Chronic pelvic pain syndrome is difficult to treat. Initial recommendations include education regarding the condition, stress management, and behavioral changes.
Non-drug treatments Current guidelines by the European Association of Urology include: •
Pain education: conversation with the patient about pain, its causes and impact. •
Physical therapy: some protocols focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as
trigger points) including intrarectal digital massage of the pelvic floor, physical therapy to the pelvic area, and progressive relaxation therapy to reduce causative stress. This process has been called the
Stanford protocol or the
Wise-Anderson protocol. Other non-drug treatments that have been evaluated for this condition include acupuncture, extracorporeal shockwave therapy, programs for physical activity, transrectal thermotherapy and a different set of recommendations regarding lifestyle changes. Neuromodulation has been explored as a potential treatment option for some time. Traditional spinal cord stimulation, also known as dorsal column stimulation has been inconsistent in treating pelvic pain: there is a high failure rate with these traditional systems due to the inability to affect all of the painful areas and there remains to be consensus on where the optimal location of the spinal cord this treatment should be aimed. As the innervation of the pelvic region is from the sacral nerve roots, previous treatments have been aimed at this region; however pain pathways seem to elude treatment solely directed at the level of the spinal cord (perhaps via the sympathetic nervous system) leading to failures. Spinal cord stimulation aimed at the mid- to high-thoracic region of the spinal cord have produced some positive results. A newer form of spinal cord stimulation called dorsal root ganglion stimulation (DRG) has shown a great deal of promise for treating pelvic pain due to its ability to affect multiple parts of the nervous system simultaneously – it is particularly effective in patients with "known cause" (i.e. post surgical pain, endometriosis, pudendal neuralgia, etc.).
Medications A number of medications can be used which need to be tailored to each person's needs and types of symptoms (according to UPOINTS, S = sexual: e.g. erectile dysfunction, ejaculatory dysfunction, postorgasmic pain). but others have questioned the utility of a trial of antibiotics. Antibiotics are known to have anti-inflammatory properties and this has been suggested as an explanation for their partial efficacy in treating CPPS. The UPOINT diagnostic approach suggests that antibiotics are not recommended unless there is clear evidence of infection. • An estrogen reabsorption inhibitor such as
mepartricin improves voiding, reduces urological pain and improves quality of life in patients with chronic non-bacterial prostatitis. •
Phytotherapeutics such as
quercetin and flower pollen extract have been studied in small clinical trials. A 2019 review found that this type of therapy may reduce symptoms of CPPS without side effects, but may not improve sexual problems. •
Diazepam suppositories are a controversial treatment for CPPS – proponents believe that by delivering the medication in a closer proximity to the area of pain that better relief can be achieved. This has never been substantiated in any research and this hypothesis is invalid due to the fact that benzodiazepines act on the
GABA receptor which is present in the central nervous system. This means that regardless of the route of administration (oral versus rectal/intra-vaginal), the drug will still need to travel to the central nervous system to work and is no more or less effective when given in this capacity. Research shows this method of delivery takes longer to achieve peak effect, lower bioavailability and lower peak serum plasma concentration.
Emerging research In a preliminary 2005
open label study of 16 treatment-recalcitrant CPPS patients, controversial entities known as
nanobacteria were proposed as a cause of
prostatic calcifications found in some CPPS patients. Patients were given
EDTA (to dissolve the calcifications) and three months of
tetracycline (a calcium-leaching antibiotic with anti-inflammatory effects, used here to kill the "pathogens"), and half had significant improvement in symptoms. Scientists have expressed strong doubts about whether nanobacteria are living organisms, and research in 2008 showed that "nanobacteria" are merely tiny lumps of abiotic limestone. The evidence supporting a viral cause of prostatitis and chronic pelvic pain syndrome is weak. Single case reports have implicated
herpes simplex virus (HSV) and
cytomegalovirus (CMV), but a study using
PCR failed to demonstrate the presence of viral
DNA in patients with chronic pelvic pain syndrome undergoing radical prostatectomy for localized prostate cancer. The reports implicating CMV must be interpreted with caution, because in
all cases the patients were
immunocompromised. For HSV, the evidence is weaker still, and there is only one reported case, and the causative role of the virus was not proven, and there are no reports of successful treatments using antiviral drugs such as
aciclovir. Due to the concomitant presence of bladder disorders, gastrointestinal disorders and mood disorders, research has been conducted to understand whether CP/CPPS might be caused by problems with the hypothetical bladder-
gut-brain axis. Research has been conducted to understand how chronic bladder pain affects the brain, using techniques like
MRI and
functional MRI; as of 2016, it appeared that males with CP/CPPS have increased grey matter in the
primary somatosensory cortex, the
insular cortex and the
anterior cingulate cortex and in the
central nucleus of the amygdala; studies in rodents have shown that blocking the
metabotropic glutamate receptor 5, which is expressed in the central nucleus of the amygdala, can block bladder pain. ==Prognosis==