Is there a role for urodynamics in chronic nonbacterial prostatitis?

The etiology of chronic nonbacterial chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS) is unclear. That may be why treatment with antibiotics and anti-inflammatory drugs often fail. The use of urodynamic testing in evaluating any patient with both pelvic/perineal pain coexistent with voiding symptoms can help identify voiding dysfunction. If identified, urodynamic voiding disorders, such as bladder neck obstruction and pseudodyssynergia, should be specifically treated to ameliorate symptoms. Through more research of nonbacterial CP/ CPPS, we will be able to further define the successful role of videourodynamics in men with this disease. The etiology of chronic nonbacterial chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS) is unclear. That may be why treatment with antibiotics and anti-inflammatory drugs often fail. The use of urodynamic testing in evaluating any patient with both pelvic/perineal pain coexistent with voiding symptoms can help identify voiding dysfunction. If identified, urodynamic voiding disorders, such as bladder neck obstruction and pseudodyssynergia, should be specifically treated to ameliorate symptoms. Through more research of nonbacterial CP/ CPPS, we will be able to further define the successful role of videourodynamics in men with this disease.     

Economic impact of chronic prostatitis

There are four types of prostatitis, including type I (acute bacterial prostatitis), type II (chronic bacterial prostatitis), type III (chronic prostatitis/chronic pelvic pain syndrome, or CP/CPPS), and type IV (asymptomatic inflammatory prostatitis). These prostatitis conditions account for approximately 2 million office visits each year to primary care physicians and urologists. The annual cost to treat prostatitis is approximately $84 million. Compared with control subjects, men with prostatitis incur significantly greater costs, predominantly due to increased outpatient visits and pharmacy expenses. CP/CPPS is the most common type of prostatitis. The condition is characterized by chronic, idiopathic pelviperineal pain. Due to the lack of effective treatments for CP/CPPS, the per-person costs associated with the condition are substantial and are similar to those reported for peripheral neuropathy, low back pain, fibromyalgia, and rheumatoid arthritis. Costs appear to be higher in men with more severe symptoms. Indirect costs (eg, work and productivity loss) are incurred by many patients with CP/CPPS. Identification of effective treatments for CP/CPPS would be expected to substantially reduce the costs associated with the condition.     

Self-reported history of sexually transmitted infection and chronic prostatitis symptoms: a cross-sectional study of a Nigerian undergraduate population

The aetiology of chronic prostatitis is poorly understood. A cross-sectional study of a population of male undergraduates in Nigeria, using a questionnaire containing the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and some other relevant sex-related questions, was conducted. A total of 14.9% of the population had chronic prostatitis symptoms (CPSs) defined as a pain score of four or more on the NIH-CPSI pain subscale. Approximately 26 or 12% of the population had at least one, or ≥ 2 location(s) of pain, respectively. The presence of CPS was found to correlate with a self-reported history of sexually transmitted infection (STI) (r = +0.237; P < 0.05) and 73% of those with a self-reported history of STI had CPS. Both voiding scores and quality-of-life scores were significantly higher in subjects with CPS, compared with those without CPS. Self-reported history of STI may be an important aetiological factor for chronic prostatitis/chronic pelvic pain symptoms.     

Complications of Chronic Prostatitis

Chronic prostatitis (CP) is a pelvic condition in men that needs to be distinguished from other forms of prostatitis, such as acute and chronic bacterial prostatitis. CP is characterized by pelvic or perineal pain lasting longer than 3 months without evidence of urinary tract infection. Symptoms may wax and wane and pain may radiate to the back and perineum, causing discomfort while sitting. Dysuria, frequency, urgency, arthralgia, myalgia, unexplained fatigue, abdominal pain, and burning sensation in the penis may be present. Post-ejaculatory pain, mediated by nerves and muscles, is a hallmark of the condition and serves to distinguish CP/chronic pelvic pain syndrome (CPPS) patients from men with benign prostatic hyperplasia and healthy men. Some patients report low libido, sexual dysfunction, and erectile difficulties. The symptoms of CP/CPPS appear to result from interplay between psychological factors and dysfunction in the immune, neurological, and endocrine systems. Some researchers have suggested that CPPS is a form of painful bladder syndrome/interstitial cystitis (PBS/IC). Therapies shown to be effective in treating IC/PBS (eg, quercetin) have shown some efficacy in CP/CPPS. Recent research has focused on genomic and proteomic aspects of the related conditions. There are no definitive diagnostic tests for CP/CPPS. This is a poorly understood disorder, even though it accounts for 90% to 95% of prostatitis diagnoses. Its peak incidence is in men 35 to 45 years old. In 2007, the National Institute of Diabetes and Digestive and Kidney Diseases began using the umbrella term urologic chronic pelvic pain syndromes to refer to pain syndromes associated with the bladder (eg, IC/PBS) and prostate gland (eg, CP/CPPS). The prognosis for CP/CPPS has improved greatly with the advent of multimodal treatment, including phytotherapy, pelvic nerve myofascial trigger point release, anxiety control, and chronic pain therapy.     

