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Diagnosis and Treatment of Chronic Bacterial Prostatitis (CBP) and Chronic Prostatitis (CP) /Chronic Pelvic Pain Syndrome (CPPS): a Consensus Guideline

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Diagnosis and Treatment of Chronic Bacterial Prostatitis (CBP) and Chronic Prostatitis (CP) /Chronic Pelvic Pain Syndrome (CPPS): a Consensus Guideline QUICK REFERENCE GUIDE Diagnosis and treatment of chronic bacterial prostatitis (CBP) and chronic prostatitis (CP) /chronic pelvic pain syndrome (CPPS): a consensus guideline Jon Rees1, Mark Abrahams2, Victor Abu3, Trevor Allan4, Andrew Doble5, Theresa Neale6, Penny Nixon7, Maxwell Saxty8, Sarah Mee9, Alison Cooper10, Kirsty Haves11 and Jenny Lee12 1GP (Chair of Prostatitis Expert Reference Group), Backwell and Nailsea Medical Group, Bristol; 2Pain Consultant, Addenbrooke’s Hospital, Cambridge; 3Clinical Nurse Specialist – Prostate, University College London Hospitals, London; 4Patient Representative; 5Consultant Urologist, Addenbrooke’s Hospital, Cambridge; 6Urology Clinical Nurse Specialist, South Warwickshire Foundation Trust; 7Physiotherapist Specialist, Addenbrooke’s Hospital, Cambridge; 8Cognitive Behavioural Therapist, Addenbrooke’s Hospital, Cambridge; 9Policy and Evidence Manager, Prostate Cancer UK; 10Senior Research Analyst, Prostate Cancer UK; 11Senior Account Manager, Hayward Medical Communications; 12Project Manager, Hayward Medical Communications Contents: Foreword 2 Table 1. Summary of physical examinations and investigations 5 Introduction 2 Table 2. Antibiotic treatment options 6 Overview 2 Table 3. Antineuropathic treatment options 7 Guideline objectives 2 Research recommendations 8 Guideline population 3 Acknowledgements 8 Priorities for implementation 3 Updating the guideline 8 Treatment algorithm for CBP and CP/CPPS patients 4 References 9 ENDORSED BY Supporting you, supporting men 2 Foreword Introduction This document provides a ‘quick reference Overview guide’ of the guideline and complements, but CBP and CP/CPPS are common, debilitating does not replace, the full guideline document. conditions, with 35–50% of men reported to be The full version of the guideline, which contains affected by symptoms suggestive of prostatitis at details about the methods and a description of some time in their life1,2. The main four symptom the evidence base used to inform the treatment domains of CBP and CP/CPPS are urogenital recommendations made, can be found at pain, lower urinary tract symptoms (LUTS), prostatecanceruk.org/prostatitisguideline. psychological issues and sexual dysfunction3. This quick reference guide includes the The most common presentation of CBP is following content: recurrent urinary tract infection (UTI), whereas pain is a predominant symptom of both CBP • Introduction – an overview of the guideline and CP/CPPS3,4. CBP and CP/CPPS also have population and objectives. a significant impact on patients’ quality of life (QoL)5 and present diagnostic and therapeutic • Priorities for implementation – an overview challenges for physicians. of the main priorities for implementation for the diagnosis and treatment of chronic Guideline objectives bacterial prostatitis (CBP) and chronic A Prostatitis Expert Reference Group (PERG) prostatitis/chronic pelvic pain syndrome was convened by Prostate Cancer UK to (CP/CPPS). develop a consensus guideline to improve the diagnosis and management of adult men with • Treatment algorithm for CBP and CP/ CBP (National Institutes of Health [NIH] category CPPS patients – a flow diagram to guide the II) and CP/CPPS (NIH category III). The main management of patients with suspected or objectives of the guideline are to: confirmed CBP or CP/CPPS. This algorithm • provide guidance to healthcare professionals is based on a combination of evidence from treating patients with CBP and CP/CPPS, the literature, consensus obtained via a Delphi both in non-specialist (for example, primary panel process and consensus obtained from care) and specialist (for example, secondary members of the guideline development group. care) settings • improve non-specialists’ awareness and • Table 1 – Clinical assessment and recognition of CBP and CP/CPPS diagnosis: a summary of physical • promote the efficient referral of care between examinations and investigations to consider non-specialists and specialists and the during the clinical assessment of CBP and involvement of the multidisciplinary team (MDT) CP/CPPS. • facilitate the improvement of patient awareness and recognition of CBP and CP/CPPS. • Table 2 – Antibiotic treatment options to consider for the treatment of CBP • Table 3 – Antineuropathic treatment options to consider for the treatment of CBP and CP/CPPS • Research recommendations – areas for potential further research. prostatecanceruk.org/health-professional 3 Guideline population 4. Early referral to specialist services should This guideline only covers symptomatic, chronic