chronic prostatitis / chronic pelvic pain syndrome ( cp / cpps ) represents one of the most commonly encountered disease entities . about 25% of patients who come to a urology clinic currently , the national institutes of health ( nih ) classifies prostatitis into 4 categories depending on urine and prostatic fluid analysis , which includes microscopic examination and cultures . of all cases , more than 90% of symptomatic prostatitis is categorized as nih category type iii , which is defined by the presence of chronic pelvic pain and possibly voiding symptoms without uropathogenic bacteria . the new nih classification for category iii further defined these men as either category iiia ( inflammatory ) or iiib ( noninflammatory ) on the basis of the presence of significant white blood cells ( wbcs ) in prostatic - specific specimens ( i.e. , expressed prostatic secretion [ eps ] , urine specimen after prostatic massage [ vb3 ] , and semen ) , however , although some research has confirmed the effectiveness of various treatments according to the nih classification , no difference in outcome was shown in the two groups . therefore , this study was conducted to evaluate clinical outcomes in the treatment of cp / cpps according to nih classification . a retrospective review was performed of 111 patients with a diagnosis of cp / cpps who were managed at yonsei university wonju severance christian hospital between june 2010 and june 2012 . the diagnosis of cp / cpps was made by physical examination , microscopic analysis of urine and standard microbiological cultures , transrectal ultrasonography , and serum prostate - specific antigen ( psa ) measurements . patients were included in the study if they had experienced pain or discomfort in the pelvic region for at least 3 months . we excluded patients with urinary tract infection , hypoechoic lesions on transrectal prostate ultrasound , serum psa levels greater than or equal to 4 ng / dl , a history of antibiotic treatment in the 6 months preceding the initial visit , invasive prostate - related procedures ( transurethral resection of the prostate , transurethral incision of the prostate , or transurethral needle ablation ) , genitourinary cancer , inflammatory bowel disease , active urethral stricture , prostate or bladder surgery , or neurologic diseases affecting the bladder . depending on the number of wbcs in the eps or vb3 , each patient was designated into the 2 nih subgroups discussed above . a patient was assigned to the nih category iiia group if the wbc count in the eps was equal to or greater than 10 per high power field ( hpf ) or the wbc count in the vb3 was equal to or greater than 5 per hpf . conversely , a patient was assigned to iiib if the wbc count in the eps was less than 10 per hpf or the wbc count in the vb3 was less than 5 per hpf . both groups were evaluated before the treatment and 6 weeks after the treatment by using nih chronic prostatitis symptom index ( nih - cpsi ) scores and the international prostate symptom score ( ipss ) . determination of the presence or absence of the therapeutic effect was defined as when the cpsi score fell 6 points or more . all the patients were treated with once - daily alpha - blockers ( alfuzosin 10 g ) and quinolone ( levofloxacin 500 mg ) for 6 weeks . the wilcoxon signed - rank test was used to compare the baseline scores with posttreatment scores . paired t - test and chi - square test were used to analyze the efficacy of treatment between groups . treatment outcome was analyzed by logistic regression , adjusted for age , prostate volume , ipss , and category of cp / cpps . of the 111 patients , 41 were classified into group 1 ( category iiia ) and 71 patients into group 2 ( category iiib ) on the basis of wbcs and culture results . the patients ' mean age was 54.9111.75 years in group 1 and 51.1513.43 years in group 2 . baseline characteristics including age , prostate volume , psa , mean maximal urine flow rate on uroflowmetry , cpsi score , and ipss were not significantly different between the two groups ( table 1 ) . table 2 lists the mean ipss and nih - cpsi before and after the combination therapy . the total ipss was significantly decreased in group 1 ( from 16.0010.86 to 12.149.02 , p=0.043 ) and group 2 ( from 17.935.19 to 17.007.32 , p=0.001 ) . the ipss voiding symptom subscore was significantly decreased in group 2 ( from 9.933.14 to 10.795.14 , p=0.002 ) . the ipss storage