Prostatitis

Cheah PY, Liong ML, Yuen KH, et al. Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: A randomized, placebo controlled trial. J Urology 2003; 169:592-596.

* PRACTICE RECOMMENDATIONS

Terazosin, an alpha-1-adrenergic blocker, is well tolerated, relieves pain symptoms, and improves quality of life in healthy men aged 20 to 50 years who have chronic prostratitis/ chronic pelvic pain syndrome.

Terazosin should be strongly considered as a first-line treatment in such patients. However, men with infectious prostatitis were excluded from this study. Also, the benefits of terazosin beyond 14 weeks are unknown.

* BACKGROUND

Lifetime prevalence of chronic prostatitis in men aged 40 to 79 years is 5%, resulting in significant morbidity, unnecessary antibiotic use, and both patient and physician frustration. (1) The vast majority of cases of chronic prostatitis are nonbacterial, recently termed chronic prostatitis/chronic pelvic pain syndrome by the National Institutes of Health (NIH) consensus classification of prostatitis syndromes.

Studies of prostatic massage, 5[alpha]-reductase inhibitors, anti-inflammatory drugs, biofeedback, allopurinol, and surgery report either insufficient data or conflicting results, preventing recommendations for routine use. Alpha-blockers have been shown to improve disease-oriented outcomes in patients with chronic prostatitis/chronic pelvic pain syndrome. (2)

* POPULATION STUDIED

One hundred men aged 20 to 50 years were recruited from hospitals in Northern Malaysia (mostly of Chinese and Malay ethnicity) during a national prostatitis awareness campaign. Eligible men met NIH criteria for chronic prostatitis, with recent pain and decreased quality of life.

Patients with chronic bacterial prostatitis, urinary tract infection within a year, significant medical problems, prior treatment with alpha-blockers, concomitant use of other prostatic medications, or use of medications potentially inhibiting lower urinary tract function were excluded.

* STUDY DESIGN AND VALIDITY

Subjects were randomly assigned in double-blind fashion to receive terazosin or identical placebo. It was not possible from the text to determine if allocation assignment was concealed. Terazosin was initiated at 1 mg/d and titrated as tolerated to 5 mg/d over 2 weeks, and continued for a total of 14 weeks. Outcomes were assessed at 2, 4, and 14 weeks using intention-to-treat analysis.

The authors used the NIH Chronic Prostatitis Symptom Index (NIH-CPSI). This validated, prostate-specific index consists of 9 questions evaluating 3 domains of chronic prostatitis: pain and discomfort, urinary symptoms, and impact on quality of life. The ninth item on this index was chosen as the primary outcome: "If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that?"

Baseline characteristics of the groups were similar for age, race, prostate size, median quality of life scores, and median NIH-CPSI pain domain scores. Mean initial prostate-specific antigen level was 0.67 ng/mL in the terazosin group vs 0.96 ng/mL in the placebo group. Patients in the placebo group reported a nonsignificantly longer duration of symptoms. Forty-three patients (86%) in each group completed all follow-up assessments.

* OUTCOMES MEASURED

The primary outcome measured was the quality-of-life item on the NIH-CPSI. Patients answered the questions 0 to 6 (0=delighted, 1=pleased, 2=mostly satisfied, 3=mixed, 4=mostly dissatisfied, 5=unhappy, 6=terrible). Patients with scores of 0, 1, or 2 at week 14 were considered responders. The secondary outcome measured was a 50% or greater reduction in the NIH-CPSI pain domain score.

* RESULTS

At week 14, 56% of patients receiving terazosin versus 33% receiving placebo responded to treatment (P=.03; number needed to treat [NNT]=4). More patients in the terazosin group reported a 50% decrease in pain domain scores (60% versus 37%; P=.03; NNT=4).

Other outcomes favoring terazosin therapy included both the mean NIH-CPSI total score (P=.01) and individual NIH-CPSI domain scores (P<.05). Interestingly, the groups did not differ in regards to peak urinary flow rate or postvoid residual. More adverse reactions were reported in the terazosin group; however, no patient withdrew from the study because of side effects.

REFERENCES

(1.) Roberts R0, Lieber MM, Rhodes T, et al. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County study of urinary symptoms and health status among men. Urology 1998; 51:578-574.

(2.) Collins M, MacDonald R, Wilt T. Diagnosis and treatment of chronic abacterial prostatitis: a systematic review. Ann Intern Med 2000; 133:367-368.

A. Christian Iudica, MD, Harrisonburg Family Practice, Hamsonburg, Va. E-mail: ciudica@aol.com.

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