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  Update on Prostatitis and Update on Prostatitis and  T r eatments  T r eatments BAUN Benign Study Day BAUN Benign Study Day 14/03/2012 14/03/2012 Mr Ri!ard "etti Mr Ri!ard "etti Speia#ist Registrar Uro#ogy$ %A Speia#ist Registrar Uro#ogy$ %A Portsmout! Portsmout!

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  • 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)