Disease State Prostatitis Indicator Classification Disease Management Strength of Recommendation

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1 Client HMSA: PQSR 2009 Measure Title DIAGNOSTIC WORKUP OF CHRONIC PROSTATITIS Disease State Prostatitis Indicator Classification Disease Management Strength of Recommendation B Organizations Providing Recommendation Clinical Intent Physician Specialties (suggested) Background International Consensus Conference on Advances in the Diagnosis and Treatment of Prostatitis International Prostatitis Collaborative Network NIH Chronic Prostatitis Collaborative Research Network To ensure that all members suspected of having chronic prostatitis receive microscopic urinalysis, urine culture, or evidence of evaluation of prostate specific specimens as part of the initial evaluation for this condition. Refer to PQSR 2009 Clinical Measures by Specialty. Disease Burden The prevalence of medically diagnosed prostatitis is estimated to be about 9% of the population, while the overall lifetime prevalence is estimated to be 14%. Of these cases, 90% are due to nonbacterial prostatitis and prostatodynia, more generally known as chronic prostatitis.[1, 2] Every year, there are almost 2 million physician visits related to prostatitis diagnosis and follow up. Further, it costs $84 million annually for treatment.[2 4] Patients diagnosed with chronic prostatitis also have lower quality of life scores.[5] Reason for Indicated Intervention or Treatment There are several types of prostatitis acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain syndrome (CPPS), and asymptomatic inflammatory prostatitis. In terms of treatment however, there has historically been misappropriate treatment applied to CP/CPPS with the frequent use of antibiotics and anti inflammatories.[6] CP/CPPS is a clinical syndrome, and is diagnosed by observing multiple symptoms and excluding risk factors and other conditions that may also cause the same symptoms.[7] There is no gold standard for the evaluation of CP/CPPS in men, with physician judgment based on different methods of examination. Mandatory examinations include history and

2 physical examination, urinalysis and urine culture. Other important recommended examinations include urinary tract localization tests, symptom index, flow rate, residual urine determination, and urine cytology. Elective techniques include semen analysis and culture, urethral swab, urodynamics, cytoscopy, imaging, and prostate specific antigen determination.[8, 9] Evidence Supporting Intervention or Treatment A large cohort study of 488 men in the National Institutes of Health Chronic Prostatitis Cohort study questioned the relevance of determining the bacterial and inflammatory status of the lower urinary tract, because the parameters do not correlate well with duration, frequency, or severity of symptoms.[10] A case control study of 463 men enrolled in the National Institutes of Health Chronic Prostatitis Cohort study showed that men with CP/CPPS had significantly higher leukocyte counts in all segmented urine samples and expressed prostate secretions, but not in semen, as compared to controls. However, since the control population also had a high prevalence of leukocytes, the differences were clinically insignificant. There was no difference in rates of localization of bacterial cultures. This raises questions about the usefulness of the standard 4 glass test as a diagnostic tool, especially as it pertains to differentiating between men with and without chronic prostatitis.[7, 11] Another prospective study of 143 patients diagnosed with chronic prostatitis showed that the 2 glass and 4 glass tests gave very similar results.[12] In 2006, a systematic review of 12 RCTs showed that current treatment regimens of antibiotics and alpha blockers do not result in significant clinical benefit to patients with CP/CPPS.[13] It is therefore important that patients diagnosed with CP/CPPS receive follow up to ensure that they receive the appropriate therapy. Clinical Recommendations Clinical Recommendations The 2000 Washington meeting of the International Prostatitis Collaborative Network and a consensus symposium of the NIH Chronic Prostatitis Collaborative Research Network held in Chantilly, Virginia in 2002 developed guidelines for evaluating patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).[16, 17] Mandatory investigations for patients presenting with CP/CPPS include history and physical examination, including digital rectal exam (DRE), urinalysis and urine culture. Recommended evaluations include some form of lower urinary tract localization study (such as the traditional

3 Meares Stamey 4 glass test or the pre and post massage 2 glass test), a flow rate, residual urine volume determination, and urine cytology. Optional evaluations include semen analysis and culture, urethral swab, pressure flow studies, cystoscopy, transrectal ultrasound of the prostate, and pelvic imaging studies. The International Consensus Conference on Advances in the Diagnosis and Treatment of Prostatitis in Giessen, Germany in 2002 came to the consensus that the diagnosis of CP/CPPS was one of exclusion.[18] Basic evaluations for patients presenting with CP/CPPS include history and physical examination, including DRE, along with urinalysis and midstream urine culture. Further evaluations include lower urinary tract localization tests (microscopic and culture), flow rate, and residual urine determination. Selected patients should get other laboratory evaluations such as urine cytology, urethral evaluation, semen analysis and culture, and prostate specific antigen. Source Denominator Denominator Definition Health Benchmarks, Inc. Continuously enrolled males diagnosed with chronic prostatitis in a faceto face encounter in any outpatient setting during the 1 year period starting 2 months prior to end of the measurement year. Denominator Exclusion Denominator Members who were diagnosed with chronic prostatitis during the 1 year Exclusion Definition prior to the index date (excluding the index date). Numerator Numerator Definition Physician Attribution Physician Attribution Description Members who had either a urinalysis and urine culture, or evidence of evaluation of prostate specific specimens from 1 month prior through 2 months after the index date. Score all physicians (in the selected specialties) who saw the member from 1 month prior through 2 months after the index date. References 1. Collins, M.M., et al., How common is prostatitis? A national survey of physician visits. J Urol, (4): p Mehik, A., et al., Epidemiology of prostatitis in Finnish men: a population based cross sectional study. BJU Int, (4): p.

4 Stamey, T., Urinary tract infections in males., in Pathogenesis and treatment of urinary tract infections., T. Stamey, Editor. 1980, Williams and Wilkins: Baltimore. p Calhoun, E.A., et al., The economic impact of chronic prostatitis. Arch Intern Med, (11): p Nickel, J.C., L.M. Nyberg, and M. Hennenfent, Research guidelines for chronic prostatitis: consensus report from the first National Institutes of Health International Prostatitis Collaborative Network. Urology, (2): p Dennis L. Kasper, E.B., Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson Harrison's Principles of Internal Medicine. 16th. 7. McNaughton Collins, M., R. MacDonald, and T.J. Wilt, Diagnosis and treatment of chronic abacterial prostatitis: a systematic review. Ann Intern Med, (5): p Meares, E.M. and T.A. Stamey, Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol, (5): p Roberts, R.O., et al., Prevalence of a physician assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology, (4): p Moon, T.D., Questionnaire survey of urologists and primary care physicians' diagnostic and treatment practices for prostatitis. Urology, (4): p McNaughton Collins, M., et al., Diagnosing and treating chronic prostatitis: do urologists use the four glass test? Urology, (3): p Nickel, J.C., The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol, (1): p Seiler, D., et al., [Four glass or two glass test for chronic prostatitis]. Urologe A, (2): p Nickel, J.C., et al., Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol, (3): p Schaeffer, A.J., et al., Leukocyte and bacterial counts do not correlate with severity of symptoms in men with chronic prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study. J Urol, (3): p Nickel, J., Special report on prostatitis: state of the art. Rev Urol, : p Nickel, J.C., Clinical evaluation of the man with chronic prostatitis/chronic pelvic pain syndrome. Urology, (6 Suppl): p. 20 2; discussion Nickel, J., Clinical evaluation of the patient presenting with prostatitis. Eur Urol, (Suppl): p Health Benchmarks and HMSA. All rights reserved.

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