Evidence-Based Treatment Ladder for Chronic Prostatitis/Chronic Pelvic Pain

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) affects 2%-10% of men worldwide, yet lacks standardized treatment algorithms. This study aimed to establish a definitive treatment hierarchy by comparing four therapeutic modalities: alpha-blocker monotherapy, alpha-blocker plus antibiotic combination, alpha-blocker plus saw palmetto combination, and transurethral resection of prostate (TUR) surgery.

This retrospective comparative cohort study analyzed 200 adult males with CP/CPPS (50 patients per group) treated at a single academic center between October 2023 and August 2025. Inclusion criteria comprised NIH Chronic Prostatitis Symptom Index (NIH-CPSI) total score ≥ 10 and pain score ≥ 4, with excluded bacterial infection. Primary endpoint was NIH-CPSI score improvement at 12 weeks; clinical response was defined as ≥ 6-point improvement. Secondary endpoints included safety profiles and histopathological findings.

Significant therapeutic efficacy differences emerged between groups (p < 0.001). TUR surgery achieved highest efficacy with 88% clinical response rate and mean 15.7-point NIH-CPSI improvement. Alpha-blocker plus saw palmetto combination demonstrated superior medical therapy effectiveness (80% clinical response, 10.7-point improvement), exceeding monotherapy by 4.2 points (p < 0.001). Critically, alpha-blocker plus antibiotic combination showed no advantage over monotherapy (6.7 vs 6.5 points, p = 1.000). Chronic prostatitis was histologically confirmed in 100% of TUR specimens, with prostatic stones identified in 76% of cases. All treatments were well-tolerated with adverse event rates of 18%-30% (p = 0.234).

This study establishes an evidence-based treatment hierarchy for CP/CPPS: TUR surgery represents the most effective approach for refractory cases, while alpha-blocker plus saw palmetto combination constitutes optimal medical therapy. Antibiotic addition provides no benefit in non-bacterial prostatitis. These findings provide robust evidence for clinical decision-making and support guideline updates emphasizing antibiotic stewardship and phytotherapeutic agent validation.

This study was not registered as a clinical trial.