Use of terazosine in patients with chronic pelvic pain syndrome and evaluation by prostatitis symptom score index

A systematic review and meta-analysis of placebo effect in clinical trials on chronic prostatitis/chronic pelvic pain syndrome

BACKGROUND

It is a common practice to control efficacy of pharmacological treatment with a placebo group. However, placebo itself may affect subjective and even objective results. The purpose of this study was to evaluate the placebo effect on symptoms of CP/CPPS to improve future clinical trials.

METHODS

A search at three databases (Scopus, MEDLINE, and Web of Science) was conducted to identify double-blind placebo-controlled clinical trials on the treatment of CP/CPPS published until April 2021. The primary outcome - National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score.

SECONDARY OUTCOMES

Qmax, PVR, IPSS, and prostate volume.

RESULTS

A total of 3502 studies were identified. Placebo arms of 42 articles (5512 patients, median 31 patients) were included in the systematic review. Systematic review identified positive changes in the primary endpoint, meta-analysis of 10 articles found that NIH-CPSI total score results were significantly influenced by placebo, mean difference -4.2 (95% confidence interval [CI]: -6.31, -2.09). Mean difference of NIH-CPSI pain domain was -2.31 (95% CI: -3.4, -1.21), urinary domain -1.12 (95% CI: -1.62, -0.62), quality of life domain -1.67 (95% CI: -2.38, -0.96); p < 0.001 for all. In case of the objective indicator - Qmax, there were three articles included in the meta-analysis. Qmax mean change from baseline was 0.68 (95% CI: -0.85, 2.22, p = 0.38). Systematic review showed no significant changes in pain, measured by VAS or other scores, IPSS and PVR.

CONCLUSIONS

Placebo significantly affected the subjective parameters (NIH-CPSI) and limitedly affected various other measurements of pain (visual analog scale, McGill pain questionnaire). There was no long-term effect on IPSS and objective measurements (Qmax, PVR). This study can be used in further clinical trials to develop general rules of CPPS treatment assessment.

Therapeutic interventions to urologic chronic pelvic pain syndrome and UPOINT system for clinical phenotyping: How far are we?

The assessment and management of urologic chronic pelvic pain syndrome (UCPPS), is controversial. It is classified by voiding symptoms, pelvic pain, and bladder pain, which is weekly treated, weekly understood, and bothersome. In the aspect of clinical efforts and research to help people with this syndrome have been hampered by the deficiency of a widely reliable, accepted, and a valuable tool to evaluate the patient symptoms and quality of life (QoL) impact. However, the etiology comes into sight is multifactorial, and available treatment options have been imprecise considerably in present years. We compiled the published literature on the assessment of the syndrome, a tentative role of pharmacological and non-pharmacological (conservative, alternative, and invasive therapy) interventions in eradicating the disease as well as improving symptoms. The previously published literature on animal models has established the association of immune systems in the etiology, pathogenesis, and progression of the disease. The UPOINT system for clinical phenotyping of UCPPS patients has six predefined domains that direct multimodal therapy, which would lead to significant symptom improvement in the medical field. The narrative review aims to scrutinize the fluctuating scientist's views on the evaluation of patient and multimodal treatment of the UPOINT system.

Diagnostic and Management Strategies for Patients with Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common and often heterogenous condition that can have severe consequences on patient quality of life. In this review, we describe the pathophysiology, diagnostic work-up, and treatment of patients with CP/CPPS incorporating the most recent literature. Studies have demonstrated that CP/CPPS involves a complex pathophysiology, including infectious, immunologic, neurologic, endocrinologic, and psychologic etiologies, with frequent intersections between the different entities. Despite robust research assessing a variety of therapeutics targeting these etiologies, clinical trials have failed to identify an empiric treatment strategy applicable specifically to older adult male patients with CP/CPPS. As such, it can be challenging to manage older male patients with this condition. The advent of clinical phenotyping of patients with CP/CPPS has led to advances in tailored management strategies. Monomodal therapy has been largely unsuccessful because of the unclear and complex etiology of CPPS. As a result, CP/CPPS therapy has transitioned to a multimodal approach, including both pharmacologic and non-pharmacologic therapies. The best studied pharmacologic therapies include antibiotics, alpha-blockers, anti-inflammatory and immunomodulatory agents, phytotherapies, phosphodiesterase inhibitors, hormonal agents, neuromodulatory agents, and antidepressants. The best studied non-pharmacological therapies include pelvic floor physical therapy, myofascial trigger point release, acupuncture and electroacupuncture, psychological support and biofeedback, and electrocorporeal shockwave therapy and local thermotherapy.

Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common disorder in which the two main clinical features are pelvic pain and lower urinary tract symptoms. There are currently many approaches for its management, using both pharmacological and non-pharmacological interventions. The National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) score is a validated measure commonly used to measure CP/CPPS symptoms. We considered a 25% decrease of NIH-CPSI baseline score or a six-point reduction as MCID.

OBJECTIVES

To assess the effects of pharmacological therapies for chronic prostatitis/chronic pelvic pain syndrome.

SEARCH METHODS

We performed a comprehensive search using CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, trial registries, grey literature and conference proceedings, with no restrictions on the language of publication or publication status. The date of the latest search of all databases was July 2019.

SELECTION CRITERIA

We included randomised controlled trials. Inclusion criteria were men with a diagnosis of CP/CPPS. We included all available pharmacological interventions compared to placebo or in head-to-head comparisons.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed the risks of bias of included studies. We assessed the quality of the evidence (QoE) using the GRADE approach.

MAIN RESULTS

We included 99 unique studies in 9119 men with CP/CPPS, with assessments of 16 types of pharmacological interventions. Unless stated otherwise, our comparisons were based on short-term follow-up (less than 12 months). Most studies did not specify their funding sources; 21 studies reported funding from pharmaceutical companies.1. Alpha blockers: (24 studies, 2061 participants). We are uncertain about the effects of these drugs on prostatitis symptoms when compared to placebo at short-term follow-up (mean difference (MD) in total NIH-CPSI score -5.01, 95% confidence interval (CI) -7.41 to -2.61; 18 studies, 1524 participants, very low QoE) and at long-term follow-up (MD -5.60, 95% CI -10.89 to -0.32; 4 studies, 235 participants, very low QoE). Alpha blockers may be associated with an increased incidence of adverse events, such as dizziness and postural hypotension (risk ratio (RR) 1.60, 95% CI 1.09 to 2.34; 19 studies, 1588 participants; low QoE). Alpha blockers probably result in little to no difference in sexual dysfunction, quality of life and anxiety and depression (moderate to low QoE).2. 5-alpha reductase inhibitors (5-ARI): (2 studies, 177 participants). Finasteride probably reduces prostatitis symptoms compared to placebo (NIH-CPSI score MD -4.60, 95% CI -5.43 to -3.77; 1 study, 64 participants; moderate QoE) and may not be associated with an increased incidence of adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.3. Antibiotics: (6 studies, 693 participants). Antibiotics (quinolones) may reduce prostatitis symptoms compared to placebo (NIH-CPSI score MD -2.43, 95% CI -4.72 to -0.15; 5 studies, 372 participants; low QoE) and are probably not associated with an increased incidence in adverse events (moderate QoE). Antibiotics probably result in little to no difference in sexual dysfunction and quality of life (moderate QoE). There was no information on anxiety or depression.4. Anti-inflammatories: (7 studies, 585 participants). Anti-inflammatories may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -2.50, 95% CI -3.74 to -1.26; 7 studies, 585 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.5. Phytotherapy: (7 studies, 551 participants). Phytotherapy may reduce prostatitis symptoms compared to placebo (NIH-CPSI scores MD -5.02, 95% CI -6.81 to -3.23; 5 studies, 320 participants; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). Phytotherapy may not improve sexual dysfunction (low QoE). There was no information on quality of life or anxiety and depression.6. Botulinum toxin A (BTA): Intraprostatic BTA injection (1 study, 60 participants) may cause a large reduction in prostatitis symptom (NIH-CPSI scores MD -25.80, 95% CI -30.15 to -21.45), whereas pelvic floor muscle BTA injection (1 study, 29 participants) may not reduce prostatitis symptoms (low QoE). Both comparisons used a placebo injection. These interventions may not be associated with an increased incidence in adverse events (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.7. Allopurinol: (2 studies, 110 participants). Allopurinol may result in little to no difference in prostatitis symptoms and adverse events when compared to placebo (low QoE). There was no information on sexual dysfunction, quality of life or anxiety and depression.8. Traditional Chinese medicine (TCM): (7 studies, 835 participants); TCM may reduce prostatitis symptoms (NIH-CPSI score, MD -3.13, 95% CI -4.99 to -1.28; low QoE) and may not be associated with an increased incidence in adverse events (low QoE). TCM probably does not improve sexual dysfunction (moderate QoE) and may not improve symptoms of anxiety and depression (low QoE). There was no information on quality of life.The most frequent reasons for downgrading the QoE were study limitations, inconsistency and imprecision. We found few trials with active comparators.

