Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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all patients

1st line – patient education

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all patients
1st line – 

patient education

Patients should be offered multimodal and phenotypically directed treatment options that address their relevant physical, emotional, and psychosocial issues.[4][51][52] It is also important that the therapeutic strategy includes elements of self-management that encourage patients to be actively involved.

Educate all patients about the nature of pain and address any fears they may have about undetected disease.[4] Ensuring patients are given appropriate information and that they understand their condition underpins self-management and adherence to agreed treatments. This can also give patients a sense of control and empowerment that can lead to a decrease in the intensity and unpleasantness of the pain itself.[4][73][74]

Encourage patients to remain physically active.[4][50][74] As well as having general health benefits, exercise may reduce pain and improve quality of life.[75] One study involving 85 participants found that a physical activity programme caused a small reduction of prostatitis-related symptoms compared with the control group (NIH‐CPSI score mean difference ‐2.50, 95% CI ‐4.69 to ‐0.31).[76]

It is also important to manage patient expectations before initiating a management plan. If the likely outcome of treatment is exaggerated, there is a significant risk that the patient will be disappointed if there is little improvement in their symptoms.

Plus – analgesia

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all patients
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Give regular paracetamol to patients with early-stage primary prostate pain syndrome (PPPS) for the management of pain symptoms.[6][50] Paracetamol is generally considered to be the preferred first-line analgesic, but can be used in combination with other analgesics if paracetamol alone is not sufficiently managing pain symptoms.[50] There is little evidence for the efficacy of paracetamol in many pain conditions.[83] Assess individual response when deciding on long-term use.[4]

Consider a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen or celecoxib, for pain management in patients whose symptoms may be due to peripheral inflammatory processes or in patients who experience inflammatory flare.[6] Take into account the higher incidence of adverse effects with prolonged use of this medication class.[78]

NSAIDs are often used for pelvic pain, although there is little evidence to support their use. One overview review of 16 systematic reviews and four individual patient data meta-analyses of standard doses in different painful conditions concluded that ibuprofen often provided superior pain relief when compared with paracetamol.[83] In another meta-analysis, anti-inflammatory drugs (such as celecoxib) were 80% more likely to have a favourable treatment response than placebo in patients with PPPS.[86] However, the treatment effect may be limited to the duration of therapy as long-term efficacy is not known.

There is no evidence that one NSAID is superior to another.[4] NSAIDs should only be offered for short-term treatment of pain, and patients should be reviewed regularly with monitoring for adverse effects (which may limit use).[6] Discontinue if there is no improvement of symptoms within 4-6 weeks of treatment.[6] NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). Therefore, NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

Refer patients with continued pain refractory to treatment and that significantly impairs their ability to participate in daily activities to a centre specialising in pain management for consideration of treatment with opioids (e.g., codeine, morphine).[4][6] Opioids should be avoided as first-line use in patients presenting in early stages of PPPS due to the risk of opioid dependency.[6] Opioids should be used as part of a broader treatment plan and only by doctors experienced in their use. There are very few data available on the use of opioid analgesics in patients with PPPS.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

celecoxib: 400 mg orally as single dose on day 1 (may give an additional 200 mg on day 1 if needed), followed by 200 mg twice daily when required

Tertiary options

codeine phosphate: 30-60 mg orally every 4 hours when required, maximum 240 mg/day

OR

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required, adjust dose according to response; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required

Consider – antibiotics

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all patients
Consider – 

antibiotics

Additional treatment recommended for SOME patients in selected patient group

Consider a trial of empirical antibiotics, initially for 4 to 6 weeks, in antibiotic-naive patients with PPPS.[4][6][78] Antibiotics may be helpful in this group of patients via treatment of an unknown uropathogen, or due to an anti-inflammatory effect.[50] Antibiotics have a moderate effect on total pain, voiding, and quality of life scores in patients with PPPS.[4] However, the evidence base for treatment of patients with antibiotics is weak and somewhat conflicting, and care must be taken to avoid unnecessary antibiotic use.

