Prostatitis - chronic - Management

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1 Prstatitis - chrnic - Management Scenari: Diagnsis f chrnic prstatitis Hw shuld I diagnse chrnic prstatitis? Diagnse chrnic prstatitis if: The man has pain in the perineum r pelvic flr and lwer urinary tract symptms: The mst prminent symptm is pain. It is ften described as an ache (deep, relentless, grinding, r gnawing) and can fluctuate frm day t day. It can be experienced in the perineum, lwer abdmen, penis (especially at the tip), testis, rectum, and lwer back, but it can be very nn-specific and may be described mre as a general ache within the pelvis. Pain r discmfrt can ccur with ejaculatin. Urinary symptms include dysuria, frequency, hesitancy, urgency, and pr stream. Other symptms include fatigue, arthralgia, and myalgia. On digital rectal examinatin, the prstate is nrmal r diffusely tender. Symptms have been present fr at least 3 mnths. Other cnditins have been excluded, fr example: Urinary tract infectin, including urethritis, epididym-rchitis, and epididymitis. Benign prstatic hypertrphy. Cancer f the prstate, bladder, r cln. Urethral stricture. Obstructive calculus in the urinary tract, r a freign bdy. Pudendal neuralgia. Urine culture shuld be dne t exclude urinary tract infectin (urine dipstick tests are negative and are unlikely t change management). Prstatic massage (t btain prstatic secretins t test fr infectin in the prstate) is nt usually dne in primary care. 1

2 Serum prstate-specific antigen (PSA) test shuld nly be cnsidered if prstate cancer is suspected, fr example if there are unexplained inflammatry r bstructive lwer urinary tract symptms, r the prstate is abnrmal n digital rectal examinatin. PSA test Serum prstate-specific antigen (PSA) test Digital rectal examinatin and a PSA test shuld be perfrmed (after cunselling) fr men with unexplained inflammatry r bstructive lwer urinary tract symptms. Urinary infectin shuld be excluded befre PSA testing. Befre having a PSA test, men shuld nt have: An active urinary tract infectin (wait at least 1 mnth after treatment). Had a digital rectal examinatin (within the previus week). Had vigrus exercise (within the previus 48 hurs). Had a prstate bipsy (within the previus 6 weeks). If the PSA test is psitive, infrm the man that this des nt necessarily mean he has cancer f the prstate. At least tw thirds f men with a raised PSA d nt have cancer. He will need t cnsult a urlgist fr specialist examinatin and further tests t make a definitive diagnsis. [Austker and Kirby, 2009] Basis fr recmmendatin These recmmendatins are based n UK natinal guidelines fr the specialist management f chrnic bacterial prstatitis and chrnic prstatitis/chrnic pelvic pain syndrme (CP/CPPS) [Luzzi, 2002; BASHH, 2008]. Prstatic massage Diagnstic prstatic massage is nt recmmended in primary care because it is nt practical and is rarely dne [BASHH, 2008]. Hwever, guidelines fr specialists recmmend that infectin f the 2

3 prstate be further assessed by culturing the urine bth befre and after massage f the prstate in an attempt t lcalize infectin t the prstate. Serum prstate-specific antigen (PSA) test Althugh the PSA level may be raised in bacterial prstatitis, it is neither specific nr sensitive fr this. It is therefre nt recmmended as a rutine investigatin r when the prstate is tender, but shuld be cnsidered if prstate cancer is suspected [BASHH, 2008]. The Natinal Institute fr Health and Clinical Excellence (NICE) recmmends using a PSA test t exclude prstate cancer in men with unexplained inflammatry r bstructive lwer urinary tract symptms [NICE, 2005]. 3

