EAU Annual Congress Paris 2024. ISBN978-94-92671-12-3. https://uroweb.org/guidelines/chronic-pelvic-pain
