Treatment for Prostatitis/Pelvic Pain Syndromes
|In the latest Stanford study, the global response assessment revealed that 82% of our patients reported improvement (59% marked/moderate, 23% slight). Click to read published research.
|Developers of the Wise-Anderson Protocol|
|David Wise, Ph.D.|
|Rodney Anderson, M.D.|
Facts about Prostatitis
Most Prostatitis Symptoms not Caused by the Prostate
Approximately ninety five percent (95%) of what is called prostatitis is not prostatitis. Most men diagnosed with prostatitis have no pathology of the prostate gland that can account for symptoms of urinary frequency, sexual and sitting pain and internal pelvic pain among other symptoms. Click here to read our published article about the failure of prostate directed medication in treating prostatitis. Also refer to this article in the Annals of Internal Medicine. (More below...)
Symptoms of Prostatitis
NOTE: Most men diagnosed with prostatitis have several of these symptoms:
- Urinary frequency (need to urinate too often)
- Urinary urgency (hard to hold urination once urge occurs)
- Sitting triggers or exacerbates discomfort/pain/symptoms
- Pain or discomfort during or after ejaculation
- Discomfort in the rectum (feels like a “golf ball” in the rectum)
- Discomfort/pain in the penis (commonly at the tip or shaft)
- Ache/pain/sensitivity of testicles
- Suprapubic pain (pain above the pubic bone)
- Perineal pain (pain between the scrotum and anus)
- Coccygeal pain (pain in and around the tailbone)
- Low back pain (on one side or both)
- Groin pain (on one side or both)
- Dysuria (pain or burning during urination)
- Nocturia (frequent urination at night)
- Reduced urinary stream
- Hesitancy before or during urination
- Reduced libido (reduced interest in sex)
- Anxiety about having sex
- Pain after intercourse
- Discomfort or relief after a bowel movement
- Anxiety and catastrophic thinking
- Social withdrawal and difficulty in intimate relations
- Impairment of self-esteem
Most cases of prostatitis mistakenly treated with antibiotics
Historically, the conventional medical viewpoint has explained most cases of what is typically diagnosed as prostatitis as an infection and/or inflammation of the prostate gland. Indeed, that’s what the name prostatitis indicates, namely, an “itis” of the prostate. The conventional advice of many urologists to men they diagnose as having prostatitis related to increasing sexual activity derives from the idea that there is inflammation or infection in the prostate gland and more frequent ejaculation will empty it of these noxious critters.
Unfortunately, many doctors make a diagnosis of prostatitis and prescribe antibiotics without verifying that there is any infection present in the prostate
When a man comes into the physician’s office and complains about pelvic/urinary/rectal/genital pain and/or urinary symptoms like frequency, urgency, dysuria (pain during urination), sitting pain or ejaculatory discomfort, where there is no evidence of structural disease, the doctor typically treats the patient as if the cause of the problem is an infected or inflamed prostate gland and routinely gives antibiotics.
|Watch Stanford's Dr. Anderson discuss the Wise-Anderson Treatment for Prostatitis|
Prostatitis, which means an infection or inflammation of the prostate gland, is often diagnosed without the doctor doing any tests at all to establish the validity of such a diagnosis. As we have seen in a study of physicians in Wisconsin, a large majority of doctors view prostatitis as an inflammation or bacterial infection, and almost all prescribe antibiotics as a treatment. Most urologists know from their own experience that antibiotic treatment for prostatitis without evidence of infection routinely fails to help the patient’s symptoms and yet almost 100% of the cases of this kind of prostatitis receive antibiotics. We are always troubled to hear this routine diagnosis and antibiotic treatment in the patients who come to see us, when the patient’s doctor made no attempt to establish the presence of infection.
We always check for evidence of infection and inflammation in the prostatic fluid with men who complain of pelvic pain and urinary dysfunction. As we will discuss, antibiotics can have serious side-effects, especially taken long-term. And we have had more than a few men suffer the consequences of inappropriate long-term antibiotic treatment.
We want to emphasize that the antibiotic treatment of bacterial prostatitis has been an achievement of modern medicine. If you have bacterial prostatitis, antibiotics are a very good treatment—certainly the only treatment.Viewing all conditions of pelvic pain and dysfunction in men, however, as acute or chronic bacterial prostatitis is an error in therapeutic judgment.