A meta-analysis of randomised controlled trials found that antibiotics had some beneficial effect in patients with PPPS, including improvement of symptoms.[12] A more recent Cochrane review of 5 studies (372 participants) of low quality of evidence found that fluoroquinolones may reduce prostatitis symptoms compared with placebo and are probably not associated with an increased incidence in adverse events. It also concluded that antibiotics probably result in little to no difference in sexual dysfunction and quality of life.[78]

If antibiotics are given, guidelines recommend a fluoroquinolone (e.g., ciprofloxacin) or a tetracycline (e.g., doxycycline); however, the choice should be guided by local resistance patterns.[4][6][50] Follow your local protocols.

Note that fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[79] Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[80][81]

Offer other therapeutic options after one unsuccessful treatment course with an antibiotic.[4]

Primary options

ciprofloxacin: 500 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

Consider – psychological therapy

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all patients
Consider – 

psychological therapy

Additional treatment recommended for SOME patients in selected patient group

Assess patients with PPPS for psychosocial symptoms, and refer for cognitive behavioural therapy (CBT) or to a psychologist experienced in treating pain if these are suspected to be contributing to the patient’s condition.[6][50][74] Psychological therapy can be targeted at the pain itself to reduce its impact on life, or at adaptation to pain to improve mood and function and reduce healthcare use with or without pain reduction.

Although there is very limited evidence from studies to support the use of psychological interventions such as CBT, its use as part of a multicomponent therapeutic may reduce associated distress, and improve quality of life and the patient's ability to self-manage and function. One small non-randomised controlled feasibility trial involving 60 participants with chronic pelvic pain found that patients receiving a combination of physical therapy and CBT had a small and non-significant intervention effect in health-related quality of life, but significant effects regarding depression severity and pain.[96]

Consider – alpha-blocker

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all patients
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with voiding symptoms
Consider – 

alpha-blocker

Additional treatment recommended for SOME patients in selected patient group

Consider treatment with a uroselective alpha-blocker (e.g., alfuzosin, tamsulosin, silodosin) in men with PPPS who have concomitant voiding symptoms.[4][6] Uroselective alpha-blockers are preferred to reduce the risk of potential adverse effects.[6]

Alpha-blockers have a moderate effect on total pain, voiding, and quality of life scores in people with PPPS.[4] A network meta-analysis of several randomised controlled trials of alpha-blockers has shown significant improvement in overall symptoms, pain, voiding ability, and quality of life.[12] However, a more recent systematic review noted that although treatment with alpha-blockers may lead to some reduction of symptoms, the durability of the effect is not entirely clear.[78]

Primary options

alfuzosin: 10 mg orally once daily

OR

tamsulosin: 0.4 to 0.8 mg orally once daily

OR

silodosin: 8 mg orally once daily

Consider – pentosan polysulfate sodium

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all patients
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with storage symptoms
Consider – 

pentosan polysulfate sodium

Additional treatment recommended for SOME patients in selected patient group

Consider pentosan polysulfate sodium in patients with pain associated with storage symptoms, such as urgency and frequency.[4] However, European guidelines note that this recommendation is based on low-quality evidence, and the drug is not routinely used for this indication in the US.

Pentosan polysulfate sodium is a semi-synthetic drug used in the treatment of interstitial cystitis. One study of 100 patients with PPPS showed that the group treated with pentosan polysulfate sodium showed significantly greater improvement in NIH-CPSI quality of life domain scores than the placebo group (-2.0 or 22% vs. -1.0 or 12%, P=0.031).[82]

It is important to consider the potential benefits of treatment alongside risk of adverse effects, which may include nausea, diarrhoea, headache, and altered liver function.[83] Note also that cases of pigmentary maculopathy have been reported rarely in patients treated with pentosan polysulfate sodium, especially after long-term use at high doses. Healthcare professionals are advised that patients should have baseline and regular ophthalmic examinations before and during treatment, and to consider stopping treatment if pigmentary maculopathy develops. Patients should be advised to seek immediate medical attention if visual changes occur.[84][85]

