How to Determine the Best Treatment for Chronic Prostatitis

Recognizing that chronic prostatitis is a complex condition that certainly involves more than just the prostate, researchers have been trying to come up with more useful and accurate ways to categorize different patients. By dividing patients into smaller groups, known as phenotypes, we hope to learn more about the underlying issues of the condition and individualize our treatment approaches for each patient.

The goal is to improve the current trial-and-error approach to treatment. If we can identify underlying phentoypes, it may be possible to predict which treatments will be most effective for a specific patient. This fits with a more individualized approach to medicine, as we realize that there’s no one-size-fits-all approach for complex conditions.

Unfortunately, this means that additional research is necessary that takes these phenotypes into consideration. Previously, if a study showed that half of patients responded positively to a treatment, we would recommend that all men try it and see if it works for them. However, if we can determine that a specific phenotype was the one who responded positively to treatment, we can direct patients to the appropriate treatment option earlier in their medical journey.

In practice, these phenotypes aren’t yet able to be helpful in directing treatment, but it’s promising that we’re starting to see the results of the first studies in this area.

One of the most prominent phenotyping methods for men with chronic prostatitis is the UPOINT system:

  • Urinary – Characterized by urinary symptoms like urgency, frequency, or having to wake at night to urinate.
  • Psychosocial – Accompanied by depression, anxiety or difficulty coping.
  • Organ-specific – Associated with inflammation of the prostate itself or pain with prostate palpation.
  • Infection – Detectable bacterial infection
  • Neurologic – Pain associated with the pelvic nerves and often associated with fibromyalgia, migraine headaches, or irritable bowel syndrome.
  • Tenderness – Tenderness and dysfunction in the pelvic floor muscles

In one of the first large studies utilizing the UPOINT system, the authors looked at more than 900 men who had been diagnosed with chronic prostatitis. They were divided into the different phenotypes, based on a physical examination, testing, and medical history.  The chart below shows the prevalence of the different phenotypes, from the more common (organ-specific, pelvic floor tenderness, urinary) to the least common (infection).

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Here are a few of the major takeaways from this emerging research:

Overlap in Phenotypes – From the data, it is clear most men fall into multiple categories. On average, each patient in this study would have qualified for just over three different phenotypes.  Future research may also show typical “clusters” – for example, we would expect urinary symptoms and pelvic floor muscle tenderness to be closely related, as muscle dysfunction can cause the urgent need to use the bathroom, and urinary frequency can irritate the pelvic floor muscles.

Infection (likely) Isn’t to Blame – While nearly all men begin their medical treatment with repeated rounds of antibiotics, the data shows that infection is the least common phenotype with chronic prostatitis. Fewer than 10% of men were diagnosed with any kind of infection. Clinical practice hasn’t yet caught up to this emerging research, but pelvic floor tenderness, inflammation (organ-specific), or urinary phenotypes are all at least 5 times more likely than infection.

Necessity of Multi-Disciplinary Approach – With the vast majority of men falling into multiple phenotypes, this research reinforces the need for a multi-disciplinary approach.  The most common phenotype was organ-specific (which may be overstated, as the authors used the presence of inflammation to determine the phenotype, rather than prostate palpation as some other studies have used). However, treatments that are focused exclusively on the prostate have no benefit for pelvic floor tenderness (69% of men), don’t down-regulate the nervous system (neurological, 46%), or address psychological considerations (34%).  Combining different treatment approaches like alpha-blockers, supplements, and pelvic floor physical therapy can address the different aspects of the condition.

With chronic prostatitis, everyone is unique–our approach to treatment needs to reflect that.  Looking at these phenotypes may help you develop a multi-disciplinary approach and recognize areas that aren’t currently being addressed.

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