Treating Chronic Prostatitis: Antibiotics No, ␣-Blockers Maybe Prostatitis is a common cause of visits to a physician. of treatment after assessing experiences reported in the lit-
The National Institutes of Health (NIH) consensus
erature (10). Finally, the lack of effect seen with ciprofloxa-
classification of prostatitis syndromes includes acute bacte-
cin plus tamsulosin merits further comment. Hypotheti-
rial prostatitis (type I), chronic bacterial prostatitis (type
cally, the combination may maximize bacterial eradication
II), chronic prostatitis/chronic pelvic pain syndrome (CP/
by improving bladder function and reducing both pain and
CPPS) (type III), and asymptomatic inflammatory pros-
voiding symptoms (10). Unfortunately, Alexander and col-
tatitis (type IV) (1). Type III, by far the most common of
leagues did not discuss possible reasons for the failure of
these syndromes, presents in 2 forms. Type III A is inflam-
matory, as shown by leukocytes in expressed prostatic se-
Of importance, approximately one third of all men
cretions, post–prostate massage urine, or semen. Type III B
with refractory CP/CPPS who undergo sequential mono-
is noninflammatory, and leukocytes are not present in
therapy experience a poor outcome (11). Multimodal ther-
these fluids. The cause of CP/CPPS is not known.
apeutic regimens may provide better results, especially in
Therapeutic strategies for patients with CP/CPPS fre-
men in whom primary therapy has failed. However, Alex-
quently include antibiotic drugs and ␣-blockers. In the
ander and colleagues’ results provide little encouragement
NIH prioritization index, both treatment categories are
for advocates of multimodal therapy. The end point of
ranked number 1 and 2 (2). Although many urologists
therapy, for individual patients and for future clinical tri-
routinely prescribe antimicrobial agents for patients pre-
als, should be an improvement in health-related quality of
senting with CP/CPPS, the emerging consensus is that an-
tibiotics do not play any role in treating patients with type
What message does Alexander and colleagues’ study
III B disease, who have no evidence of inflammation (3).
have for the clinician caring for a patient with CP/CPPS? I
Some data suggest that colonization, infection, or both oc-
believe that past research (3, 9) and Alexander and col-
cur in the prostate of patients with CP/CPPS (4). This
leagues’ study show that antibiotics aren’t useful. I don’t
finding is one rationale for the suggestion that antimicro-
think a firm conclusion can be drawn about the effective-
bial therapy ex juvantibus may be justified in patients with
ness of ␣-blockers, since 1 trial of 6 weeks of therapy and 1
inflammatory CP/CPPS (type III A) (5). ␣-Blockers re-
trial of 6 months of therapy have shown a favorable effect
lieved symptoms in men with CP/CPPS in 2 recent ran-
and the 6-week regimen used by Alexander and colleagues
domized, placebo-controlled trials (6, 7). ␣-Blockers are
showed none. Clinically, a longer trial of ␣-blockers—for
especially useful in alleviating pelvic pain, although studies
example, 3 to 6 months—is a reasonable intervention for
have indicated that prolonged treatment (14 to 24 weeks)
patients with CP/CPPS. Alexander and colleagues’ study is
is necessary to show a clinical effect (7).
an important step forward in understanding the cause and
In this issue, Alexander and colleagues (8) report the
treatment of CP/CPPS, but it is clearly not the last word
results of a large, multicenter randomized trial of treatment
in patients with CP/CPPS. The authors compared 6 weeksof therapy with ciprofloxacin, tamsulosin, both drugs, or
Wolfgang Weidner, MDUniversity of Giessen
placebo in men with refractory, long-standing CP/CPPS.
The primary outcome measure was the change in totalscore on the NIH Chronic Prostatitis Symptom Index
Potential Financial Conflicts of Interest: None disclosed.
(NIH-CPSI) from baseline to 6 weeks. The key message ofthe study is that there was no proven difference among
Requests for Single Reprints: Wolfgang Weidner, MD, Department of
these drugs, singly or in combination, for treatment of
Urology, University of Giessen, D-35382 Giessen, Germany; e-mail,
CP/CPPS. Recently, a similar outcome was reported for
Wolfgang.Weidner@chiru.med.uni-giessen.de.
Concerning ␣-blockers, the negative outcome is disap-
Ann Intern Med. 2004;141:639-640.
pointing because 2 earlier randomized, double-blind,placebo-controlled clinical trials showed them to be effec-
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