Prostate news article, March 2008
| CHRONIC
PROSTATIS/CHRONIC PELVIC PAIN: FINDING A WAY FORWARD
IN THE UK
A report from the first Symposium in the UK on Chronic
Prostatitis J. Curtis Nickel, MD,
FRCSC1 Meesha Patel, BSc.
Hons2 Marina Cameron, BSc.
Hons2 |
 |
Chronic prostatitis or chronic pelvic pain syndrome (CP/CPPS) is a painful, prevalent and economically important condition. In spite of recent advances it remains the least understood prostate condition. Countries such as the United States and Canada produce the majority of the research and have better levels of awareness amongst healthcare professionals and the public. In contrast there is a dearth of CP/CPPS research in UK, few specialists, and a lack of awareness amongst doctors and the public alike. This interactive symposium sought to address these issues by bringing together experts in various disciplines. This article highlights some of the findings from that meeting.
Chronic prostatitis: past, present and future
J. Curtis Nickel from Queen's University gave the keynote address. He noted that at least 15% of men aged over 50 years will have had a diagnosis of prostatitis; 3–12% of men will have suffered symptoms of prostatitis in the past month; and that prostatitis is the third most likely diagnosis in men presenting to their GPs in North America. Prostatitis also places a huge economic burden on society, as a patient with this condition will cost the health service more than a patient with type 1 diabetes. Additionally, prostatitis severely affects a man’s quality of life. Major advances have been made but the optimal way to examine the recent evidence on CP/CPPS treatments is to focus on research that conforms to strict criteria and good methodology by:
- Use of the NIH classification system for the definition of CP/CPPS and characterization of patients
- Use of randomized, placebo-controlled trials
- Use of validated outcome parameters (such as the NIH-CPSI)
- Being subject to peer-review
Bacteria and Antibiotics in CPPS
Daniel Shoskes (Cleveland Clinic) outlined that antibiotics must cover an adequate spectrum for typical bacteria and must give an adequate penetration (eg lipid-soluble, high pKa, low serum protein binding). Best candidates include: quinolones, trimethoprim-sulfamethoxazole, macrolides and tetracylcines. Second line antibiotics include: macrolides (eg erythromycin or azithromycin), which have higher cure rates for Chlamydia than ciprofloxacin, highest cure rates in vitro against mycoplasma and may penetrate and inhibit biofilms; and tetracyclines, which are active against Chlamydia and have good epididymal penetration.
Antibiotic therapy should typically last 4–6 weeks. Patients must be warned of possible complications, such as diarrhoea, photosensitivity, tendon rupture with quinolones, and oesophagitis with tetracyclines. The future will involve the identification of biofilms, recovery of bacteria, bacterial identification with DNA probes, characterization of microbial ecology, and drug delivery systems that penetrate physical barriers.
Mechanisms in CP/CPPS
Michel Pontari from Temple University, reviewed this subject from a ‘urologist’s perspective’. This included the epidemiology of CP/CPPS, the role of psychological, infection/immune dysfunction, neurological and endocrine factors, and the relation to other chronic pain conditions.
Dr Pontari noted that although ‘prostatitis’ implies a problem associated with the prostate, men with CP/CPPS are significantly more likely to have other abnormalities not related to the prostate including other urological conditions, unexplained somatic symptoms and psychiatric conditions. Also men with CP/CPPS have been found to have a low androgen status, perhaps because of polymorphisms causing problems with androgen receptors. Men with CP/CPPS have also lower levels of testosterone than controls. Testosterone plays a neuroprotective role, aiding in nerve healing after injury. In the past, CP/CPPS was often termed ‘stress prostatitis’. Ullrich et al (2005) found that the greater the perceived stress at 6 months of diagnosis, the greater the pain intensity and disability at 12 months.
Tripp et al (2005) explored outcomes of pain and disability in men with CP/CPPS. They found that pain correlated with urinary symptoms, depression and helplessness/catastrophising. Catastrophic helplessness was a prominent pain predictor. There are many overlapping symptoms between CP/CPPS and fibromyalgia, irritable bowl syndrome and chronic fatigue syndrome. The common link between these conditions includes central sensitization, alterations in psychological factors, immunity and neuroendocrine function.
