What treatments are effective for chronic prostatitis?

for confounders (clinical, exercise, and nuclear scintigraphic variables), LBBB was an independent predictor
of mortality (hazard ratio [HR] 1.5; 95% CI, 1.0–2.0).2
One study specifically evaluated bundle branch
block as a risk factor in noncardiac, nonemergent
surgery. This retrospective cohort study investigated
patients with LBBB (n=119) or right bundle branch
block (RBBB; n=336) undergoing preoperative evaluation for noncardiac surgery. Mean age was 67 years
(range 40–93), 64% had hypertension, 18% CHF, 18%
a history of CAD, and 22% angina. No cardiovascular complications were observed in the patients with a
bundle branch block intraoperatively. Postoperatively,
no patients with a bundle branch block experienced
myocardial infarction, pulmonary edema, or ventricular
dysrhythmias. One patient with LBBB developed atrial
fibrillation postoperatively. Four patients (0.9%) with
bundle branch blocks (1 with RBBB, 3 with LBBB) died
postoperatively compared with 2 (0.4%) in the control
cohort. All 3 of the LBBB deaths were due to sepsis (2
after prolonged postoperative hospitalization) and all
had known heart disease. Hence, LBBB may be associated with increased noncardiac postoperative complications; however, a larger cohort study is needed to
validate this finding.3
The ACC/AHA 2007 Perioperative Executive Summary considers the presence of a LBBB a “minor clinical predictor.” In the absence of clinically active cardiac
conditions, such individuals may proceed to low-risk
surgery. In patients undergoing other than low-risk surgery, further workup is not required if their functional
capacity is greater than 4 metabolic equivalent tests
(METs). Patients with poor (<4 METs) or unknown
functional capacity undergoing other than low-risk surgery require a clinical risk factor assessment to determine if further evaluation is warranted.4
Robert Gauer, MD
Womack FMR Clinic
Fort Bragg, NC
1.Imanishi R, Seto S, Ichimaru S, Nakashima E, Yano K, Akahoshi M. Prognostic significance of incident complete left bundle branch block observed over a 40-year period. Am
J Cardiol. 2006; 98(5):644–648. [LOE 2b]
2.Hesse B, Diaz LA, Snader CE, Blackstone EH, Lauer MS. Completed bundle branch block
as an independent predictor of all-cause mortality: report of 7,073 patients referred for
nuclear exercise testing. Am J Med. 2001; 110(4):253–259. [LOE 2b]
3.Dorman T, Breslow MJ, Pronovost PJ, Rock P, Rosenfeld BA. Bundle-branch block as a
risk factor in noncardiac surgery. Arch Intern Med. 2000; 160(8):1149–1152. [LOE 2b]
4.Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative
cardiovascular evaluation and care for noncardiac surgery: executive summary: a report
of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation. 2007; 116(17):1971–1996. [LOE 5]
8
Evidence-Based Practice / July 2009
What treatments are effective for chronic
prostatitis?
Evidence-Based Answer
No treatments for chronic prostatitis/chronic pelvic
pain syndrome have been proven effective. Ciprofloxacin, tamsulosin, corticosteroids, and rofecoxib have all
failed to show benefit. (SOR B, based on a single study
for each agent.)
Chronic prostatitis/chronic pelvic pain syndrome is a
common disorder that is defined clinically by inflammation of the prostate and discomfort or pain in the
perineal or pelvis region, and lower urinary tract symptoms with or without bacteriuria.
In 2001, a double-blind, double-dummy trial compared the effectiveness of ciprofloxacin, tamsulosin,
a combination of both drugs, and placebo in patients
with chronic prostatitis/chronic pelvic pain syndrome.
This trial evaluated 196 men with a score of at least
15 on the National Institute of Health Chronic Prostatitis Symptom Index (the NIH-CPSI, with a maximum
of 43 points) and a mean of 6.2 years of symptoms.
They were randomized to 1 of 4 groups: 49 were given
ciprofloxacin 500 mg twice daily, 49 were given tamsulosin 0.4 mg once daily, 49 were given combination of
both drugs, and 49 were given placebo. The NIH-CPSI
was readministered at the end of 6 weeks of treatment.