be considered when patients fail to respond forms of prostatitis; that is, CBP (NIH category to initial measures. Referral should ideally II) and CP/CPPS (NIH category III). The patient be to a clinician with an interest in the populations under the NIH classification management of CBP and/or CP/CPPS, but categories I (acute bacterial prostatitis) and not necessarily a urologist. IV (asymptomatic inflammatory prostatitis) were, thus, not considered during guideline 5. An MDT approach should be implemented development. By definition, a diagnosis of CBP and made available to CBP and CP/CPPS (NIH category II) or CP/CPPS (NIH category patients. The MDT should include urologists, III) should be based on a history of persistent pain specialists, nurse specialists, or recurrent symptoms, and the absence specialist physiotherapists, GPs, cognitive of other urogenital pathology (for example, behavioural therapists/psychologists and active urethritis, urogenital cancer, urinary tract sexual health specialists. disease), for a minimum of three out of the past six months6-9. 6. Patients should be fully informed about the possible underlying causes and treatment options of CBP and CP/CPPS. The MDT Priorities for implementation responsible for the management of these patient groups, should be able to explain In addition to the main treatment the chronic pain cycle and other relevant recommendations made in the full guideline information to improve patient understanding document, which can be found on the Prostate of the conditions. Cancer UK website, the PERG concluded the following areas are priorities for implementation: 1. Patients with CBP or CP/CPPS should be managed according to their individual symptom pattern – no single management pathway is suitable for all patients with these conditions. 2. Most patients with CP/CPPS do not have an infection, and repeated use of antibiotics such as quinolones should be avoided where no obvious benefit from infection control is evident or cultures do not support an infective aetiology. 3. Early use of antineuropathic pain medication should be considered for all CBP and CP/ CPPS patients refractory to initial treatments. If neuropathic pain is suspected, ensure a quick referral to the MDT, which includes pain specialists. Supporting you, supporting men 4 Treatment algorithm for CBP and CP/CPPS patients Patient presents with symptoms* Clinical assessment, including history*, physical examination† and investigations‡ Empirical antibiotics (4–6 weeks), If voiding LUTS present, alpha If pain present, simple analgesics if antibiotic naïve for CP/CPPS blockers for 4–6 weeks ± NSAIDs Symptoms resolve Follow up at 4–6 weeks Persistent symptoms No bacterial cause identified and no If bacterial cause confirmed or partial response to antibiotics: response to antibiotics: • consider one further course of antibiotics at sufficient • consider sexual abuse/trauma. dosage and duration for each instance of a confirmed bacterial cause or partial response to antibiotics • consider sexual abuse/trauma, psychosocial factors and yellow flags. Persistent symptoms Symptoms resolve Pain Psychosocial symptoms Urinary symptoms Sexual symptoms Explain neuropathic pain to Full assessment in primary Full LUTS assessment. Assessment and patient (refer to Box 1§). care and management management as per along local pathways, BSSM guidelines. including PHQ-9 and Stop simple analgesics Management as per GAD-7 (refer to NICE NICE CG97. and NSAIDs, unless CG90 and NICE CG91). nociceptive/inflammatory route is suspected. Low threshold for Refer for specialist referral for psychosexual Initiate neuropathic assessment if not counselling and/or pain treatment. Consider referral to local responding, including specialist urology/ Refer to NICE CG173. mental health services. involvement of MDT¶. andrology services. Consider referral to the MDT¶, specialist pain service and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews, especially if the patient has severe pain or their pain significantly limits their lifestyle, or their underlying health condition has deteriorated. BSSM = British Society for Sexual Medicine; CP/CPPS = chronic prostatitis/ transmitted infection screen, tests to rule out differential diagnosis. chronic pelvic pain syndrome; GAD-7 = Generalised Anxiety Disorder 7; ¶ Members of the MDT may include: urologist, pain consultant/specialist, LUTS = lower urinary tract symptoms; MDT = multidisciplinary team; NICE nurse specialist, nurse practitioner, physiotherapist, GP, cognitive = National Institute for Health and Care Excellence; NSAIDs = non-steroidal behavioural/psychological therapist and sexual health specialist. anti-inflammatory drugs;PHQ-9 = Patient Health Questionnaire-9. § Box 1 can be found in the full version of the guideline: * LUTS, including overactive bladder, urgency, hesitancy, slow prostatecanceruk.org/prostatitisguideline flow,
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