Prostatitis and urinary tract infection in men: what's new; what's true?

Urinary tract and prostatic infections are common in men, and most are treated by primary providers. Acute bacterial prostatitis is caused by uropathogens, presents with a tender prostate gland, and responds promptly to antibiotic therapy. Chronic bacterial prostatitis is a subacute infection, may present with a variety of pelvic pain and voiding symptoms, and is characterized by recurrent urinary tract infections. Effective treatment may be difficult and requires prolonged antibiotic therapy. Nonbacterial prostatitis and chronic pelvic pain syndrome are more common than bacterial prostatitis, and their etiologies are largely unknown. Treatment for both nonbacterial disorders is primarily symptomatic. An underlying anatomic or functional condition usually complicates urinary tract infections in men, but uncomplicated infections occur, often related to sexual activity. Gram-negative bacilli cause most urinary tract and prostate infections. Therapy for prostatic infections requires an agent that penetrates prostatic tissue and secretions, such as trimethoprim-sulfamethoxazole or, preferably, a fluoroquinolone. Duration of antibiotic therapy is typically 1 to 2 weeks for cystitis, 4 weeks for acute bacterial prostatitis, and 6 to 12 weeks for chronic bacterial prostatitis. Long-term suppressive antibiotic therapy and nonspecific measures aimed at palliation may be useful in selected patients with recurrent bacteriuria or persistent symptoms of chronic bacterial prostatitis.     

Treatment response to conventional and novel therapies in chronic prostatitis

Chronic prostatitis is a common and poorly understood condition that significantly impacts quality of life. Conventional therapy usually consists of prolonged courses of antibiotics; however, the efficacy of this approach is defined better by clearance of bacteria than by improvement in symptoms. Newer therapies with some evidence for efficacy include α blockers, anti-inflammatory drugs, phytotherapy (quercetin, bee pollen), physiotherapy, neuroleptics, and others with unique actions (finasteride, pentosan polysulfate). The National Institutes of Health Chronic Prostatitis Symptom Index is a validated symptom score that, in preliminary use, appears to be responsive to patient improvement. As more well-designed clinical trials in chronic prostatitis and chronic pelvic pain syndrome come to completion, physicians will be able to make rational treatment choices for patients with this common and frustrating condition.     

Acute and chronic prostatitis: diagnosis and treatment

Several distinct types of prostatitis, or prostatitis syndromes, are now recognized. The most common types include acute and chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Bacterial prostatitis, caused mainly by enterobacteria, is often difficult to cure, and chronic bacterial prostatitis is a common cause of relapsing recurrent urinary tract infection in men. Nonbacterial prostatitis, the most common syndrome, is an inflammation of the prostate of unknown cause. Patients with prostatodynia typically have sterile cultures and normal prostatic secretions but demonstrate an acquired voiding dysfunction on video-urodynamic testing. Since nonbacterial types of prostatitis have no recognized infectious cause, treatment using antimicrobial agents is ineffective and unwarranted.     

Role of bacteria in chronic prostatitis/ chronic pelvic pain syndrome

Throughout the past century, we have refined our understanding of prostatitis, moving from using a primarily clinical definition to considering it as a complex inflammatory condition. The inconsistency in identifying uropathogens in patients with symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has led to controversy in therapeutic management. There is compelling evidence that the normal prostate has minimal inflammation and no bacteria. Clinicians using the Meares/Stamey criteria identified uropathogens localized to the prostate in only 6% to 8% of CP/CPPS patients. This suggests that bacteria may have a role in less than 10% of men with CP/CPPS. That some patients respond to antimicrobials could suggest that eradication of bacteria reduces symptoms. However, the beneficial effect of antimicrobial drugs may not be due to their antibacterial action, but to their anti-inflammatory action. The normal prostate shows minimal inflammation, but only 50% of CP/CPPS patients exhibit prostatic leukocytosis. Prudence demands that we examine the function of the white blood cells—the cytokines produced. Several basic science advances allowed new avenues of research regarding the detection of molecular evidence of causative uropathogens. New research brings new controversy and unexpected findings, but further refines our understanding of the immune system and the CP/CPPS disease process.     

Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome

Category III chronic prostatitis/chronic pelvic pain syndrome is a syndrome rather than a specific disease and the cause can be multifactorial. In clinical practice, monotherapy often has proven ineffective. Multimodal therapy, which sequentially or simultaneously can address infection, inflammation, and neuromuscular spasm appears to have the greatest potential for symptom improvement, especially in patients with longstanding symptoms.     

New therapies in chronic prostatitis

The optimal management of category III prostatitis (chronic pelvic pain syndrome) is not known. Conventional therapy usually consists of prolonged courses of antibiotics; however, clinical trials have never shown their efficacy. Newer therapies with some evidence for efficacy include α-blockers, anti-inflammatory phytotherapy (quercetin, bee pollen), physiotherapy, neuroleptics, and others with unique actions such as antinanobacterial treatment. A stepwise approach involving multiple treatment modalities is often successful for patients with this common and frustrating condition.     

Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome continues to pose a treatment challenge for urologists. Most commonly prescribed medications, such as antibiotics, α-blockers, androgen inhibitors, and anti-inflammatory agents, have been shown to help some patients. However, the efficacy and durability of such treatments lack consistency among men suffering from this disorder. The rationale for such treatments is described in this article, along with possible explanations for the apparent shortcomings. Also included is a brief summary of alternative therapies, which are growing in popularity among patients and gaining acceptance in our medical communities.     

Category III chronic prostatitis/chronic pelvic pain syndrome: Insights from the National Institutes of Health Chronic Prostatitis Collaborative Research Network studies

Chronic prostatitis/chronic pelvic pain syndrome remains an enigmatic medical condition. Creation of the National Institutes of Health-funded Chronic Prostatitis Collaborative Research Network (CPCRN) has stimulated a renewed interest in research on and clinical aspects of chronic prostatitis/chronic pelvic pain syndrome. Landmark publications of the CPCRN document a decade of progress. Insights from these CPCRN studies have improved our management of chronic prostatitis/chronic pelvic pain syndrome and offer hope for continued progress.     

Chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: Are they related?

Interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome are clinical syndromes characterized by pelvic pain with or without voiding symptoms such as urgency and frequency. There are many similarities in their epidemiology, adverse effect on quality of life, etiology/pathophysiology, natural history, and response to similar treatments. However, overlapping clinical definitions and similar entrance criteria for large-scale cohort studies make comparisons problematic. Newer efforts to classify pelvic pain syndromes should help in our recognition that interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome likely are not organ-specific syndromes but urogenital manifestations of regional or systemic abnormalities.     

Management of chronic prostatitis in Genitourinary Medicine clinics in the United Kingdom's North Thames Region 2000

Twenty-two Genitourinary Medicine (GUM) clinics in North Thames participated in a survey of policies and case notes audit of chronic prostatitis managed within the past 2 years, compared with the UK National Guideline. For 32/33 cases notes reviewed (97%) chronic abacterial prostatitis/chronic pelvic pain syndrome (CAP/CPPS) were diagnosed. Of these, 14/32 cases (44%) were following non-chlamydial non-gonococcal urethritis (NGU), 1/32 cases (3%) followed Chlamydia trachomatis infection and for 17/32 cases (53%) no predisposing cause was identified. The single case of chronic bacterial prostatitis (CBP) was caused by prostatic infection with Staphylococcus spp. All cases were prescribed antibiotics, initial follow-up appointments coinciding with completion of antibiotics. Fourteen cases (42%) were discharged following GUM clinic management; only 7 of these cases (50%) were asymptomatic, the others having residual problems. Nine cases (27%) were referred to a specialist. Ten cases (30%) defaulted follow-up appointments; 7 of these did not attend their first follow-up appointments.     

Chronic prostatitis and sensory urgency: Whose pain is it?

