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Antibiotics and alpha-blockers best for chronic prostatitis: meta-analysis

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Alpha-blockers and antibiotics relieve symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) better than other therapies, according to a network meta-analysis in the January 5th issue of the Journal of the American Medical Association.

However, the best tack to take for this difficult-to-treat condition may be to target these and other treatments – anti-inflammatories, finasteride, glycosaminoglycans – to the individual patient’s symptoms, the researchers suggest.

Led by Dr. Thunyarat Anothaisintawee at Ramathibodi Hospital in Bangkok, Thailand, the research team found that the benefits of any treatment were modest, probably reflecting the diversity of clinical phenotypes “based on the various etiologies and pathogenic pathways that underlie this enigmatic condition.”

They searched MEDLINE and EMBASE for randomized controlled trials comparing drug treatments for CP/CPPS categories IIIA (inflammatory) or IIIB (noninflammatory).

They identified 23 trials, published since 1999, studying alpha-blockers, antibiotics, steroidal and nonsteroidal anti-inflammatory drugs, finasteride, glycosaminoglycan, phytotherapy, pregabalin, and placebo.

Sample sizes were generally small (range 17 to 321). Mean subject age varied from 29.1 to 56.1 years, and treatments lasted from 4 to 52 weeks.

Because of the large number of treatment options and small number of studies for any given treatment, the authors conducted a network meta-analysis to better identify the most effective treatment. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was the primary outcome.

Total symptom scores at follow-up were identified from 13 studies of 1541 subjects. The reduction in score compared with placebo was greatest for alpha-blockers plus antibiotics (-13.8 units). Results were also statistically significant for alpha-blocker monotherapy (-11.0), antibiotic monotherapy (-9.8) and finasteride (-4.6).

Pain scores followed a similar pattern (-5.7, -4.1, -4.4 and -3.0, respectively).

Thirteen studies included data on voiding scores for 631 participants, for which only alpha-blockers and antibiotics were significantly better than placebo; dual therapy was most effective. Twelve studies examining quality of life showed the same outcome.

However, in studies of treatment response rate, anti-inflammatories were best (relative risk 1.8), followed by phytotherapy (RR 1.6) and alpha-blockers (RR 1.3) compared with placebo.

Dr. Anothaisintawee and colleagues note that after correcting for publication bias and small-study effects, alpha-blockers on their own had no significant treatment effect.

As to why antibiotics would be beneficial – since the diagnosis of CP/CPPS excludes infection – they theorize that the condition may in some cases be due to uncultured or unrecognized uropathogens. It has even been suggested that “nanobacteria” may be responsible. (See Reuters Health story of January 26, 2005).

They conclude that when voiding is the worst problem, an alpha blocker may be most helpful, whereas a history of urinary tract infection might respond best to antibiotics. When pain is predominant, an anti-inflammatory and/or gabapentinoid would be the best choice.

They note that researchers recently started a trial of phenotypically directed multimodal therapy for CP/CPPS.

Co-author Dr. J. Curtis Nickel, from Queens University in Kingston, Ontario, Canada, reports having served as consultant and/or investigator for several pharmaceutical companies.

JAMA 2011;305:78-86.