Primary Care Perspective
Michael Kirby from the University of Hertfordshire, highlighted the issues facing GPs in diagnosing and treating CP. GPs face a multitude of different patients presenting with their problems yet it is imperative that GPs make a correct and early diagnosis. A major problem is that GPs have been given little information about prostatitis, and up to 60% of GPs feel inadequate at giving a urological evaluation. In the UK, men with prostatitis present less often to their GP than their North American counterparts, and contribute to less than 1% of clinic visits. In Dr Kirby’s own general practice in Hertfordshire, only 44 cases of prostatitis were seen among 4,500 men, with no new cases added in the past year; either men are not presenting with their symptoms or GPs are not making the diagnosis. GPs are given about 200 guidelines each year to follow, but none on prostatitis. He called for the formulation of appropriate guidelines and the education of health professionals. Dr Kirby also encouraged GPs to ask men about lower urinary tract symptoms, as men will often not volunteer this information.
In the discussion session that followed, J. Curtis Nickel concurred that primary care physicians need guidelines. He said that GPs in the UK are good at screening for prostate cancer and treating BPH, but are unsure about prostatitis. However, physicians in North America have been educated on how best to diagnose and treat prostate problems; most are confident at dealing with all conditions of the prostate, including prostatitis.
A delegate who has been a sufferer of CP/CPPS for nearly 30 years felt that the most helpful approach is for doctors to take patients presenting with symptoms of prostatitis seriously.
Terminology
Paul Abrams (Bristol Urological Institute) noted that a name gives status and makes the patient feel he will be taken seriously; however, ‘chronic prostatitis’ was a term of spurious diagnostic authority. If an accurate medical term can be given to a patient’s symptoms; the patient then believes he will be treated seriously. It is therefore important to consider terminology from a patient’s perspective. It is especially important to give a name to a diagnosis when the symptoms are having a huge impact on the patient’s quality of life.
During the panel discussion Roger Kirby (Chairman, Prostate UK) said that patients want their symptoms resolved and need to be able to tell their friends and family what they have got and who they need to be referred to. J. Curtis Nickel said that in his clinic, they use both terms (CP and CPPS) in patient records and use the terminology appropriately i.e. refer to CP when talking to the patient and CPPS when talking to a doctor.
Pain Syndrome from a Consultant/Pain Team Perspective
Andrew Baranowski from The National Hospital for Neurology and Neurosurgery in London, explained that in order to define a condition, it needs to be phenotyped and this has only recently been applied to urogenital pain medicine.
The psychosocial consequences of urogenital pain include loss of self-esteem, a breakdown of relationships, sexual dysfunction, anxiety, depression, cognitive-behavioural dysfunction and catastrophising. When looking at psychology as a cause of urogenital pain, there are methodological problems with retrospective studies. Systematic trauma, abuse or torture may produce well-recognised structural changes in the nervous system with central sensitisation.
The final discussion session was chaired by Robert Winston, Imperial College London. He noted that if CP/CPPS is indeed so prevalent in the UK, as healthcare professionals they are all under-performing for their patients. He drew comparisons between the reluctance of people to discuss fertility problems several years ago and prostatitis today. He also compared similar issues surrounding endometriosis in women and prostatitis in men. Charities such as Wellbeing of Women had successfully raised the profile of endometriosis so the same should be achievable for CP/CPPS. A priority should be to gather UK specific prevalence and incidence data on CP/CPPS as none currently exist. Funding could be sought from The Medical Research Council and perhaps the NHS. There was little incentive for pharmaceutical companies to fund research into this condition due to lack of ground-breaking opportunities. J. Curtis Nickel explained that the same situation existed in Canada several years ago, until high profile politicians who had CP/CPPS were pushed to improve research funding and raise awareness following lobbying from advocacy groups and clinicians. Daniel Shoskes agreed that a multi-pronged approach is required, involving an advocacy group, such as Prostate UK.