Difficulties encountered in diagnosing and effectively treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is frustrating for clinicians and patients. Scientific evidence cannot establish an exact relationship between the prostate and the symptoms of CP/CPPS, and the prostate continues to be the diagnosis of convenience in this complex syndrome in men. However, if the pain is not the prostate’s, whose pain is it? A heterogeneous group of insults can result in a common neurogenic pain response, resulting in recurring pain and voiding or sexual dysfunction. To add to this dilemma, certain life-threatening diagnoses, such as carcinoma-in-situ, is in the differential diagnosis and must be excluded. Urodynamics may be useful in evaluating and treating patients whose voiding symptoms predominate. However, many patients with CP/ CPPS will not have measurable abnormalities by conventional methods and likely suffer from a functional somatic syndrome that is best treated with a multimodality approach.     

Male Pelvic Pain Syndrome: Escaping the Snare of Prostatocentric Thinking

Decades of prostatocentric research and publications have hampered care for men with genital or pelvic pain syndromes who are often misdiagnosed with prostatitis. The prostatitis classification system as well as other misuse of terminology may have direct and indirect influence on physicians and lay persons alike. Taxonomy, medical culture, and gender issues perpetuate the substandard evaluation of men with this condition as well as the continued overuse of antibiotics. Because the vast majority of men with this condition have neither an infection nor a disease of the prostate gland, physicians must alter their approach to these patients. Thankfully, there is growing interest and evidence to show that male pelvic pain can and should be approached more broadly, even as a nonurological condition.     

Prostate cancer and chronic prostatitis

Prostate cancer and chronic prostatitis are prevalent disorders in men. The cause of prostate cancer and chronic prostatitis is multifocal and diverse. Both disorders exhibit characteristic elevation of serum prostate-specific antigen, currently the primary screening test for prostate cancer. Prostate inflammation, regardless of cause, is the histopathologic hallmark of chronic prostatitis. In general, inflammation is associated with multiple cancers, and prostate inflammation, in particular, is a suggested factor in the development and progression of prostate cancer. This review addresses the link between chronic prostatitis and prostate cancer, especially as it relates to clinical practice.     

The characterization of bacterial and nonbacterial prostatitis by prostatic immunoglobulins

Although inflammatory diseases of most human secretory surfaces are difficult to investigate clinically, the secretory immune system of the human prostate may be studied relatively easily because prostatic fluid may be obtained from the gland by digital massage. We studied inflammatory conditions of the prostate to establish whether we could use the humoral immune response to differentiate these conditions. Using a sensitive solid-phase radioimmunoassay, we measured total IgA and IgG, and IgA and IgG antibodies to Enterobacteriaceae in the serum and prostatic fluid of men with and without prostatic inflammation. These studies show that levels of IgA and IgG in the prostatic fluid of men with bacterial prostatitis are higher than those in men without histories of urinary or prostatic infections. In men with bacterial prostatitis, prostatic antibodies to Enterobacteriaceae were elevated 12 to 18 months after curative treatment and indefinitely after ineffective treatment; anti-Enterobacteriaceal IgG levels returned to normal after infection only with cure. Total IgA and IgG in the prostatic fluid of men with nonbacterial prostatitis--men who have signs of prostatic inflammation without evidence of old or ongoing bacterial infection--are also higher than levels found in uninfected individuals. Although this finding supports an inflammatory etiology for the symptoms seen in nonbacterial prostatitis, no significant IgA or IgG Enterobacteriaceal antibody titers were detected in these patients. This excludes a remote Enterobacteriaceal infection as a cause of nonbacterial prostatitis. These observations confirm that the prostate gland is a distinct part of the male secretory immune system.     

Fluoroquinolone antimicrobial agents in the treatment of prostatitis and recurrent urinary tract infections in men

Chronic bacterial prostatitis is the most frequent cause for recurrent urinary tract infection in young and middle-aged men. The selection of an appropriate antimicrobial agent that has optimal pharmacokinetics for urine and prostatic secretion and tissue is important in both entities. Fluoroquinolones possess several pharmacologic characteristics that favor them for treatment of urinary tract infection and prostatitis. The pharmacokinetics of fluoroquinolones and the theoretical background of drug penetration into the prostate is outlined. Analyzing the concentrations of various fluoroquinolones in urine, prostatic and seminal fluid, and in prostatic tissue, it becomes obvious that the fluoroquinolones differ in plasma concentrations and in their concentrations at these sites. Nevertheless, overall, the concentrations at the site of infection of most of the fluoroquinolones should be sufficient for the treatment of chronic bacterial prostatitis and vesiculitis and recurrent urinary tract infection in men caused by susceptible pathogens.