Despite a slight decrease in the NIH-CPSI total score
in all treatment groups, no statistically significant outcomes were noted.1
In 2002, a randomized controlled trial (RCT) evaluated the effectiveness of a short course of oral prednisone therapy for chronic prostatitis/chronic pelvic pain
syndrome. The trial enrolled 21 men with the condition
for at least 6 months, for whom antibiotic therapy had
failed. They were randomized to oral prednisone (20 mg
daily for 1 week, 15 mg daily for 1 week, 10 mg daily
for 1 week, and 5 mg daily for 1 week) or an equivalent
placebo. No difference was noted between the groups in
outcomes measured by the McGill Pain Questionnaire,
the Hospital Anxiety and Depression Scale, General
Health Questionnaire-30, and the NIH-CPSI score. A
significant limitation in this study was the small number
of patients and failure to use intent-to-treat analysis.2
A 2003 multicenter RCT evaluated the effects of
rofecoxib therapy for 161 patients with chronic prostatitis: 53 were given rofecoxib 25 mg PO, 49 were
given rofecoxib 50 mg PO, and 59 were given a placebo PO. NIH-CPSI pain scores were used to evaluate
the patients at baseline and after 6 weeks of treatment. The NIH-CPSI total scores were lowered by
–4.18, –4.92, and –6.22 points in the placebo, rofecoxib 25-mg, and rofecoxib 50-mg groups, respectively, compared with baseline. None of these changes
was statistically significant.3
Bryant Huy Nguyen, MD
Barbara Jo McGarry, MD
Beatrix Roemheld-Hamm, MD, PhD
UMDNJ-RWJMS FMR
New Brunswick, NJ
1.Alexander RB, Propert KJ, Schaeffer AJ, et al, for the Chronic Prostatitis Collaborative Research Network. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic
pain syndrome: a randomized, double-blind trial. Ann Intern Med. 2004; 141(8):581–
589. [LOE 1b]
2.Bates SM, Hill VA, Anderson JB, et al. A prospective, randomized, double-blind trial to
evaluate the role of a short reducing course of oral corticosteroid therapy in the treatment
of chronic prostatitis/chronic pelvic pain syndrome. BJU Int. 2007; 99(2):355–359.
[LOE 1b–]
3.Nickel JC, Pontari M, Moon T, et al, for the Rofecoxib Prostatitis Investigator Team. A randomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis. J Urol. 2003; 169(4):1401–
1405. [LOE 1b]
How can we best manage chronic pain
for patients taking long-term narcotic
analgesics?
Evidence-Based Answer
Tramadol has proven efficacy up to 6 months and less
abuse potential than hydrocodone over 1 year. (SOR B,
based on randomized controlled trials [RCTs].) Transdermal fentanyl and sustained-release morphine have been
proven effective for longer-term use, although constipation is more common with morphine. (SOR A, based on
consistent RCTs.) Tricyclic and tetracyclic antidepressants appear to be moderately effective for reduction
of chronic back pain. (SOR B, based on a systematic
review with heterogeneity.)
The long-term management of chronic noncancer pain
is challenging as no consistent, high-quality data are
available to guide therapeutic decisions.
Tramadol, an analgesic that is not a controlled substance but binds weakly to opioid receptors and inhibits
the reuptake of serotonin and norepinephrine, has the
most evidence supporting its use for noncancer pain.
However, studies are primarily short-term and sponsored by the manufacturer.
A Cochrane review pooled data from 3 RCTs
(N=914) lasting 7 to 12 weeks that compared tramadol with placebo among patients with chronic low back
pain.1 Tramadol was more effective than placebo for
pain relief (standardized mean difference [SMD] 0.71;
95% CI, 0.39–1.02) and for improving function (SMD
0.17; 95% CI, 0.04–0.30).
In a separate RCT with 11,352 chronic pain patients,
a series of structured interviews was performed over a
12-month period to calculate an “abuse index” for each
patient randomized to tramadol, nonsteroidal antiinflammatory drugs (NSAIDs), or hydrocodone.2 The
percentage of patients who scored positive for abuse
at least once during the 12-month period was 2.5%
for NSAIDs, 2.7% for tramadol, and 4.9% for hydrocodone. The percentages of patients scoring positive for
abuse more than once (indicating persistent abuse) were
0.5% for NSAIDs, 0.7% for tramadol, and 1.2% for
hydrocodone. Tramadol had similar rates of abuse as
NSAIDS, but significantly less abuse than hydrocodone
(P<.01).
The only evidence supporting long-term use of tramadol was a 6-month open extension trial of 117 patients
with diabetic neuropathy that followed a 6-week RCT
and demonstrated continued pain relief.3
According to a recent evidence-based guideline, the
opioids with the best evidence for efficacy with therapy 6 months or longer are sustained-release morphine
and transdermal fentanyl.4 This guideline referenced 5
studies with a total of 688 patients that demonstrated
persistent improvement of pain scores and quality of
life with sustained-release morphine in chronic noncancer pain. For transdermal fentanyl, 3 studies with
a total of 1,399 patients demonstrated persistent
improvement of pain scores and quality of life. All of
the long-term studies were open-label and used variable outcome measures, making it difficult to quantify
the pooled results.
One open RCT over 13 months compared sustained-release morphine and transdermal fentanyl in
the treatment of chronic low back pain.5 This study
found similar improvement in pain relief and quality
of life with the 2 treatments, but significantly less constipation with fentanyl. At the study endpoint, 31% of
the transdermal fentanyl patients and 48% of the sustained-release morphine patients reported constipation
(P<.001). Baseline levels constipation were similar for
both groups at 23% and 26%, respectively.
continued
Evidence-Based Practice / Vol. 12, No. 7
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