Despite the clear scientific evidence to the contrary and almost every urologist’s clinical experience of the ineffectiveness of antibiotics for nonbacterial prostatitis, it is amazing that giving antibiotics routinely for nonbacterial prostatitis is the common practice. This is very important to understand, particularly if you have been diagnosed with prostatitis and it has not been determined whether infection or inflammation is present. We would consider it quite appropriate for a patient diagnosed with prostatitis to ask his doctor if there is clear evidence of bacteria, should the doctor prescribe antibiotics.
The prostate gland is not the problem with most men diagnosed with prostatitis
In the majority of men diagnosed with chronic prostatitis, the symptoms of pain arise from tender trigger points in the pelvic muscles. In recent years, there is clear evidence that a large majority of men typically complaining of the following symptoms have no prostate pathology and no infection demonstrated by culture. Even the evidence of inflammation (white cells found in the prostatic fluid) does not account for the following symptoms because typically when inflammation is removed, symptoms remain.
Chronic tension in the pelvic muscles is the source of pain in a majority of men diagnosed with prostatitis
The great majority of men (95%) complaining of prostate and pelvic pain have no evidence of prostate infection. This is why antibiotics fail to resolve symptoms. Additionally, even when there is some inflammation seen in the prostatic fluid it does not appear to be related to the degree of pain being suffered. The fact that is unfortunately resisted by many medical professionals is that most men with the following symptoms suffer from chronically tightened muscles inside the pelvic floor. When areas of this chronic tension are pressed on, as confirmed in our 2009 study published in the Journal of Urology, many symptoms above are recreated. When pelvic floor trigger points are resolved, the pelvic floor muscles are relaxed, the anxiety related to them calms down, and the symptoms tend to significantly reduce or dissappear. Teaching our patients to release pelvic floor trigger points and lower the nervous system arousal related to them is the aim of our 6-day clinics.
READ ABOUT THE SUCCESS OF THE WISE-ANDERSON PROTOCOL
IN PUBLISHED STUDIES
The Journal of Urology
April 2011 Volume 185, Issue 4 p. 1294
RODNEY U. ANDERSON,*,† DAVID WISE, TIMOTHY SAWYER,PATRICIA GLOWE AND ELAINE K. ORENBERG
From the Department of Urology, Stanford University School of Medicine,
Stanford (RUA, PG, EKO) and Sebastopol (DW, TS), California
6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training.
PURPOSE: Chronic prostatitis/chronic pelvic pain syndrome continues to elude conventional therapy. Evidence supports the concept that phenotypes of pelvic muscular tenderness and psychosocial distress respond to myofascial trigger point release and specific relaxation training. This case series reports long-term outcomes of a 6-day intensive combination of such therapies in refractory cases.
MATERIALS AND METHODS: A total of 200 men with pain for a median of 4.8 years referred themselves to Stanford University Urology for participation in an established protocol. Daily 3 to 5-hour sessions including intrapelvic/extrapelvic physiotherapy, self-treatment training and paradoxical relaxation training provided a solid introduction to facilitate self-management. Subjects answered baseline and followup questionnaires at variable intervals after initiation of therapy including the National Institutes of Health Chronic Prostatitis Symptom Index, global response assessment and a psychological query.
RESULTS: We followed 116 men for a median of 6 months. Baseline total symptom index was 26 out of a maximum 43 points. Scores decreased by 30% (p <0.001) at followup with 60% of subjects demonstrating a 6-point or greater decrease (range 6 to 30). Domains of pain, urinary dysfunction and quality of life showed significant improvement (p <0.001). Global response assessment revealed that 82% of subjects reported improvement (59% marked to moderate, 23% slight).
CONCLUSIONS: Men with chronic pelvic pain refractory to traditional treatment benefit from intensive myofascial trigger point therapy and concomitant paradoxical relaxation training. Education in techniques for self-administered trigger point release and continued pelvic muscle relaxation help patients reduce pain and dysfunction. Refinement of clinical phenotyping and selection of patients with pelvic muscle tenderness should enhance the success rate with this treatment modality.
Rodney U. Anderson MD,1 David Wise PhD,2 Timothy Sawyer PT2 and Brian Nathanson PhD3
1Department of Urology, School of Medicine, Stanford University, Stanford, CA, 2Sebastopol, CA and 3Longmeadow, MA
SAFETY AND EFFECTIVENESS OF AN INTERNAL PELVIC MYOFASCIAL TRIGGER POINT WAND FOR UROLOGICAL CHRONIC PELVIC PAIN SYNDROME (UCPPS)
Clin J Pain. 2011 Nov;27(9):764-8.
