Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 52-year-old man is evaluated for a 3-month history of perineal and suprapubic pain. He has experienced urinary frequency and dysuria for 4 to 6 weeks. The patient reports fatigue, insomnia, and low mood for the past 6 months. He has hypertension. Current medications are hydrochlorothiazide and acetaminophen as needed for pain.

On physical examination, temperature is normal, blood pressure is 138/80 mm Hg, and pulse rate is 78/min. BMI is 29. Abdominal examination is normal with mild suprapubic tenderness. The prostate is not enlarged; it is mildly tender without nodularity. Testicular examination is normal.

On laboratory study, urinalysis is normal, and urine culture is negative. Prostate-specific antigen level is 0.8 ng/mL (0.8 µg/L).

Which of the following is the most appropriate treatment for this patient?

A) Levofloxacin
B) Naproxen
C) Oxybutynin
D) Saw palmetto
E) Terazosin

MKSAP Answer and Critique

The correct answer is E) Terazosin. This item is available to MKSAP 15 subscribers as item 14 in the General Internal Medicine section. More information about MKSAP 15 is available online.

The most appropriate treatment for this patient is terazosin. This patient has chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). CP/CPPS is manifested by genitourinary/pelvic pain and voiding symptoms. There are no diagnostic physical or laboratory findings. Urine cultures are typically negative, and the presence or absence of leukocytes in the urine has limited clinical utility in diagnosis or in predicting treatment response.

α-Blockers have the most evidence of efficacy among pharmacologic therapies for the treatment of CP/CPPS. Several specific α-blockers have been evaluated in randomized clinical trials, including terazosin, in doses ranging from 1 to 5 mg/d. Other α-blockers tested in trials include tamsulosin and alfuzosin. Clinical response is often modest, however, and long-term efficacy is uncertain.

Current evidence does not support a bacterial cause of CP/CPPS. Although a 4- to 6-week trial of antibiotics is still commonly prescribed, there is a lack of clinical trial evidence supporting their use. In contrast to bacterial prostatitis, in which urinalysis and urine culture typically show signs of an infection, results of these tests are normal in CP/CPPS. Acute bacterial prostatitis is unlikely in this patient with an indolent course of symptoms and a prostate that on examination is only mildly rather than exquisitely tender.

NSAIDs are another class of drugs commonly recommended as empiric treatment, and there is preliminary evidence that inflammatory markers such as interleukin and tumor necrosis factor are elevated in patients with CP/CPPS. However, only one randomized controlled trial has been conducted, which showed modest benefits for rofecoxib, a COX-2 inhibitor. The efficacy of other NSAIDs has not been established.

Anticholinergic drugs such as oxybutynin are effective therapy for urge incontinence but are not indicated for other genitourinary syndromes.

Quercetin, a bioflavonoid found in red wine, onions, and other foods, has proven beneficial in one small trial, but other popular “prostate health” supplements, including saw palmetto, do not appear effective for CP/CPPS.

Key Point

• α-Blockers may be effective in the treatment of chronic prostatitis/chronic pelvic pain syndrome.

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