A pain in the bottom

Everyone knows the expression “a pain in the butt.” It usually refers to a temporary irritation, as in That sales guy was such a pain in the butt or Replacing the sink trap turned out to be major pain in the butt.

For men, a chronic non-bacterial prostate inflammation is literally a pain in the bottom – the pelvic floor area – but managing this long-term condition also happens to be a metaphoric pain in the butt. That’s because very few treatments are efficiently successful.

Chronic prostatitis/chronic pelvic pain syndrome

I have previously written about chronic prostatis and chronic pelvic pain syndrome (CPPS). Unlike a short-term bacterial infection (called acute prostatitis), chronic means it lingers for months at a time, or comes and goes over a period of years. It is estimated to affect roughly 8-14% of men, which translates to millions of unhappy males. It has been called complex and debilitating^[i], suggesting it is far worse than a mere pain in the butt. It is associated with erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Men who experience chronic prostatitis are more prone to a condition called chronic pelvic pain syndrome, so it is common to put them together as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

CP/CPPS is considered the most common prostate problem in men below age 50, one that greatly lowers quality of life. The underlying causes are complicated and varied, making treatment difficult. Doctors often prescribe antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), alpha blockers, and management techniques like prostate massage, pelvic floor therapy, behavioral therapy and lifestyle changes to cope with stress. Whether used alone or in combination, none of these are easy solutions.

Tadalafil for CP/CPPS?

The world of men with ED was transformed by a drug called sildenafil, also known by the brand name Viagra, or simply the little blue pill. When used as directed, it was an easy fix for male sexual dysfunction. Viagra was quickly followed by its competitors vardenafil (Levitra) and tadalafil (Cialis). All of them belong to a class of drugs called PDE-5 inhibitors, which block the action of an enzyme that switches off erections. NOTE: Of the three major brands, Cialis earned the nickname “the weekend drug” because the effects of tadalafil lasts several times as long as the other two.

All three drugs have been shown to have multipurpose effects because they relax smooth muscle cells lining the blood vessels supplying the prostate and lungs For example, some years back, I reported on a study with the surprising discovery that sildenafil reduced LUTS symptoms in sufferers who were also using the little blue pill for ED. This resolved two pelvic problems with one medication. Now there’s promising news about the ability of tadalafil to ease CP/CPPS, another ED medication two-fer.

A journal article by Pineault et al. suggests that daily use of tadalafil is “…associated with durable decreases in CP/CPPS symptoms past 3 months.”^[ii] One theory holds that CP/CPPS is due to higher tissue pressures and reduced blood flow within the gland itself. Therefore, the researchers wanted to test the effect of a PDE-5 inhibitor on intraprostatic pressure, which could enhance blood flow for better oxygenation other positive anti-inflammatory effects.

Although the number of participants was small (25 men diagnosed with CP/CPPS for an average of 5.8 years prior to initiating daily tadalafil use), the results after 3 months of daily use were gratifying. Twenty-three of 25 men had significantly lower pelvic symptom scores, and overall pain and LUTS scores were reduced.

In their paper, the authors explain that early animal experiments with PDE-5 inhibitors demonstrated reduced inflammation, and they wondered if this class of drugs could help with CP/CPPS. They chose tadalafil for their clinical study because it has a 5x greater sensitivity for a specific enzyme that is concentrated in the human prostate. They write,

As a result of smooth muscle relaxation and reduced intraprostatic pressures, retrograde flow of urine in the transitional and peripheral zones of the prostate is reduced, decreasing recurrent episodes of prostatitis.^[iii]

This study, which is one of the only studies regarding the effects of 3-month daily use of a PDE-5 inhibitor on CP/CPPS, could turn out to be an important contribution. More studies at a higher level of research are needed, but it certainly looks like a classic ED medication will deliver much better results than alpha blockers, antibiotics and all the other remedies that have not worked for men with a long-standing “pain in the bottom.”

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Sharp VJ, Takacs EB. Prostatitis: Diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406.
[ii] Pineault K, Ray S, Gabrielson A, Herati AS. “Phosphodiesterase type 5 inhibitor therapy provides sustained relief of symptoms among patients with chronic pelvic pain syndrome” Transl Androl Urol 2020; 9: 391-397.
[iii] Ibid.