Prostatitis. Work-up and treatment of men with telltale symptoms

Prostatitis describes a spectrum of disorders involving inflammation of the prostate gland. This common yet poorly understood condition produces an array of symptoms, the most common of which are urinary obstruction, perineal pain, and ejaculatory complications. Although several theories have been proposed regarding its etiology, the exact mechanism of disease remains elusive. Definitive diagnosis can be hampered by a somewhat cumbersome testing procedure, but symptomology tends to be a reliable guide for treatment. Although treatment with antibiotics often fails, the fluoroquinolones are among the most effective agents for symptom management. Other interventions that may be appropriate include alpha-1-adrenergic blockers, a 5-alpha reductase inhibitor, or surgery. Chronic prostatitis may result in repeated urinary tract infections and chronic pain syndromes.

[Antioxidant therapeutic efficiency after the use of carnitine in infertile patients with bacterial or non bacterial prostato-vesiculo-epididymitis]

OBJECTIVE

In the male genital tract, reactive oxygen species (ROS) overproduction generated by infiltrating WBC or spermatozoa is one of the major causes of defective sperm function. Recently, we demonstrated that prostato-vesiculo-epididymitis (PVE) is the male accessory gland infection more crucial for the establishment of this cellular (sperm and/or WBC oxidative) response. This biochemical stress is due to an imbalance of pro and antioxidants factors and persists even after treatment with antimicrobials. Thus, the antioxidative properties of Carnitines (in terms of combined "Carnitine-Acetil-Carnitine" system) have currently found more attention as part of antimicrobial therapies. In this study, we compared which antioxidative strategy was more beneficial for the treatment of PVE.

MATERIALS AND METHODS

We selected two groups of infertile patients. One group consisted of 55 abacterial PVE patients (mean age 34 yrs, range 27-40) (group A); the other included other 35 bacterial PVE patients (mean age 35 yrs, range 28-38) (group B). Each group was randomly subdivided into the following treatment subsets: 1) A1 (n = 14) and B1 (n = 23) subsets received respectively a combined antibiotic and/or antiphlogistic regimen (x 14 days/ monthly x 3 months) (first step) followed by L-Carnitine 1 g x 2 day + acetyl-Carnitine 0.5 g x 2/day x other 3 months (second step) and finally no drug x other 3 months (third step). 2) A2 (n = 8) and B2 (n = 16) subsets received, for a 3 month period, in the meantime the combined antibiotic and/or antiphlogistic regimen (x 14 days/monthly) and L-Carnitine 1 g x 2/day + acetyl-Carnitine 0.5 g x 2/day (first step) and finally no drug x other 3 months (second step). 3) A3 (n = 8) and B3 (n = 12) subsets received for a 3-month period L-Carnitine 1 g x 2/day + acetyl-Carnitine 0.5 g x 2 day (first step) and finally no drug x other 3 months (second step). Before and after each step of the therapeutical design, all patients underwent semen and quantitative bacteriological analyses and 60/90 semen specimens were also investigated about ROS production analysis by chemiluminescence in their 45% and 90% Percoll-generated fractions.

RESULTS

The antioxidative response either in terms of significant decrease in the ROS production and increase in some semen parameters (sperm motility and viability) were highest in the patients of A1/B1 subsets, followed by A2/B2 subsets and lowest in the A3/B3 subsets.

CONCLUSION

These results indicate that in PVE patients antimicrobials and/or antiphlogistic drugs get a full positive antimicrobial response but a partial antioxidative response, which seems to be potentiated by the addition of antioxidative agents (Carnitines). Furthermore, it is important to underline that the antioxidative treatment with Carnitines administered in the meantime with antiinfectious agents is less effective, and finally this treatment is unsuccessful without the eradication of the pro-oxidant (germs and WBC) agents.

[Mepartricin in the treatment of male pelvic pain syndrome secondary to chronic nonbacterial prostatitis/prostatodynia]

BACKGROUND

The aim of this paper is to compare the activity of mepartricin vs placebo in male pain pelvic syndrome secondary to chronic nonbacterial prostatitis/prostatodynia.

METHODS

Forty-two patients have been tested (mean age: 35 years; range 29-44), these proved affected by male pain pelvic syndrome secondary to chronic nonbacterial prostatitis/prostatodynia, and were randomized into 2 groups: the 1st treated with mepartricin 40 mg/die for 60 days, the 2nd with placebo (C vitamin 500 mg/die) for 60 days. The following patterns were examined: spontaneous and rectal examination pain, diurnal and nocturnal urinary frequency and prostatic volume. Side effects in course of therapy were examined as well.

