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In patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), antibiotics and α-blockers improve total symptom, pain, voiding, and quality-of-life scores vs placebo, according to the findings of a recent systematic review and network meta-analysis.

Thunyarat Anothaisintawee, MD, with the Ramathibodi Hospital and Mahidol University, in Bangkok, Thailand, and colleagues reported their findings in the January 5 issue of the Journal of the American Medical Association.

According to the researchers, antibiotics, α-blockers, and combination therapies of the two "appear to improve all clinical symptom scores compared with placebo, while anti-inflammatory drugs, finasteride, and phytotherapies have a lesser but measureable effect on select variables (ie, pain, voiding symptoms, and treatment response rate, respectively)."

The current analysis was designed to compare the clinical symptom scores and response rates of α-blockers with other therapies vs placebo in CP/CPPS, and included 23 studies in the systematic review and network meta-analysis.

With use of standardized mean differences, α-blockers were associated with improved symptoms, including total symptom scores (−1.7; 95% confidence interval [CI], −2.8 to −0.6), pain scores (−1.1; 95% CI, −1.8 to −0.3), voiding scores (−1.4; 95% CI, −2.3 to −0.5), and quality-of-life scores (−1.0; 95% CI, −1.8 to −0.2) vs placebo. Similarly, the network meta-analysis showed that antibiotics decreased total symptom scores (−9.8; 95% CI, −15.1 to −4.6), pain scores (−4.4; 95% CI, −7.0 to −1.9), voiding scores (−2.8; 95% CI, −4.1 to −1.6), and quality-of-life scores (−1.9; 95% CI, −3.6 to −0.2) vs placebo.

Combination therapies of α-blockers and antibiotics also yielded similar results, with reduced total symptom scores (−13.8; 95% CI, −17.5 to −10.2), pain scores (−5.7; 95% CI, −7.8 to −3.6), voiding scores (−3.7; 95% CI, −5.2 to −2.1), and quality-of-life scores (−2.8; 95% CI, −4.7 to −0.9) vs placebo.

Furthermore, treatment response rates were greatest for α-blockers (pooled relative risk [RR], 1.6; 95% CI, 1.1 - 2.3) and anti-inflammatory drugs (pooled RR, 1.8; 95% CI, 1.2 - 2.6).

"Our review suggests that α-blockers, antibiotics, or combinations of both are most appropriate for therapy of CP/CPPS, particularly for patients with voiding symptoms," Dr. Anothaisintawee and colleagues conclude.

Despite these encouraging findings, the researchers report a publication bias for smaller studies of α-blockers, which likely increased the magnitude of positive findings involving this treatment.

They also recommend anti-inflammatory medications for patients with pain. "While finasteride and phytotherapy may provide benefit to some patients, these therapies require more evaluation, perhaps in selected subgroups of CP/CPPS patients," the researchers suggest.

The study was funded in part by the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, the Canada Institute for Health Research, and the Canada Research Chair Program. The study authors have disclosed no relevant financial relationships.

JAMA. 2011;305:78-86.

Clinical Context

Prostatitis is a common condition with an estimated prevalence of 9% in the community. It accounts for nearly 2 million ambulatory visits annually, and CP/CPPS accounts for more than 90% of cases.

This is a systematic review and meta-analysis of therapies for CP/CPPS to examine the effect of different treatments on symptoms.

Study Highlights

• The investigators searched MEDLINE and EMBASE for studies from 1949 and 1974, respectively, to 2010.
• They selected identified studies on the basis of assessment by 2 independent authors.
• The total symptom score was defined as a summation of pain, voiding, and quality-of-life scores.
• Inclusion criteria were randomized controlled trials; CP/CPPS categories IIIA or IIIB according to the National Institutes of Health (NIH) classification; comparison of treatments vs placebo; and measured outcomes that included pain, voiding, and quality-of-life scores.
• For bias assessment, 6 domains were examined: sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias.
• Outcomes of interest were scores of total symptoms, pain, voiding, and quality of life. Response rates were as defined in the original articles.
• Tools that were used for scoring included the NIH Prostatitis Symptom Index, the International Prostate Symptoms Score, and the Prostatitis Symptom Score Index.
• A longitudinal mixed regression model was used for network meta-analysis to indirectly compare treatment effects.
• Among 262 identified studies, 25 met inclusion criteria.
• 7 studies examined α-blockers, 2 examined antibiotics, 2 examined finasteride, 4 examined anti-inflammatory agents, and 3 examined phytotherapy.
• Most studies used NIH-CPSI scores for measurement of outcomes.
• Mean age of participants ranged from 29.1 to 56.1 years.
• The highest quality was in the domain of selective outcome reports (95.7% low risk) followed by blinding (87.4%).
• 5 studies comparing α-blockers vs placebo were pooled.
• α-Blockers were associated with significantly better outcomes of improved total symptom, pain, voiding, and quality-of-life scores of −1.7 (95% CI, −2.8 to −0.6), −1.1 (95% CI, −1.8 to −0.3), −1.4 (95% CI, −2.3 to −0.5), and −1.0 (95% CI, −1.8 to −0.2), respectively, vs placebo.
• Patients receiving α-blockers or anti-inflammatory agents had a higher chance of favorable response vs placebo, with pooled RRs of 1.6 (95% CI, 1.1 - 2.3) and 1.8 (95% CI, 1.2 - 2.6), respectively.
• The network meta-analysis suggested benefits of antibiotics in reducing total symptom scores (−9.8; 95% CI, −15.1 to −4.6), pain scores (−4.4; 95% CI, −7.0 to −1.9), voiding scores (−2.8; 95% CI, −4.1 to −1.6), and quality-of-life scores (−1.9; 95% CI, −3.6 to −0.2) vs placebo.
• Combining α-blockers with antibiotics yielded the greatest benefits vs placebo, with decreases of −13.8 (95% CI, −17.5 to −10.2) for total symptom scores, −5.7 (95% CI, −7.8 to −3.6) for pain scores, −3.7 (95% CI, −5.2 to −2.1) for voiding scores, and −2.8 (95% CI, −4.7 to −0.9) for quality-of-life scores.
• The authors concluded that α-blockers, antibiotics, or combinations of the two are effective for reducing symptoms of CP/CPPS, but finasteride and phytotherapy require more evaluation for their efficacy in symptom alleviation.

Clinical Implications

• α-Blockers and anti-inflammatory agents are associated with symptom alleviation in patients with CP/CPPS.
• α-Blockers and antibiotics alone or in combination are associated with symptom alleviation in patients with CP/CPPS.