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Guide
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common urological andrology disease, its pathogenesis is complex and diverse, treatment options are complex, and the efficacy is uncertain, which brings great trouble
to clinical work.
The Andrology Branch of the Chinese Medical Association compiles CP/CPSS diagnosis and treatment guidelines to provide useful guidance and assistance to the clinical working group, and Yimaitong has compiled the key points of diagnosis and treatment as follows
.
Prostatitis is a common disease in adult men, and patients with prostatitis account for 8%-25% of
urology outpatients.
CP/CPPS is the most common and difficult to treat type of prostatitis, accounting for more than 90% of all prostatitis, and the incidence of CP/CPPS tends to be
younger.
Studies have shown that occupation, environment, spicy food, alcohol consumption, sedentary, holding urine, sexual habits and mental factors are the main risk factors
for the pathogenesis of CP/CPPS.
A thorough and detailed history of a patient with CP/CPPS not only helps to confirm the diagnosis, but also assists in the evaluation of the condition, further analysis of the cause, targeted treatment, and understanding of the prognosis
.
The collection of medical history mainly includes four main aspects
: chief complaint, present medical history, past history, and personal history.
CP/CPPS patients focus on the following on the basis of the whole physical examination: lower abdomen, lumbosacral region, perineum, urethral meatus, penis, testes, epididymis, spermatic cord and other genitourinary system examination, pay attention to the presence of tenderness and abnormal mass, which is helpful for diagnosis and differential diagnosis
.
Pay attention to epididymitis, epididymal nodules, varicocele veins, spermatitis, testicular tumors and other diseases that cause similar perineal swelling pain, etc.
, which need to be distinguished
from prostatitis.
Most patients with CP/CPPS have a prolonged and recurrent disease, often more than 3-6 months, and the individualized symptoms vary greatly
.
Most patients present with one or more of the symptoms of
pain, lower urinary tract symptoms (LUTS), psychosocial symptoms, and sexual dysfunction.
The clinical symptoms of CP/CPPS are complex and changeable, and there is a lack of objective diagnostic evaluation indicators
in actual clinical diagnosis and treatment.
At present, it is believed that the NIH Chronic Prostatitis Symptom Score (NIH-CPSI) can be relatively objective and comprehensive for symptom assessment of patients with CP/CPPS, and can be used as an auxiliary diagnostic evaluation tool for symptom severity or as an important efficacy evaluation tool
in treatment follow-up.
Patients with CP/CPPS with sexual dysfunction can use the International Erectile Dysfunction Index (IIEF-5) to assess erectile function and the Premature Ejaculation Diagnostic Tool (PEDT) to assess ejaculatory function
.
Patients with urinary storage symptoms predominating urinary frequency and urgency can be evaluated
preferentially or in combination with the Self-Evaluation Scale (OABSS score) for patients with overactive bladder (OAB).
Patients with psychiatric symptoms such as anxiety and depression can be assessed
on the Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Anxiety Self-rating Scale (SAS), and Generalized Anxiety Disorder Scale (GAD-7).
CP/CPPS examination items include: urine routine examination, prostate small effatoprotein (PSEP) test, prostate massage fluid (EPS) test, semen test, prostate endocrine function test, semen white blood cell test, oxidation and antioxidant test, pathogenic microorganism test
.
Imaging tests and other special tests (urodynamic studies, urethral cystoscopy, prostate biopsy, etc.
).
Principles of treatment
1.
Actively look for the cause, strive to treat the cause, and take symptomatic treatment at
the same time.
2.
For most people who have no clear cause and significant symptoms, symptomatic treatment is used to control symptoms and improve the quality of life
of patients.
3.
A variety of diagnosis and treatment programs are jointly applied, and multidisciplinary diagnosis and treatment mode (MDT)
can be adopted if necessary.
General treatment options
These include lifestyle improvements (forming good diet and habits), psychological counseling (focusing on the patient's mental health), self-management programs (physical activity, regular sexual activity), and physical therapy in the home (hot sitz baths, hot compresses to the lower abdomen), etc
.