symptom subscore was significantly decreased in group 2 ( from 8.143.99 to 6.213.57 , p=0.004 ) . the cpsi pain score was significantly decreased in group 1 ( from 8.284.68 to 5.333.64 , p=0.006 ) and group 2 ( from 8.525.13 to 5.944.32 , p=0.001 ) . the cpsi voiding symptom score the cpsi qol symptom score was significantly decreased in group 1 ( from 7.332.35 to 6.062.07 , p=0.015 ) and group 2 ( from 7.712.74 to 5.812.75 , p=0.001 ) . the total cpsi score was significantly decreased in group 1 ( from 20.117.63 to 15.116.93 , p=0.006 ) and group 2 ( from 21.239.38 to 15.397.87 , p=0.001 ) . the cpsi total score was reduced by 6 points or more in 50% of the patients in group 1 ( n=18 ) and 51.6% of the patients in group 2 ( n=32 ) . no significant differences ( p=0.913 ) in treatment outcomes were observed between the two groups . as shown in table 3 , there were no statistically significant differences in treatment outcomes after adjustment for age , prostate volume , and ipss . cp / cpps is a common disorder that is typically accompanied by pain with ejaculation or discomfort in the pelvic or perineal region with prominent lower urinary tract symptoms . although prostatic inflammation has been identified in many patients with this syndrome , the etiology and pathophysiology of cp / cpps remain unknown . the nih consensus group identifies cp / cpps on the basis of wbcs in the eps , vb3 , or semen without any evidence of uropathogenic bacteria detected by standard microbiological methodology . the meares - stamey 4-glass test or simpler 2-glass test has been used to diagnosis cp . since mobley reported the usefulness of a semen culture in combination with urine culture , the new nih consensus classification is broader than the traditional approach , which was limited to the examination of eps . krieger et al .   reported an increase in inflammation from 52% to 93% when the diagnosis was based on the addition vb3 and seminal fluid analysis ( sfa ) to eps . in contrast , the nih - cpcrn case - control study determined that seminal evaluation had little clinical value in differentiating prostatitis patients from normal controls . in the present study in fact , most urologists rarely perform the 4-glass test and sfa in clinical practice . potential reasons are that the test is not sensitive nor specific , the therapeutic predictive value is poor , and the test is relatively expensive , time - consuming , and quite uncomfortable for the patients . the most common treatments in clinical practice are antimicrobial agents and alpha - adrenergic receptor antagonists . a european consensus report suggested that antibiotics are recommended for nih category iiia but not for nih category iiib . .   found no significant differences between nih category ii , iiia , and iiib after antibiotic treatment . first , the antimicrobial agent may have a placebo effect ; second , the antimicrobial agent may eradicate noncultured microorganisms ; and third , the antimicrobial agents may have immunosuppressive or anti - inflammatory effects . also , the treatment outcome was checked after 6 weeks , because this is the usual interval of treatment with an antimicrobial agent and it is generally believed that the bacterial organisms responsible for symptoms should be eradicated within this time . alpha - adrenergic receptor blockers are proven to be an effective treatment for benign prostatic hypertrophy . they inhibit the smooth muscle tone within the prostate gland and in the region of the bladder neck . presumably , these drugs are used empirically in the management of cp / cpps because of overlapping pathogenesis , such as sympathetic over - activation . a recent systemic review showed that alpha - adrenergic receptor blocker therapy was associated with significant improvement in cp / cpps symptoms . moreover , antibiotics and alpha - blocker combination therapy was more effective than monotherapy in treating cp / cpps . in this study , the combination alfuzosin and levofloxacin therapy resulted in significant improvements in both ipss and nih - cpsi scores . however , no significant difference in treatment outcome ( improvements of at least 6 points or more on the nih - cpsi total and domain scores ) was observed between nih category iiia and iiib . this suggests that a systemic approach other than nih classification by the wbc count may be necessary . in fact , our understanding of cp / cpps has evolved with