Treatment of Chronic Prostatitis

The approach to the treatment of any disease, including prostatitis, includes assessment of what is known about proposed treatments. However, not all proposed treatments are equally well understood because the level of evidence gathered about them is not uniform. The proposed treatments for chronic prostatitis are here sub-grouped by level of evidence, starting with those that are best understood.

Data from Randomized Clinical Trials

As a general reflex, because antibiotics work well in acute prostatitis, nearly all patients who present with the symptoms of chronic prostatitis are first treated with antibiotics. However, these medications are used to great excess: Good quality randomized clinical trials and medical studies have demonstrated that they work poorly, if at all. Moreover, many patients are treated with so many antibiotics and for so long that they suffer serious side effects: Diarrhea, nausea, inner ear toxicity with inability to balance, tendonitis, and more.

Alpha blockers, a common treatment for the symptoms of prostate enlargement, are also commonly used to treat prostatitis. As with antibiotics, good quality studies have shown that they bring about little relief.

Less commonly used but equally convincingly ineffective is pregabalin (Lyrica), a medication used to treat the neuropathic pain in advanced diabetes and shingles, Saw Palmetto, a complementary botanical often used by patients to treat prostate enlargement, and prostate massage.

Good quality, randomized clinical trials have shown that the supplement quercetin, an antioxidant found in apples and onions, and the supplement bee pollen, are on average associated with mild symptomatic relief. So are global therapeutic massage, aerobic exercise, flexibility exercise, acupuncture, and finasteride (Proscar) and dutasteride (Avodart), medications used to treat prostate enlargement.

In interpreting the results of randomized, clinical trials of treatments for chronic prostatitis, one should keep in mind that, when there is some symptomatic relief, it is often no better than what is seen in the placebo arms of the trials. In other words, good studies have shown that the most commonly prescribed treatments for chronic prostatitis – antibiotics, alpha blockers, prostate massage – work poorly, if at all. They have shown that less commonly prescribed treatments – pregabalin, Saw Palmetto, finasteride, dutasteride, supplements, global massage, exercise, acupuncture – in some cases work a little but often little better than placebo.

The best quality data do not show a clear and obvious treatment path for men with chronic prostatitis.

Data from Single-Arm Case Series

Because they do not involve comparison groups, case series are of lower scientific quality than randomized trials. Here is a summary of current knowledge as based upon single-arm case series.

Intra-prostatic injection of antibiotics have been in one study associated with a mild symptomatic response; this response is of a level seen with placebo in other studies of other treatments; some patients who have had prostate injections have had reported substantial worsening of their prostatitis symptoms.

As of October, 2010, there is a single abstract, not a fully published paper, on pudendal nerve release, a form of neurosurgery that targets a nerve running in the buttocks. The available abstract suffers from an odd form of data censoring that makes it basically impossible to know if the patients on average had any relief at all.

An abstract on intra-pelvic trigger point release, a form of physical therapy, combined with relaxation, shows a mild average symptomatic relief, again on a level seen with placebo in other studies.

Anecdotal Data from Individual Cases

Because they are so often unable to find relief with conventional treatments, patients with chronic prostatitis often try treatments that have no scientifically demonstrated therapeutic effect. For example, patients have tried spinal cord implants and spine fusion; as of October, 2010 we have not found any prostatitis patient who found relief with spine surgery.

Prostate surgery is sometimes done for men with chronic prostatitis. Perhaps most, patients have transurethral surgery done as transurethral prostatectomy (TURP; “Roto Rooter”), laser prostatectomy, and/or prostate microwave treatments. There are few data on the effect of these approaches. Moreover, we are aware of patients who, as with intraprostatic injections, became worse with these treatments.

Laparoscopic radical prostatectomy (LRP), an operation for prostate cancer that removes not only the prostate but also the seminal vesicles, has been associated in individual cases of severe chronic prostatitis with immediate, complete, and durable relief. The degree of symptomatic relief seen with LRP appears in these cases to be greater than what has been described for other treatments. Presentations of individual LRP treatment cases are available on the Prostatitis Surgery web site.