Chemotherapy
Commonly used drugs include antibiotics (empiric use can improve clinical symptoms in some patients with inflammatory CP/CPPS, non-inflammatory is not recommended), α receptor blockers (often used to improve pain and LUTS in CP/CPPS patients), nonsteroidal anti-inflammatory drugs (anti-inflammatory, antipyretic and analgesic), antidepressants and anxiolytics (for CP/CPPS patients with mood disorders such as depression and anxiety), other drugs (M blockers, beta-3 agonists, 5-alpha reductase inhibitors, etc.
)
。
Other treatment options
Other treatment options include the use of botanicals (pollen preparations), TCM characteristic treatments (dialectical treatment, acupuncture, etc.
), biofeedback training, electrophysiological therapy, magnetic therapy, microwave hyperthermia, psychotherapy (psychological support, cognitive behavioral therapy, etc
.
).
comorbid erectile dysfunction (ED)
There is still a lack of direct and sufficient evidence-based medical evidence, and there are the following tips: 1.
Receptor blockers and pelvic floor muscle relaxation training have α been reported to improve erectile function
while treating CP/CPPS-related symptoms.
2.
Studies have confirmed that phosphodiesterase type 5 inhibitors combined with α receptor blockers can effectively improve LUTS and ED problems in patients with benign prostatic hyperplasia (BPH), and tadalafil alone can also relieve BPH/LUTS and ED symptoms
.
3
.
It is necessary to pay attention to active health education and psychological counseling for patients, and encourage patients to maintain good eating and rest habits and regular sexual life.
Combined with premature ejaculation
A history of premature ejaculation is recommended for patients with CP/CPPS, and routine CP/CPPS screening
is recommended for patients with premature ejaculation.
For patients with established CP/CPPS comorbidities and premature ejaculation, treatment
for CP/CPPS should be prioritized.
Combined male infertility
Careful communication with the patient and a complete history
are required.
Some patients without CP/CPPS symptoms and elevated white blood cells in EPS/semen on laboratory tests should be differentiated for type IV prostatitis
.
The treatment of CP/CPPS complicated with infertility should focus on eliminating pathogenic microorganisms that may be present in prostate fluid and semen, improving inflammation and glandular secretion function, and improving sperm quality to enhance fertility
.
Combined with anxiety and depression
Combined with the results of self-assessment and other evaluation of the mood scale, CP/CPPS patients with moderate/severe anxiety, depressed mood or obvious suicidal tendencies are recommended to be transferred to psychiatric and psychological treatment first; For general patients with anxiety and depression, it is recommended to combine psychotherapy on the basis of drug treatment to reduce the impact
of their bad emotions on the physical symptoms of the disease.
Merge BPH/LUTS
The treatment of CP/CPPS and BPH/LUTS has similar therapeutic goals, that is, to reduce symptoms and improve quality of life, and BPH/LUTS patients also need to consider relieving obstruction and preventing complications
.
Therefore, when the two are comorbid, the treatment measures should take into account the above goals, and combine physical therapy and surgical treatment on the basis of general treatment and drug treatment
.
The treatment of CP/CPPS is also suitable for the management
of comorbidities of CP/CPPS and BPH/LUTS.
5-alpha reductase inhibitors are more effective
in patients with CP/CPPS with a large BPH prostate volume.
Surgical treatment is performed
only when indicated for BPH/LUTS surgery.
Patients should be made to correctly understand CP/CPPS and its diagnosis and treatment; Patients are advised to do moderate aerobic exercise; Improve the patient's diet, choose foods with high zinc content, eat a light diet and drink plenty of water; Pay attention to the mental health of patients and provide timely counseling and intervention
.
References
1.
Guidelines for diagnosis and treatment of chronic prostatitis/chronic pelvic pain syndrome[J].
Chinese Journal of Andrology,2022,28(06):544-559.
)
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