the development of the nih classification . in our contemporary concept , cp / cpps is not prostate - specific but incorporates other extraprostatic factors including pelvic muscle dysfunction , neurological disease , and psychiatric conditions . developed the clinical phenotyping system with six domain : urinary , psychosocial , organ specific , infection , neurologic / systemic , and tenderness ( upoint ) , and a european study modified the clinical phenotyping system with an additional sexual dysfunction domain ( upoints ) . they showed that the number of positive domains correlated with symptom severity , and upoint - directed multimodal therapy improved symptoms and quality of life . therefore , because leukocytosis on eps or vb3 and voiding symptoms only reveal organ - specific domains according to the upoint system , each patient should be assessed for not only laboratory findings such as a lower urinary tract localization test , but also the nature of symptoms . although 51% of the patients showed clinical improvement in our study , there was no significant difference between nih category iiia and iiib . this may reflect the heterogeneous aspect of cp / cpps rather than the laboratory results . as a result , we think that the nih classification for cp / cpps based on the presence or absence of wbcs in eps , vb3 , or semen is necessary as an initial diagnostic approach . however , from a therapeutic viewpoint , it has a limited role because of the multiple pathophysiologic factors that affect cp / cpps . krieger et al .   noted that semen analysis will increase the rate of detection of category iiia . therefore , if the semen analysis had been enforced in our study , more patients would have been diagnosed with iiia . second , the treatment outcome was measured only after 6 weeks . it may take a longer period of treatment before an improved symptom score is seen . third , our study was designed as a retrospective review and had too small a number of cases to properly evaluate the impact of nih classification on the outcomes of cp / cpps . as such , a prospective randomized trial and long - term follow - up are needed . cp / cpps is a highly prevalent , multifactorial condition that affects men of all ages . the nih classification provided useful information regarding potential etiologies and treatment in patients with cp / cpps . however , the treatment response rate between nih classification iiia and iiib was not significantly different after antibiotics and alpha - blockers combination treatment . therefore , we think that factors other than inflammation also contribute to symptoms associated with cp / cpps , and consideration of multiple phenotypes by use of upoint will help in the treatment of cp / cpps .
purposewe determined the effects of alpha - blockers and quinolone in patients with chronic prostatitis / chronic pelvic pain syndrome ( cp / cpps ) classified by national institute of health ( nih ) consensus group.materials and methodsdata from a total of 111 patients who were diagnosed with cp / cpps between june 2010 and june 2012 were analyzed retrospectively . 
 the patients were classified into group 1 ( category iiia , n=40 ) and group 2 ( category iiib , n=71 ) . 
 treatment using alfuzosin and levofloxacin was given to both groups for 6 weeks . 
 international prostate symptom score ( ipss ) and nih chronic prostatitis symptom index were measured before and after therapy.resultsgroup 1 had a significant decrease in total ipss score , cpsi pain score , cpsi quality of life ( qol ) score , and total cpsi score ( p=0.043 , p=0.006 , p=0.015 , and p=0.006 , respectively ) . 
 group 2 had a significant decrease in ipss voiding symptom score , ipss storage symptom score , total ipss , cpsi pain score , cpsi voiding score , cpsi qol score , and total cpsi score ( p=0.002 , p=0.004 , p=0.001 , p=0.001 , p=0.006 , p=0.001 , and p=0.001 , respectively ) . 
 the cpsi score was reduced by 6 points or more in 50.0% of patients ( n=18 ) in group 1 and in 51.6% of patients ( n=32 ) in group 2 . however , there was no statistically significant difference between the changes in ipss and cpsi scores across the 2 groups.conclusionsalthough combination treatment reduced the cpsi score in both groups , there was no significant difference between the groups after combination treatment . 
 we suggest that factors other than inflammation also contribute to symptoms associated with cp / cpps .