How should I approach the management of a patient with CP/CPPS who has not responded to initial treatment?

For a patient with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) who has not responded to initial treatment, consider a multimodal management approach guided by the UPOINT classification system to target specific symptom domains such as urinary, pain, psychosocial, and sexual dysfunction symptoms. This approach has shown significant symptom improvement in clinical studies.

Continue or initiate symptom-directed treatments: for pain, use paracetamol and/or NSAIDs but avoid opioids; consider referral to a pain specialist if neuropathic pain is suspected. For lower urinary tract symptoms, a trial of an alpha-blocker (e.g., doxazosin or tamsulosin) for 4–6 weeks may be beneficial. If constipation is present, offer stool softeners like lactulose or docusate. Address psychosocial symptoms with cognitive behavioural therapy, counselling, or antidepressants. For sexual dysfunction, prioritise non-pharmacological interventions and consider phosphodiesterase inhibitors if appropriate.

If symptoms persist despite these measures, consider a single course of antibiotics such as trimethoprim or doxycycline for 4–6 weeks, especially if symptoms have been present for less than 6 months, but be cautious with fluoroquinolones due to safety concerns and regulatory restrictions.

Referral to a urologist is recommended if there is diagnostic uncertainty, severe symptoms, or persistence after initial management to exclude other causes and consider specialist interventions.

Acupuncture may be considered as an adjunct treatment, as evidence suggests it can reduce symptoms compared with sham or standard therapy.