The management of patients with chronic pelvic pain attributed to chronic prostatitis has long been rather unsatisfactory. Even prolonged treatment with an aminoquinolone, such as ciprofloxacin, and an anti-inflammatory agent, or, alternatively an alpha blocker, seldom results in rapid resolution of the symptoms, and is commonly completely ineffective.
We recently encountered a patient, effectively disabled by prostatodynia, unresponsive to standard treatment, who had been taking morphine to control the pain from 2001 – 2008. He was unable to tolerate non-steroidal anti-inflammatory analgesics. In 2008 he was prescribed initially 10 mgs, then 20 mgs daily, of the phosphodiesterase type 5 (PDE5) inhibitor tadalafil, with immediate marked improvement of his symptoms. On cessation of the medication on 4 separate occasions, his symptoms returned; recommencement of treatment each time, with 5 mgs tadalafil daily, has resulted in similar persisting improvement of his symptoms, and he has been able to discontinue treatment with morphine. As a direct consequence of the conversation with this individual we have prescribed tadalafil 5 mgs daily in several of our patients with prostatitis; so far with uniformly beneficial results. Of course, we should point out that this is an off-label indication for this medication.
However, in addition to the symptom of pelvic pain, many men suffering from chronic abacterial prostatitis/prostatodynia also complain of associated lower urinary tract symptoms and ejaculatory discomfort. Consequently treatment with tadalafil at a dose of 5 mgs per day for a period of time would seem logical. It could be surmised that many of its beneficial effects might stem from an improvement of blood flow to pelvic organs as a consequence of its anti-inflammatory and vasodilatory activity, as well as a relaxant effect on smooth muscle, as has been previously suggested in the case of lower urinary tract symptoms by Karl-Eric Andersson and others.
Clearly the hypothesis that daily treatment with a PDE5 inhibitor might be beneficial in men suffering from the prevalent condition of chronic abacterial prostatitis/prostatodynia needs to be formally tested in the context of a randomized controlled trial. If the results of such a study were to prove positive the quality of life of very many sufferers of this disorder might be significantly improved. One might also speculate that it could provide a concomitant benefit to the partners of these often very unhappy men.
Roger Kirby, The Prostate Centre
Culley Carson III, The University of North Carolina
Prokar Dasgupta, The Prostate Centre, Guy’s Hospital, King’s College London