Conventional Medical Approach
Treatments for Pain and Urinary Symptoms
by Drs Alexander and Pontari at the AUA Meeting 2001
If symptoms persist after using antibiotics, alpha blockers and NSAID's, focus symptom specific treatment on pain symptoms or urinary symptoms (or both)
(1) Treatment for pain:
- Tricyclic antidepressant medications: Mechanism: blocks
H1 receptor, anticholinergic action, inhibit reuptake of 5HT and
NE, desensitizes: Amitriptyline (Elavil) 25-75 mg po qhs (max
150mg). Has anticholinergic action which helps frequency, nocturia;
side effects: sedation, dry mouth. Other medications in this class
are Nortriptyline, Imipramine.
- Neurontin is an anticonvulsant that appears useful in
chronic pain. The mechanism is unknown as it does not work through
GABA receptors. It has been shown to be useful in post herpetic
neuralgia and diabetic neuropathy. Main side effect is somnolence.
Start slow titration up to 2400-3600 mg per day in three divided
doses. Start 400 mg po qd for 3 days, then bid for 3 days, then
tid for 3 days, then 800 tid, etc.
- Tizanidine is a centrally acting alpha-2 agonist which
helps in pain and skeletal muscle spasm. Main side effect is somnolence.
Start 2 mg intervals given qhs. Can also be given during day as
- Finasteride. Inhibits the conversion of testosterone
to dihydrotestosterone. Leskinen et al (1999) reported using Finasteride
5 mg po for 12 months in chronic prostatitis. Prostatitis Symptom
Severity Index and prostatitism scores dropped significantly in
finasteride group. Significant decrease in pain scale on finasteride
Reasons for effectiveness may include (1). Reduce edema and pressure
sensation (2). Reduce glandular elements in the prostate which
could be inflamed (3). Some anti inflammatory effect. No mention
of relation to size of gland. Another trial of CPCRN sites examining
role of Finasteride in CPPS is underway.
Ultram is a new oral pain medication, a synthetic analgesic.
Dose is 25-50 mg po q46 hrs prn.
- Opiates can also be used. Consider referral to a pain center for help with management of patients requiring chronic opioid use.
(2) Urinary symptoms
For patients with persistent urinary symptoms after initial
therapy, consider urodynamic evaluation. Use videourodynamics
if possible. Further therapy can be based on the findings of
the urodynamic study:
Sensory urgency on UDS: Medications that are useful in treating
BPS/IC can also be effective in treating chronic
Amitriptyline (see above)
Antihistamines: Hydroxyzine (Vistaril) blocks H1 receptors,
neuronal activation of mast cells. Dose is 25-50 mg po qhs or
bid. Side effects include sedation, weakness.
Pyridium plus. Combines pyridium, hyosciamine and butabarbital.
Use up to qid. Intravesical DMSO instillations every 1-2 weeks
for 4-8 treatments.
For detrusor hyperreflexia use anticholinergic medications.