Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis / chronic pelvic pain syndrome: A consensus guideline - Beyond the Abstract

Men present commonly in primary care with symptoms suggestive of a diagnosis of chronic prostatitis / chronic pelvic pain syndrome. What happens next is extremely variable – there is poor understanding of this condition amongst Primary Care Practitioners (PCP), which is hardly surprising given the controversies that persist about the aetiology of the condition and the best treatment modalities. This means that many men remain undiagnosed or poorly treated, usually with relentless cycles of quinolone antibiotics, and thus live with uncontrolled symptoms with huge implications for their overall quality of life.

As a result of qualitative research with men in the UK with prostatitis and benign prostatic enlargement, the charity Prostate Cancer UK (which has a remit for benign prostate disease as well as prostate cancer, despite it’s name) recognised a gap in guidance on how to diagnose and manage prostatitis. There are guidelines in existence for this condition, most notably those published by the European Association of Urology1, but these are weighty academic tomes, written by and largely for physicians with a specialist interest in the management of pelvic pain and prostatitis. There is no awareness or usage of these guidelines by PCP’s, who want clear pragmatic guidance on how to diagnose, assess, initiate treatment and appropriately refer patients with symptoms of chronic prostatitis. Whether the condition is called chronic prostatitis, prostate pain syndrome, chronic pelvic pain syndrome or anything else, is of little importance in primary care and can be left to those with a greater interest in the condition to argue over.

Prostate Cancer UK convened the ‘Prostatitis Expert Reference Group’ (PERG) in early 2014 and a consensus guideline and Quick Reference Guide, aimed predominantly at non-specialists in primary care, was released in September 2014 on the Prostate Cancer UK website (www.prostatecanceruk.org/prostatitisguideline ). The guideline was subsequently published as a peer-reviewed article in British Journal of Urology International in March 20152. The PERG consisted of a multi-disciplinary team including Primary Care, Urology (including Urology Specialist Nursing), Pain Management, Physiotherapy, Psychology and, crucially, Patient representation. The guideline aims to improve recognition of prostatitis by dividing elements of the symptom complex into four main groups: Uro-genital pain (perineal, scrotal, suprapubic, rectal etc), Urinary symptoms (storage & voiding LUTS), Sexual symptoms (e.g. erectile dysfunction, ejaculatory dysfunction or discomfort) and Psychosocial symptoms (e.g. anxiety & depression).

A treatment algorithm is then proposed to aid PCP’s in the simple management measures that can be undertaken in primary care or following referral to secondary care (Figure 1). We describe a number of key priorities for implementation in the future by PCP’s:

1. An individualised approach to management based on the symptom pattern.
2. Avoidance of recurrent courses of antibiotics unless clear evidence of infective aetiology.
3. Early use of anti-neuropathic pain medication.
4. Early referral to a multi-disciplinary specialist team.
5. Clear explanation of the condition to patients including the basis of the chronic pain cycle.

Since publication, the guideline has been widely published in UK Primary Care journals and websites, as well as the British Journal of Urology International2, and accepted for an oral presentation at the annual conference of the Royal College of General Practitioners (RCGP) in November 2015. In the past couple of months, elements of the guideline have also been incorporated into the updated NICE Clinical Knowledge Summary on chronic prostatitis3 and in the RCGPs Essential Knowledge Update 154. It is hoped that this guideline will improve the understanding of the condition in primary care and lead to a better outcome for many of the men with this frustrating and complex condition.

References:
1. Fall M et al. EAU Guidelines on Chronic Pelvic Pain. Eur Urol 2010; 57: 35-48.
2. Rees J, Abrahams M, Doble A, Cooper A, The Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015 Feb 24;
3. National Institute for Health and Care Excellence. Prostatitis - chronic - NICE CKS [Internet]. 2015 [cited 2015 Apr 23]. Available from: http://cks.nice.org.uk/prostatitis-chronic
4. Royal College of General Practitioners. Essential Knowledge Update 15 [Internet]. 2015 [cited 2015 Apr 23]. Available from: http://www.rcgp.org.uk/professional-development/online-learning/ole/essential-knowledge-update-15.aspx

Written by:
Dr Jon Rees, General Practitioner with special interest in Urology, North Somerset, UK, Chair of the Prostatitis Expert Reference Group.
Dr Alison Cooper, Prostate Cancer UK.

Abstract: Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis / chronic pelvic pain syndrome: A consensus guideline.

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