AUTHORS' CONCLUSIONS

We found low- to very low-quality evidence that alpha blockers, antibiotics, 5-ARI, anti-inflammatories, phytotherapy, intraprostatic BTA injection, and traditional Chinese medicine may cause a reduction in prostatitis symptoms without an increased incidence of adverse events in the short term, except for alpha blockers which may be associated with an increase in mild adverse events. We found few trials with active comparators and little evidence of the effects of these drugs on sexual dysfunction, quality of life or anxiety and depression. Future clinical trials should include a full report of their methods, including adequate masking, consistent assessment of all patient-important outcomes, including potential treatment-related adverse events, and appropriate sample sizes.

Interventions to chronic prostatitis/Chronic pelvic pain syndrome treatment. Where are we standing and what's next?

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a frustrating syndrome. The pathogenesis and state of the art treatment of CP/CPPS are not known. A wide variety of therapies including anti-inflammatories, antibiotics, alpha-blockers, neuropathic pain modulators, and 5α-reductase inhibitors are in practice. These treatment strategies focus on alleviating symptoms in specific domains without treating root-cause and therapeutic outcome is far from satisfactory. We review the literature on current pharmacological treatments for CP/CPPS in detail and suggest future perspectives to modify the treatment strategies. We suggest that introducing novel treatment strategies such as gene editing, and T_regs expressing chimeric receptors may improve the treatment outcomes by inducing immune tolerance and controlling expression of pro-inflammatory cytokines.

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline

Objectives

To improve awareness and recognition of chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) among non‐specialists and patients. To provide guidance to healthcare professionals treating patients with CBP and CP/CPPS, in both non‐specialist and specialist settings. To promote efficient referral of care between non‐specialists and specialists and the involvement of the multidisciplinary team (MDT).

Patients and Methods

The guideline population were men with CBP or CP/CPPS (persistent or recurrent symptoms and no other urogenital pathology for ≥3 of the previous 6 months). Consensus recommendations for the guidelines were based on a search to identify literature on the diagnosis and management of CBP and CP/CPPS (published between 1999 and February 2014). A Delphi panel process was used where high‐quality, published evidence was lacking.

Results

CBP and CP/CPPS can present with a wide range of clinical manifestations. The four main symptom domains are urogenital pain, lower urinary tract symptoms (LUTS – voiding or storage symptoms), psychological issues and sexual dysfunction. Patients should be managed according to their individual symptom pattern. Options for first‐line treatment include antibiotics, α‐adrenergic antagonists (if voiding LUTS are present) and simple analgesics. Repeated use of antibiotics, such as quinolones, should be avoided if there is no obvious symptomatic benefit from infection control or cultures do not support an infectious cause. Early use of treatments targeting neuropathic pain and/or referral to specialist services should be considered for patients who do not respond to initial measures. An MDT approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, general practitioners, cognitive behavioural therapists/psychologists, and sexual health specialists) is recommended. Patients should be fully informed about the possible underlying causes and treatment options, including an explanation of the chronic pain cycle.

Conclusion

Chronic prostatitis can present with a wide variety of signs and symptoms. Identification of individual symptom patterns and a symptom‐based treatment approach are recommended. Further research is required to evaluate management options for CBP and CP/CPPS.

Role of alpha blocker therapy in chronic prostatitis/chronic pelvic pain syndrome: limited options with promising results

Chronic prostatitis / chronic pelvic pain syndrome (NIH-type II and type III prostatitis) are common cause of chronic pelvic pain. The exact etiology of these entities are unknown. They are associated with varying degree of voiding and sexual dysfunction. Consensus regarding treatment of these pain syndromes is lacking. Review of literature suggest a therapeutic role of alpha adrenergic receptor blockers in the management of NIH-type II and type III prostatitis. A trial of alpha-blocker is reasonably inexpensive and appropriate for most patients suffering from NIH-type III prostatitis and NIH-type II prostatitis. A general consensus is that if a patient agrees to a trial of alpha-blocker therapy which subsequently shows a good response then it should be continued for at least 6 months for a proper therapeutic effect. This review analyses the role of alpha-blockers in this disease/syndrome; discusses the possible mechanism of action through which these drugs provide relief and also highlights some of the important trials which have paved way for this particular treatment option in this intriguing disease /syndrome.

Chronic prostatitis/chronic pelvic pain syndrome: role of alpha blocker therapy

INTRODUCTION

This article reviews the rationale and data supporting alpha blocker therapy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), the most common and difficult prostatitis syndrome.