4 Prstatitis - chrnic - Management Scenari: Prstatitis - chrnic Hw shuld I manage a man with chrnic prstatitis? Assess the severity f pain, urinary symptms, and impact n quality f life. The infrmatin will guide management (and the assessment may have therapeutic value in itself). Reassure that chrnic prstatitis is nt cancer and is nt a sexually transmitted infectin, althugh the cause is nt understd. Althugh the cnditin is chrnic and treatment is difficult, in mst cases the trend is fr symptms t imprve ver mnths r years. Refer t urlgy fr specialist assessment and management (which will ften include a trial f an alpha-blcker fr at least 3 mnths). If defecatin is painful, ffer a stl sftener such as lactulse r dcusate see the CKS tpic n Cnstipatin. Cnsider a trial f paracetaml r a nnsteridal anti-inflammatry drug (NSAID) fr 1 mnth see the CKS tpic n NSAIDs - prescribing issues. If there is a histry f urinary tract infectin (r an episde f acute prstatitis) within the last 12 mnths, cnsider a single curse f antibitic treatment with a quinlne while waiting fr the specialist appintment. Optins include: Ciprflxacin 500 mg twice a day fr 28 days, r Levflxacin 500 mg nce a day fr 28 days, r Oflxacin 200 mg twice a day fr 28 days, r Nrflxacin 400 mg twice a day fr 28 days. If quinlnes are nt suitable, treat with trimethprim while waiting fr specialist review. Trimethprim 200 mg twice a day fr 28 days. If the respnse t management recmmended by the urlgist is inadequate, cnsider referral t a chrnic pain specialist. 4

5 Assessment Assessing pain, urinary symptms, and quality f life Pain is likely t be the mst imprtant symptm. The Natinal Institutes f Health Chrnic Prstatitis Symptm Index, NIH-CPSI (pdf), is recmmended in guidelines fr specialists, and is widely used in research fr assessing the severity f pain, urinary symptms, and lss f quality f life [Nickel, 2000]. The NIH-CPSI scre can be useful in demnstrating that treatment has resulted in an bjective imprvement even if the man feels there has been n subjective imprvement. Hwever, it may nt be practical fr rutine use in primary care. Basis fr recmmendatin These recmmendatins are in line with guidelines published by the British Assciatin fr Sexual Health and HIV (BASHH) [BASHH, 2008]. Assessment: Althugh the NIH-CPSI questinnaire is widely used in research and is recmmended in guidelines fr specialists, its usefulness in primary care has nt been assessed, and it is therefre nt recmmended fr rutine use. Trial f simple analgesics: Althugh a trial f simple analgesics is nt cnsidered in the BASHH guideline [BASHH, 2008], a Eurpean guideline n chrnic pelvic pain recmmends (n the basis f expert pinin) a trial f NSAIDs [Fall et al, 2008]. Little research has been cnducted n the effects f NSAIDs in chrnic prstatitis, but there is sme evidence f limited clinical benefit. There are n clinical trials n the use f paracetaml fr chrnic prstatitis. Referral: There are n studies r guidelines n referral fr chrnic prstatitis. The recmmendatins reflect the pinin f CKS n what is cnsidered t be gd clinical practice. Antibitics fr chrnic bacterial prstatitis: 5

6 UK and Eurpean guidelines recmmend antibitics fr chrnic bacterial prstatitis n the basis f weak evidence [BASHH, 2008; Eurpean Assciatin f Urlgy, 2008]. There are n placeb-cntrlled, randmized cntrlled trials (RCTs) f antibitics fr bacterial prstatitis. Three RCTs cmparing different antibitics suggest that between 70% and 98% f men with bacterial prstatitis will be cured r imprved when treated with a quinlne. There is n evidence frm these trials t suggest that any quinlne is mre effective r safer than any ther quinlne. There is n gd evidence n ther classes f antibitics. Quinlnes are preferred t trimethprim because they are effective against a wider range f urinary pathgens. Other antibitics either d nt penetrate the prstate as well, r are less effective against urinary pathgens. There is n evidence t suggest that any particular quinlne is mre effective r mre hazardus than any ther. CKS recmmendatins f ciprflxacin, levflxacin, flxacin r nrflxacin are cnsistent with thse made by the British Assciatin fr Sexual Health and HIV (BASHH) [BASHH, 2008]. The benefits f treatment utweigh the risk f precipitating an antibitic-induced infectin with Clstridium difficile r meticillin-resistant Staphylcccus aureus (MRSA), and the risk f prmting resistance t quinlnes. CKS recmmends empirical treatment with a quinlne fr men with a histry f urinary tract infectin because it is mre likely that the presenting symptms are caused by chrnic infectin, and because diagnstic prstatic massage (t cnfirm infectin) is nt practical in primary care. Antibitics fr abacterial prstatitis: BASHH guidelines d nt recmmend antibitics fr abacterial prstatitis, but bserve that they are widely used [BASHH, 2008]. Very weak evidence supprts the use f antibitics fr chrnic abacterial prstatitis. One small RCT fund weak evidence that levflxacin may be mre effective than dxazsin (and as effective as a cmbinatin f the tw). Imprvements were nt significant 2 weeks after treatment, but were significant 6 weeks after treatment. Participants had nt previusly been treated with antibitics and had been symptmatic fr less than a year n average. Tw RCTs fund that quinlnes were nt effective in men wh had experienced symptms fr 6 years n average and had previusly had a number f treatments including antibitics. 6

