Drug Therapy

Patients come to the physician hoping that a simple prescription of a medication will resolve their condition.Unfortunately,for most patients, this is usually not the case. However, drug ther­ apy, either monotherapy or in difficult cases, multimodal therapy, do help ameliorate symp­ toms in the majority of patients.

Antibiotics

Probably the most controversial drug therapy for CP/CPPS is antibiotics. While the benefits of antibiotics are indisputable in Cat I and Cat II Prostatitis, the effect is less evident when employed in patients with no history of bacte­ rial infection. When fluoroquinolones are used in early diagnosed (less chronic), less heavily pretreated patients, it has been shown that antibiotics can result in significant improve­ ment in 50–75% of patients. However, when used in more chronic and heavily pretreated (including previous therapy with antibiotics), the benefits of levofloxacin and ciprofloxacin appear to be no more evident than that achieved with placebo.

Anti-inflammatories

It is intuitive to consider anti­inflammatory medications for a condition that includes inflammation and pain and while a number of small studies suggest efficacy, the only ran­ domized placebo controlled trial has demon­ strated that the COX­2 inhibitor, rofecoxib, may not be beneficial as a monotherapy except as a long­term high dose therapy.45 Rofecoxib is not available anymore, but it is reasonable that the results can be extrapolated to the class and therefore anti­inflammatories should be considered as an ancillary treatment only. Pentosan­polysulfate sodium, a drug indicated for interstitial cystitis, has demonstrated very

Alpha blockers

Five small randomized placebo controlled studies have indicated that the alpha blockers terazosin,47 doxazosin,48 tamsulosin44,49 and alfuzosin,50 may have a potential role as a pri­ mary therapy for CP/CPPS but the results were not conclusive. Analyses trying to explain the discrepancies in these trial results, have con­ cluded that these agents provide the most bene­ fit when used for longer than 6 weeks in alpha blocker naïve men with symptoms of short duration.51,52 A recently completed NIH trial enrolling newly diagnosed, alpha blocker CP/ CPPS men showed that 12 weeks of alfuzosin was not significantly better than placebo ther­ apy.53 Alpha blockers may not be considered as primary therapy, but may play a role in a multi­ modal strategy, particularly in men with obs­ tructive voiding symptoms.

Hormone Therapies

A number of small trials including a poorly designed randomized placebo controlled trial suggested that finasteride may provide amelio­ ration of symptoms, however a better designed trial, which showed a numerical improvement in symptom score over placebo, failed to reach statistical significance.54 However, in older men with concurrent benign prostatic hyper­ plasia, a 5­alpha reductase inhibitor can be considered.

Phytotherapies

The bioflavonoid, quercetin, was one of the first agents to be evaluated in a randomized placebo controlled trial using the CPSI as the primary outcome. This trial showed a moderate benefit over placebo with quercetin.55 There is also evi­ dence for the use of pollen extract and saw pal­ metto, although the main evidence for pollen extract and saw palmetto has published in a peer reviewed journal.