METHODS

Systematic review identified ten clinical trials evaluating alpha blocker therapy for patients with CP/CPPS, including five open-label or small prospective studies and five double-blinded and placebo-controlled clinical trials.

RESULTS

Encouraging results in uncontrolled and small clinical trials led to the development of reasonably powered, double-blinded, placebo-controlled, randomized clinical trials evaluating terazosin, doxazosin, tamsulosin, and alfuzosin.

CONCLUSIONS

Current data suggest that treatment-naïve and/or newly diagnosed patients appear more likely to respond than long-term, chronic refractory patients. Longer courses of treatment (12 weeks to 6 months) appear superior to shorter courses, and less selective agents appear superior to more selective alpha1 blockers. These observations outline important questions that must be answered to define optimal treatment strategies for patients with CP/CPPS.

Role of α-Blockers in Type III Prostatitis: A Systematic Review of the Literature

PURPOSE

We examined the evidence for the effectiveness of alpha-blockers for type III prostatitis.

MATERIALS AND METHODS

Studies were identified through a search of MEDLINE, EMBASE and The Cochrane Library as well as a manual search of bibliographies of identified articles and abstract books of recent major international urology conferences. Inclusion criteria included randomized, placebo controlled trials of treatment for type III prostatitis and use of the National Institutes of Health-Chronic Prostatitis Symptom Index outcome measure.

RESULTS

Six unique trials in a total of 386 patients met inclusion criteria. One study showed no difference between alpha-blockers and placebo in terms of total or domain National Institutes of Health-Chronic Prostatitis Symptom Index scores and another did not report the p value. All of the remaining 4 studies showed a statistically significant difference in the total score in favor of alpha-blockers, while only 2 showed improved quality of life. Individual treatment effects were statistically significant more often when treatment was administered for 3 months or longer. Despite a common tool for outcome assessment meta-analysis of the results in individual trials was not possible due to differences in the manner of interpreting outcomes and reporting data.

CONCLUSIONS

The current published literature is insufficient to conclude with certainty that alpha-blockers are effective for type III prostatitis. Future studies should incorporate uniformity in data collection and reporting with improved health related quality of life as the end point of therapy.

Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome continues to pose a treatment challenge for urologists. Most commonly prescribed medications, such as antibiotics, a-blockers, androgen inhibitors, and anti-inflammatory agents, have been shown to help some patients. However, the efficacy and durability of such treatments lack consistency among men suffering from this disorder. The rationale for such treatments is described in this article, along with possible explanations for the apparent shortcomings. Also included is a brief summary of alternative therapies, which are growing in popularity among patients and gaining acceptance in our medical communities.

The use of alpha1-adrenoceptor antagonists in lower urinary tract symptoms: beyond benign prostatic hyperplasia

The first empirical use of alpha(1)-adrenoceptor antagonists in urology occurred about 25 years ago in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH), or LUTS/BPH. Today, many randomized, controlled trials have provided evidence for the efficacy and tolerability of alpha(1)-adrenoceptor antagonists in LUTS/BPH, and they are the most frequently used initial treatment option for this cause of LUTS. For many years, alpha(1)-adrenoceptor antagonists have also been used empirically in other types of lower urinary tract dysfunction (LUTD), such as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and neurogenic LUTD (NLUTD). Several investigators have shown that alpha(1)-adrenoceptor antagonists may be useful in patients with CP/CPPS. This was recently confirmed by a 6-week, double-blind, placebo-controlled pilot study evaluating the efficacy and safety of tamsulosin in 58 CP/CPPS patients. Further well-designed and -powered research into the use of alpha(1)-adrenoceptor antagonists in patients with CP/CPPS is currently ongoing. Several small-scale predominantly open-label studies have suggested that alpha(1)-adrenoceptor antagonists may be of benefit in patients with NLUTD. Data from 2 recent large-scale studies with tamsulosin in patients with NLUTD caused by suprasacral spinal cord injury suggest that long-term tamsulosin treatment improves bladder storage and emptying and also reduces symptoms of autonomic dysreflexia. Tamsulosin has also shown promise in ameliorating (early) storage symptoms and urinary retention associated with transurethral microwave thermotherapy, external-beam radiotherapy, and brachytherapy. In BPH patients presenting with the ultimate form of LUTS-acute urinary retention-treatment with tamsulosin before catheter removal results in a higher success rate of catheter-free voiding. Finally, it seems that alpha(1)-adrenoceptor antagonists may reduce the occurrence of urinary retention after (general) surgery. We can therefore conclude that alpha(1)-adrenoceptor antagonists, such as tamsulosin, may be useful for treating men with LUTS beyond BPH.