RESULTS

Mepartricin proved significantly more active than placebo in reducing spontaneous pain, rectal examination pain, diurnal urinary frequency, nicturia and prostatic volume. No significant difference proved to emerge between placebo and mepartricin in terms of side effects.

CONCLUSIONS

These data allow us to substain that mepartricin may be a useful and safe drug for the therapy of male pain pelvic syndrome secondary to chronic nonbacterial prostatitis/prostatodynia.

Chronic urologic pain syndromes

Chronic pains typically evaluated by a urologist are discussed from the perspective of a non-urologist pain clinician. The pathophysiology of some pains is understood and so we believe the patient's symptoms: examples are cancer-related pain and recurrent urolithiasis. We treat these pains with traditional analgesics. Other pains, such as those of interstitial cystitis, chronic prostatodynia, and chronic orchialgia are less understood and so are treated in a more conservative and often empiric fashion. Proposed therapies for these disorders are discussed.

[Chronic obstructive prostatitis]

The authors review current classifications of chronic prostatitis and propose their own classification which reflects routes of prostatic infection, division of infectious prostatitis into obstructive and non-obstructive forms, etiology of chronic prostatitis. Original methods and facilities for prostatic drainage via transurethral and transrectal approaches are described.

[Hyperbaric oxygenation in the treatment of patients with chronic congestive prostatitis and lower fertility]

Due to deteriorated demographic indices in the country, male infertility is a highly pressing problem. Chronic prostatitis is one of its causes. Hyperbaric oxygenation was used to affect male genital microcirculation, thus improving the spermatic morphological and functional characteristics. Positive effects of the method are ascribed not only to better microcirculation, but also to improved redox processes in spermatogenesis.

Effectiveness and limits of antimicrobial treatment on seminal leukocyte concentration and related reactive oxygen species production in patients with male accessory gland infection

To evaluate whether bacteriological cure, sperm outcome, spontaneous pregnancy rate and white blood cell (WBC)-related reactive oxygen species (ROS) production were related to the extent of the infection and to an intermittent and repetitive antimicrobial treatment, 122 patients with bacterial [>10(5) colony-forming units (CFU)/ml] male accessory gland infections (MAGI) were studied. According to ultrasound criteria, patients had prostatitis (PR, n = 52), prostatovesiculitis (PV, n = 32) or prostatovesiculoepididymitis (PVE, n = 38). Each group was further subdivided into two subsets: one subset (PR, n = 40; PV, n = 20; PVE, n = 25) was given ofloxacin or doxycycline for 14 consecutive days per month for 3 months; the other subset (PR, n = 12; PV, n = 12; PVE, n = 13) received no treatment. The female partners were also treated. All patients were evaluated before, during (1 and 3 months) and after (3 months) treatment. The bacteriological cure rate was the highest (92.5%) after the third antibiotic course in PR, followed by PV (70.4%), and the lowest in PVE (52.0%). At 3 months after therapy discontinuation, some sperm parameters, seminal WBC concentration and ROS generation (assessed in the 45% Percoll fraction) were ameliorated in PR and PV, whereas no improvement occurred in patients with PVE, except for the percentage of coiled tails. Antibiotic treatment in PR and PV patients led to positive effects on sperm output and spontaneous pregnancy rate (40%) by removing pro-oxidant noxae (microbial and/or WBC-related ROS production). The persistent infertility, dyspermia and sperm-derived ROS overproduction in PVE may relate to a significant percentage of antibiotic-independent re-infection and/or to low antioxidative epididymal properties, which persisted following antimicrobial treatment.

Ciprofloxacin as cure of premature ejaculation

This article presents the case report of a 31-year-old patient of mine with both an inflamed prostate gland and, unknown to his doctor, premature ejaculation, both of which were treated successfully by the antibiotic ciprofloxacin.

Short course oral prednisolone therapy in chronic abacterial prostatitis and prostatodynia: case reports of three responders and one non-responder

OBJECTIVE

To report on a small group of patients with chronic abacterial prostatitis/chronic pelvic pain syndrome treated with oral corticosteroids in order to suggest a hypothesis for a future randomised controlled trial.

DESIGN

A retrospective, observational report.

RESULTS

Three out of the four patients reported improvement in symptoms following steroid treatment.

CONCLUSIONS

These reports suggest that there is scope for conducting a randomised, placebo controlled study to investigate the role of oral corticosteroids in patients with chronic abacterial prostatitis/chronic pelvic pain syndrome who have failed on conventional therapy.

