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Clinical Research

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): look to the future

Prostate Cancer and Prostatic Diseases (2023)Cite this article

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Why are we still talking about the management of chronic prostatitis 50 years after the first historical paper describing the culture technique for prostatitis-like symptoms [1] and 40 years after the first traditional classification [2]? In 2000, Nickel et al. initiated a new era in prostatitis research and management [3] by presenting a new classification system followed by general consensus on the direction of prostatitis research [3]. However, still today prostatitis, particularly the chronic cases, represents a perplexing challenge in everyday clinical practice. In this perspective article, we discuss the relevant missing needs in the clinical management and research in chronic prostatitis, specifically chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Main clinical outcomes in prostatitis: the paradigmatic shift from symptoms to quality of life. What do the patients want from the therapy? Generally, in all areas of medicine, patients request a reduction of symptoms rather than an improvement in laboratory test results. Prostatitis represents an enigmatic clinical entity that impacts many aspects of a patient’s life. In 2009, Nickel et al. described the ‘Snow Flake Hypothesis’, hypothesising that chronic prostatitis patients are not a homogenous group suffering from a single disease entity but suffer from a complex multi-faceted symptomatic syndrome [4]. From this theory arose the first holistic approach to CP/CPPS, with the introduction in everyday clinical practice of UPOINT (urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness domains) clinical phenotyping classification [4]. For the first time, the target of the treatment was not the ‘prostate’ alone but a systemic approach targeting the entire clinical picture associated with each unique patient. This concept led to a patient-centred or personalised medicine management strategy [5]. A patient-centred approach has proven useful to patient’s understanding of what is causing their symptoms, improving adherence to treatment, potentially reducing complications, costs and ultimately offering the best chance of ameliorating symptoms and improving patients’ quality of life [6]. A holistic approach incorporating an individual patient phenotype-directed management strategy for patients affected by prostatitis is needed in order to make a real beneficial impact with respect to a patient’s pain and urinary symptoms, life activities and quality of life.

History and symptom evaluations, using the validated versions of NIH-Chronic Prostatitis Symptom Index questionnaire, are mandatory as the first approach to the patient with prostatitis-like symptoms [7]. The physical examination must include an assessment of both the prostate and pelvic floor incorporating either the Meares–Stamey test or the less cumbersome, less costly and easier to perform 2-glass test in order to classify the patient into the categories of the classification NIH/NIDDK CP/CPPS categories [7, 8]. Other laboratory and instrumental investigations (e.g., urodynamics, cystoscopy, imaging, semen culture, etc.) can be useful in selected patients with specific indications [9]. The grey zones in diagnosis and management continue to be the presence or absence of bacterial pathogens. It has proven difficult to identify potential pathogenic roles of many bacteria in prostatitis, using standard microbiological analyses [10]. New non-culture microbiological approaches such as polymerase chain reaction and next-generation sequencing (NGS) techniques evaluating the urinary and prostate microbiota in men with chronic prostatitis who are negative for the ordinary bacteria by routine culture [10] have opened up a whole new area of inquiry about the role of infectious agents in chronic prostatitis. However, despite these technological advances in microbiological and genetic analysis, we are far from the clinical applicability of these findings. Other investigations, such as cytokine analysis or cytological typing of immune cells, that could help stratify the immune response may add diagnostic or predictive value in the future [11, 12]. Moreover, recent evaluations demonstrated that NGS detected uropathogens more frequently in those with clinical symptoms suggestive of urinary tract infection but more clinical outcome trials are needed before these observations become clinically applicable [13]. Research should be focused on next-generation investigations that are practical to use for the diagnosis and follow-up evaluation of the disease. It is important that all the limitations of such diagnostic steps and approaches are discussed with the patient.

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Fig. 1: The figure shows our purposed approach to patients with CP/CPPS.

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Authors and Affiliations

  1. Department of Urology, Santa Chiara Regional Hospital, Trento, Italy

    Tommaso Cai

  2. Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    Tommaso Cai

  3. Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University, Giessen, Germany

    Jakhongir Alidjanov & Florian M. E. Wagenlehner

  4. Institute of Antimicrobial Chemotherapy, Smolensk State Medical University, Smolensk, Russia

    Ivan Palagin

  5. Department of Urology, Hospital Universitario 12 de Octubre, Madrid, Spain

    José Medina-Polo

  6. Department of Urology, Queen’s University School of Medicine, Kingston, ON, Canada

    J. Curtis Nickel

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  1. Tommaso Cai
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TC and FMEW designed the study and wrote the manuscript. JA, JM-P and IP performed the literature research. JCN performed the revision of the manuscript and supervised.

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Correspondence to Tommaso Cai.

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Cai, T., Alidjanov, J., Palagin, I. et al. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): look to the future. Prostate Cancer Prostatic Dis (2023). https://doi.org/10.1038/s41391-023-00645-7

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