Anderson R, Wise D, Sawyer T, Nathanson BH.
Department of Urology, Stanford University, School of Medicine, Stanford, CA.
Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome.
OBJECTIVES: Pelvic muscle tenderness occurs often in patients with urologic chronic pelvic pain syndrome; symptoms frequently can be reduced with pelvic myofascial physical therapy. This open-label pilot study evaluated the safety of a personal wand that enables patient's self-treatment of internal myofascial trigger points in the pelvic floor and its effect in reducing pelvic muscle tenderness.
METHODS: A specially designed curved wand served as an extended finger to locate and release painful internal myofascial trigger points; an integrated algometer monitors and guides appropriate applied point pressure. Patients used the wand several times weekly after education and careful supervision. Evaluations for adverse events and assessments of pain sensitivity were conducted at 1 and 6 months after commencing use.
RESULTS: One hundred and thirteen of the enrolled 157 patients completed 6 months of wand use-106 men and 7 women; 44 patients withdrew before study completion but none for adverse events. Median age was 41 years and 93% were male. Baseline median sensitivity visual analog scale score (1 to 10, 10=most sensitive) was 7.5 and decreased significantly at 6 months to 4 (P<0.001, Wilcoxon matched-pairs signed-rank test). Most patients (95.5%) reported the wand as either very or moderately effective in alleviating pain. No serious adverse events occurred.
CONCLUSIONS: A multimodal protocol using an internal pelvic therapeutic wand seems to be a safe, viable treatment option in select refractory patients with pelvic pain.
Nature Reviews Urology
Anderson, R.U. & Nathanson, B.H., Nat.Rev.Urology 8, 236-237 (2011)
Department of Urology, Stanford University School of Medicine, CA 94305-5118,
OptiStatim LCC, P.O. Box 60844, Long Meadow, Mass 01116
Drug Therapies for CP/CPPS: help or hype
A recent network meta-analysis of α-blockers, antibiotics and other drug therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) found that they provided modest-to-no benefit for this condition, confirming previous findings. However, a casual reading of the article may give a false impression of the efficacy and appropriateness of these drugs.
The conundrum of treating CP/CPPS continues to frustrate physicians. Innumerable clinical studies have described the condition and the potential therapeutic options for its management. In an article published in the January issue of JAMA,1 the authors conducted a systematic review and network meta-analysis of clinical studies of the various oral medications used for the management of CP/CPPS, and concluded that “α-blockers, antibiotics, and combinations of these therapies appear to achieve the greatest improvement in clinical symptom scores compared with placebo.”
The title of the article implies a proposal from the American Medical Association for the best management of CP/CPPS. However, after adjusting for publication bias in their direct meta-analysis, there was no clinically or statistically significant treatment benefit associated with α-blockers or antibiotics in terms of reducing either total NIH Chronic Prostatitis Symptom Index (NIH-CPSI) scores or pain, voiding (urinary) and quality-of-life subscores, which should have been a main conclusion. Also, most urologists often find these treatment options to be ineffective, and, unfortunately, the article does a disservice by minimizing the factual evidence from randomized clinical trials that these universally used oral medications fail to help millions of men achieve effective symptom relief. The authors do state that “the total sample sizes [of the studies] are relatively small and the effect sizes are modest and often below the minimal clinically significant difference. Furthermore, even these estimates may be overinflated given the evidence for publication bias,”1 but these points are not adequately emphasized.
Moreover, several methodological issues in this study are worthy of comment. The outcomes of interest were the NIH-CPSI scores or related measures (such as the International Prostate Symptom Score or the Prostatitis Symptom Score Index). The authors note that a reduction of 4 points on the total NIH-CPSI score is necessary to be considered clinically perceptible, and a reduction of >6 points is considered clinically significant. A P-value low enough to signify statistical significance (P <0.05) is misleading if the difference between groups is not clinically meaningful. To prevent this distortion, the analysis should have made the alternative hypothesis state that the significant difference was >4 (the clinically perceptible threshold) and not merely >0, and should have noted where the confidence intervals included this threshold.