Cryptococcal prostatitis in a patient with chronic lymphocytic leukemia

Cryptococcosis is a systemic mycosis usually affecting patients of immunodeficiency i.e. transplants recipients, patients on chemotherapy for neoplastic diseases and in those suffering from human immunodeficiency virus infection. We report a 52-year old male suffering from chronic lymphocytic leukemia (CLL) on chemotherapy who presented with fever and features of prostatism. Cryptococcus neoformans infection (CN) was diagnosed on aspiration of a prostatic nodule. Subsequent investigations revealed a disseminated involvement by cryptococcus. The case represents an unusual presentation of disseminated cryptococcosis.

Pentosan polysulfate therapy for chronic nonbacterial prostatitis (chronic pelvic pain syndrome category IIIA): a prospective multicenter clinical trial

OBJECTIVES

Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CPPS) has clinical and perhaps etiologic characteristics similar to interstitial cystitis. Pentosan polysulfate sodium (PPS), an oral medication indicated for the treatment of interstitial cystitis, has shown moderate benefit in reducing chronic pelvic pain and voiding symptoms in patients with interstitial cystitis. We undertook a prospective open-label, multicenter Phase II pilot study to examine the potential efficacy of PPS in the treatment of CPPS in men, using outcome tools validated for CPPS in men.

METHODS

Patients with a diagnosis consistent with National Institutes of Health (NIH) CPPS category IIIA (inflammatory) were treated with PPS, 100 mg three times daily, for 6 months. The evaluation at baseline, 3 months, and 6 months consisted of the Symptom Severity Index, a Symptom Frequency Questionnaire, the NIH-Chronic Prostatitis Symptom Pain Index (NIH-CPSI), a quality-of-life assessment, and a subjective global assessment.

RESULTS

Thirty-two patients (mean age 45.5 +/- 11 years; duration of symptoms 9.2 +/- 12 years) were enrolled in five centers; 28 patients were available for evaluation. Seven patients experienced drug-related side effects, including hair loss (n = 2), headache (n = 2), mild nausea (n = 1), mild weight gain (n = 1), and skin flushing (n = 1). The decrease in frequency (Symptom Frequency Questionnaire 28.1 to 17.9), severity (Symptom Severity Index 53.6 to 36.3), and combined location/frequency/severity of pain (NIH-CPSI pain 14.5 to 9.2) symptom scores at 6 months compared with baseline was significant. The decrease was associated with a significant improvement in patients' quality of life (quality-of-life assessment 5.3 to 3.8). Forty-three percent of the patients had a greater than 50% improvement in the Symptom Frequency Questionnaire, Symptom Severity Index, and NIH-CPSI (rated as clinically significant improvement). At 6 months, mild, moderate, and marked improvement was noted (subjective global assessment) by 33%, 19%, and 15% of the patients, respectively.

CONCLUSIONS

PPS is well tolerated and appears to have efficacy in reducing the severity and frequency of general symptoms, reducing specific pain symptoms, and improving the quality of life in many male patients with CPPS. The results of this study justify the initiation of a randomized controlled trial comparing the safety and efficacy of PPS to placebo.

[Tamsulosin in the treatment of patients with chronic prostatitis]

Combined treatment including alpha-1a-adrenoreceptor blocker tamsulosine was given to 92 patients with chronic prostatitis having marked urination disorders (IPSS score 12.1 +/- 2.4). The response was achieved in 98.9% of cases. There was attenuation of the urination symptoms, speeding up of the maximal urine flow, decreased amount of the residual urine. It is recommended to add alpha-1-adrenoreceptors to combined treatment of chronic prostatitis patients with urination disorders.

IL-1beta and TNF-alpha in prostatic secretions are indicators in the evaluation of men with chronic prostatitis

PURPOSE

Chronic Prostatitis, or Chronic Pelvic Pain Syndrome [CPPS], is a common disorder characterized by pelvic pain and varying degrees of inflammation in expressed prostatic secretions (EPS). In search of markers to more clearly define CPPS, we compared proinflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) levels in EPS from men with CPPS, to healthy men and men with Benign Prostatic Hyperplasia (BPH).

METHODS

78 men: controls (n = 16), BPH (n = 14), CPPS IIIA [>/=10 white blood cells per high power field (WBC/hpf) in EPS] (n = 18), CPPS IIIB [<10 WBC/hpf in EPS] (n = 20), and asymptomatic inflammatory prostatitis (AIP) (n = 10) were evaluated for EPS WBC, and IL-1beta and TNF-alpha by ELISA.