Primary options

pentosan polysulfate sodium: 100 mg orally three times daily

Consider – physical therapy

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all patients
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with pelvic floor muscle dysfunction or myofascial pain
Consider – 

physical therapy

Additional treatment recommended for SOME patients in selected patient group

Refer patients with pelvic floor pathology or myofascial pain to a specialist physiotherapist for targeted treatment of pelvic floor pathology or for more general treatment of myofascial pain.[4][50] Because of the low risk of adverse effects, myofascial treatments may be offered as an initial therapy option.[4]

Evidence suggests that the symptoms of PPPS may result from pelvic muscle tenderness and spasm.[24][25] Specialist physical therapy and techniques that encourage relaxation and coordinated use of the pelvic floor muscles may therefore help to improve symptoms.[6] Patients with chronic pelvic pain and pelvic floor muscle dysfunction may benefit from learning to relax the muscles when the pain starts, as this may allow them to break the vicious cycle of pain-cramp-pain. Repetitive or chronic muscular overuse can activate trigger points (hyperirritable sites within a taut band) in the muscle, which are often found in patients with chronic pelvic pain. Physical therapy treatments that target these trigger points can have a positive effect on the pain. 

Consider treatment with acupuncture to help improve symptoms and quality of life.[4][6][50][74][75] A review of three studies concluded that acupuncture probably leads to a clinically meaningful reduction in prostatitis symptoms compared with sham procedure (mean difference [MD] in total NIH‐CPSI score ‐5.79, 95% CI ‐7.32 to ‐4.26), with little to no difference in adverse events.[75] Two systematic reviews and a meta-analysis of seven randomised controlled trials comparing acupuncture with sham control or oral medical treatment concluded that acupuncture is effective and safe, and significantly reduces symptom scores compared with control groups.[91][92]

Several small sham controlled randomised studies have reported improvements in pain and NIH-CPSI scores with perineal extracorporeal shockwave therapy compared with simulated procedures/control groups.[93][94] Two recent systematic reviews and meta-analyses have concluded that extracorporeal shockwave therapy is effective for the improvement of pain and quality of life over the short term, but long-term data are lacking.[78][95]

Consider – neuromodulator

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all patients
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with neuropathic pain
Consider – 

neuromodulator

Additional treatment recommended for SOME patients in selected patient group

In patients with neuropathic pain whose pain persists following initial treatment with paracetamol or an NSAID, switch to a neuromodulator.[6][77]

Neuromodulators should be given in the context of a regular and long-term treatment plan. Although the efficacy of neuromodulators in chronic pelvic pain syndromes has not been clearly established, they have been proven to be effective in other chronic pain conditions.[87][88]

If nociceptive pain or an inflammatory route is considered to be the cause of pain, simple analgesics and NSAIDs may be continued alongside neuromodulator treatment.[6]

Initial treatment options include an antidepressant (e.g., amitriptyline, duloxetine) or a gabapentinoid (e.g., gabapentin, pregabalin).[6][77][89][90] If the initial treatment is not effective or is not tolerated, switch to a different neuromodulator. Consider switching again if the second and third neuromodulators tried are also not effective or not tolerated.[6][77]

Titrate the dose against the response and adverse effects.[4] Note that patients who are considered for gabapentinoids should be evaluated for a history of drug misuse before prescribing, and followed up with observation for development of signs of misuse and dependence.[74]

Primary options

gabapentin: 300 mg orally once daily for 1 day, followed by 300 mg twice daily for 1 day, then 300 mg three times daily thereafter, increase gradually according to response, maximum 3600 mg/day

OR

pregabalin: 50 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 600 mg/day

OR

amitriptyline: 25 mg orally once daily at bedtime initially, increase gradually according to response, maximum 150 mg/day

OR

duloxetine: 30-60 mg orally once daily initially, increase gradually according to response, maximum 120 mg/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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