Chronic Prostatitis

Abstract

The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this re...

Acupuncture and Traditional Chinese Medicine for the management of a 35-year-old man with chronic prostatitis with chronic pelvic pain syndrome

“…Studies report that up to 10% to 15% of the male population has chronic prostatitis with chronic pelvic pain syndrome (CP/CPPS) at any one time, 1 and it accounts for 2 million outpatient visits per year. The etiology of CP/CPPS is unknown, and yet it is the most common clinical entity of the National Institutes of Health's (NIH) prostatitis categories (Table 1).…”

“…The impact on quality of life associated with CP/CPPS is comparable to that of angina, Crohn disease, or a previous myocardial infarction. 1,2 There is no known cure for this condition.…”

“…This self-administered questionnaire, called the Chronic Prostatitis Symptom Index (CPSI), considered "psychometrically robust," evaluates valid clinical outcome measures and is useful in both clinical and research settings. 1,6,7 This questionnaire is considered the international standard for prostatitis symptom evaluation (Fig 1). 1 Gram-negative bacteria, specifically Escherichia coli, are the most common causative uropathogens in Categories I and II, acute and chronic bacterial prostatitis.…”

“…1,6,7 This questionnaire is considered the international standard for prostatitis symptom evaluation (Fig 1). 1 Gram-negative bacteria, specifically Escherichia coli, are the most common causative uropathogens in Categories I and II, acute and chronic bacterial prostatitis. 1 Higher levels of oxidative stress have been found to be present in prostate tissue not only when pathogenic bacteria are identified but also in inflammatory and noninflammatory prostatitis (Categories III A and III B), that is, independent of leukocyte and bacteria counts.…”

“…1 Gram-negative bacteria, specifically Escherichia coli, are the most common causative uropathogens in Categories I and II, acute and chronic bacterial prostatitis. 1 Higher levels of oxidative stress have been found to be present in prostate tissue not only when pathogenic bacteria are identified but also in inflammatory and noninflammatory prostatitis (Categories III A and III B), that is, independent of leukocyte and bacteria counts. [8][9][10] Although this does not shed light on the unknown etiology of Category III A and III B prostatitis, studies are now confirming a correlation between measurements of lowered markers of oxidative stress and successful outcomes of treatment in all categories.…”