The noted heterogeneity of the included studies raises serious methodological issues, particularly for the study’s network (indirect) meta-analysis. A network meta-analysis is a new statistical method that is used to compare multiple therapies when the comparisons were not performed “head to head” in a randomized trial (that is, when trials that directly compare treatment A and treatment B do not exist). The assumptions that are necessary for a valid network meta-analysis are more complex than those for a traditional meta-analysis.2 In short, all the studies analyzed must be homogeneous enough in design, study population and placebo group, both within and among each other, to make the comparisons clinically reasonable, as the exchangeability of results across trials is even more important than in a traditional meta-analysis. We cannot tell from the manuscript whether all these assumptions have been met for each of the studies analyzed. The authors tried to analyze a dichotomous response versus non-response outcome, but the studies’ thresholds were too different (for example, ‘response’ was defined as a 25% decrease in NIH-CPSI score in two studies, and as a 50% decrease in three studies) to make a meta-analysis appropriate.
The story of oral medications for CP/ CPPS has already been told.3 The largest NIH-sponsored randomized controlled trials do not support the use of the α-blockers alfuzosin or tamsulosin, nor the antibiotic ciprofloxacin, either alone or in combination with tamsulosin.4,5 Randomized controlled trials are the gold standard in evidence-based medicine, and this network meta-analysis essentially confirms rather than refutes these previous findings. However, the way the authors present their conclusions, particularly in their abstract, minimizes these facts.
While the ineffectiveness of these drugs is old news to those of us who specialize in treating CP/CPPS, they are still routinely prescribed by most clinicians treating this condition—and patients continue to suffer from CP/CPPS. Underlining the failure of these conventional oral medications should have been the main conclusion of this article. The authors admit that “the reason for the benefit associated with antibiotics is not immediately clear.” Other nonpharmacological therapies for CP/CPPS do exist, however, and the logical trend in the diagnostic evaluation of CP/CPPS is to utilize careful phenotyping in the initial work-up of the suffering patient. This phenotyping approach has recently been proposed and evaluated in a multimodal therapy setting, with excellent results.6 The differences in the management strategies used depend upon recognizing the heterogeneity of the condition and the specificity of symptoms, which are characterized by the six domains of the UPOINT phenotyping system (urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness of skeletal muscles) that are used for focusing treatment. Each of these domains should be treated with state-of-the-art therapy, which might sometimes require more than one treatment modality. Notably, pelvic tension and muscle tenderness make up the majority of the specific symptoms and physical findings in patients with CP/CPPS.
In our personal experience of treating this condition, we have found alternatives to failed oral medications, such as multimodal physical therapy and cognitive behavioral therapy, and suggest that innovative treatment strategies be explored after patients have been carefully phenotyped and once traditional antibiotic or α-blocker therapy of CP/CPPS has been deemed inappropriate.
J Urol. 2005 Jul;174(1):155-60.
Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men.
Department of Urology, Stanford University School of Medicine, Stanford, California, USA. firstname.lastname@example.org
PURPOSE: A perspective on the neurobehavioral component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT).
MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with a pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom Index. Patient reported perceptions of overall effects of therapy were documented on a global response assessment questionnaire.
RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptom scores, as assessed by the PPSS. In those at the 50% or greater improvement level median scores decreased 69% and 80% for pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy.
CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy
“The goal of the Stanford Protocol is to enable the patients to reduce and/or resolve their symptoms without dependency on drugs or others to do so for them.”
David Wise, Ph.D.
Plenary address to the
National Institutes of Health (NIH)
Scientific Workshop on Prostatitis/Chronic Pelvic Pain Syndromes
October 21, 2005
Thank you for giving me the opportunity to discuss the Stanford Protocol at this National Institutes of Health sponsored scientific meeting on Prostatitis/Chronic Pelvic Pain Syndrome.
How I became involved in treating chronic pelvic pain syndrome
I happened to have had the unusual experience of the slow motion nightmare of chronic pelvic pain for a period of over twenty years– at one time or another having had almost all of the symptoms you typically hear from patients, and then unrelieved, unrelenting pain 24 hours a day 7 days a week …and no one to talk to or no one to help me --- and then around ten years ago, I had the fortune of experiencing the resolution of my own symptoms by finding and implementing the elements of what is now called the Stanford Protocol that I am going to discuss. I gratefully remain pain and symptom free. So I speak to you both someone who understands this problem as a clinician who has seen many, many patients with pelvic pain over the past years, and as someone who has had the direct experience of pelvic pain of long duration and then the experience of the resolution of the pain.