7 Sme urlgists recmmend that all men with chrnic prstatitis be treated with an antibitic [Nickel, 2008a; Nickel et al, 2008]. Hwever, thers have raised the cncern that, under this plicy, many men withut infectin are being treated unnecessarily and bacterial resistance may be prmted [Taylr et al, 2008]. Eurpean guidelines recmmend treatment f chrnic pelvic pain syndrme with antibitics if infectin is strngly suspected [Eurpean Assciatin f Urlgy, 2008]. As all men with chrnic prstatitis shuld be referred t a urlgist wh can exclude infectin (fr example with cultures f urine bth befre and after prstatic massage), CKS recmmends that antibitics are nt prescribed in primary care fr men wh have chrnic prstatitis (unless, as explained abve, infectin is suggested by a histry f urinary tract infectin). Prescriptins Fr infrmatin n cntraindicatins, cautins, drug interactins, and adverse effects, see the electrnic Medicines Cmpendium (emc) ( r the British Natinal Frmulary (BNF) ( 1st-line antibitics (histry f UTI): quinlnes Age frm 16 years nwards Nrflxacin tablets: 400mg twice a day Nrflxacin 400mg tablets Take ne tablet twice a day fr 28 days. Supply 56 tablets. Age frm 18 years nwards Ciprflxacin tablets: 500mg twice a day Ciprflxacin 500mg tablets Take ne tablet twice a day fr 28 days. Supply 56 tablets. Oflxacin tablets: 200mg twice a day Oflxacin 200mg tablets Take ne tablet twice a day fr 28 days. Supply 56 tablets. Levflxacin tablets: 500mg nce a day 7 Age: frm 16 years nwards NHS cst: Age: frm 18 years nwards NHS cst: 3.34 Age: frm 18 years nwards NHS cst: 43.85

8 Levflxacin 500mg tablets Take ne tablet nce a day fr 28 days. Supply 28 tablets. Age: frm 18 years nwards NHS cst: Alternative antibitic (histry f UTI): trimethprim Age frm 16 years nwards Trimethprim tablets: 200mg twice a day Trimethprim 200mg tablets Take ne tablet twice a day fr 28 days. Supply 56 tablets. Age: frm 16 years nwards NHS cst: 3.60 Analgesia: use when required Age frm 16 years nwards Paracetaml tablets: 1g up t fur times a day Paracetaml 500mg tablets Take tw tablets every 4 t 6 hurs when required fr pain relief. Maximum f 8 tablets in 24 hurs. Supply 100 tablets. Ibuprfen tablets: 400mg up t three times a day Age: frm 16 years nwards NHS cst: 1.56 Ibuprfen 400mg tablets Take ne tablet three times a day when required fr pain relief. D nt exceed the stated dse. Supply 84 tablets. Age: frm 16 years nwards NHS cst: 2.38 OTC cst: 4.08 Stl sfteners: dcusate r lactulse Age frm 16 years nwards Dcusate capsules: 100mg t 200mg nce r twice a day Dcusate 100mg capsules Take ne t tw capsules nce r twice a day when required. Supply 100 capsules. 8 Age: frm 16 years nwards NHS cst: 8.00 OTC cst: 13.80

9 Lactulse slutin: 15ml twice a day Lactulse g/5ml ral slutin Take three 5ml spnfuls twice a day. Supply 1000 ml. Age: frm 16 years nwards NHS cst: 5.80 OTC cst:

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