RESULTS

IL-1beta and TNF-alpha levels in EPS were usually detectable in men with CPPS IIIA (89% and 45%, respectively) or AIP (90%; 100%), but less often in controls (31%; 17%), BPH (57%; 15%), and CPPS IIIB (35%; 15%) respectively. IL-1beta and TNF-alpha levels were higher in CPPS IIIA versus CPPS IIIB, and in AIP versus controls or BPH (p's <0.001). Cut-points for IL-1beta and TNF-alpha discriminated AIP from controls (predictive values = 94% and 83%, respectively) and CPPS IIIA from CPPS IIIB (predictive values 84% and 100%). Overall, there was a correlation between IL-1beta and TNF-alpha (p <0.003), but no correlation between WBC and IL-1beta (p <0.1) or TNF-alpha (p <0.50).

CONCLUSIONS

Cytokines are frequently present and elevated in the EPS from men with CPPS IIIA and AIP and provide a novel means for identification, characterization and potential management of men with CPPS that differs from traditional methods based on WBC.

Seminal oxidative stress in patients with chronic prostatitis

OBJECTIVES

An association between prostatitis and male infertility has been suspected, yet is poorly understood. Prostatitis is often associated with granulocytes in the prostatic fluid that generate reactive oxygen species (ROS), known to impair male fertility. We compared ROS, the total antioxidant capacity (TAC), and a novel index of oxidative stress (ROS-TAC score) in patients with chronic prostatitis and in healthy controls.

METHODS

Semen specimens from 36 men with chronic prostatitis (National Institutes of Health category IIIa), 8 men with prostatodynia (National Institutes of Health category IIIb), and 19 controls attending our urologic clinic were examined according to the World Health Organization criteria. Leukocytospermia was measured by the Endtz test (myeloperoxidase assay). ROS and TAC production was measured by chemiluminescence assay. A composite ROS-TAC score was also calculated in patients and controls.

RESULTS

The sperm concentration, percentage of motility, and morphology among the groups did not differ. The mean +/- standard error log-transformed ROS level was significantly higher in patients with leukocytospermia (3.2 +/- 0.6) than in patients without leukocytospermia (1.8 +/- 0.2; P = 0.04) and controls (1.3 +/- 0.3, P = 0.01). TAC was significantly lower in patients with or without leukocytospermia (859.69 +/- 193.0 and 914.9 +/- 65.2, respectively) than in controls (1653.98 +/- 93.6, P = 0.001). The mean ROS-TAC score of controls (50.0 +/- 4.1) was significantly higher than those of patients with chronic prostatitis and leukocytospermia (8.2 +/- 9.2) and those without leukocytospermia (34.2 +/- 2.9; P <0.001).

CONCLUSIONS

Men with chronic prostatitis or prostatodynia have seminal oxidative stress, irrespective of their leukocytospermia status. These observations may help shed light on the long-standing controversy surrounding prostatitis and infertility.

Treatment of prostatitis

The term prostatitis is applied to a series of disorders, ranging from acute bacterial infection to chronic pain syndromes, in which the prostate gland is inflamed. Patients present with a variety of symptoms, including urinary obstruction, fever, myalgias, decreased libido or impotence, painful ejaculation and low-back and perineal pain. Physical examination often fails to clarify the cause of the pain. Cultures and microscopic examination of urine and prostatic secretions before and after prostatic massage may help differentiate prostatitis caused by infection from prostatitis with other causes. Because the rate of occult infection is high, a therapeutic trial of antibiotics is often in order even when patients do not appear to have bacterial prostatitis. If the patient responds to therapy, antibiotics are continued for at least three to four weeks, although some men require treatment for several months. A patient who does not respond might be evaluated for chronic nonbacterial prostatitis, in which nonsteroidal anti-inflammatory drugs, alpha-blocking agents, anticholinergic agents or other therapies may provide symptomatic relief.

[The significance of the androgen-estrogen ratios in the clinical picture of sexual disorders in men]

Correlation interrelations between indices for SMF (sexual formula male proper) were studied together with values for testosterone in blood serum and testosterone-estradiol relations in 63 male subjects presenting with sexual problems of various genesis. No correlation was established between blood serum testosterone levels or testosterone-estradiol relations as well as between SMF indices characterizing the state of libido and erection both in cases of psychogenic sexual dysfunction and in those precipitated by prepubertal hypogonadism, insulin-dependent diabetes mellitus, and chronic prostatitis. It is only in those cases of the above-mentioned dysfunction related to chronic prostatitis that there exists a positive correlation between testosterone-estradiol ratio and SMF index characterizing ejaculation.

Prostate brachytherapy in patients with prior evidence of prostatitis

PURPOSE

To refute a misconception that a prior history of prostatitis is a contraindication to prostate brachytherapy.

METHODS AND MATERIALS

Five patients with clinical or pathologic evidence of prior prostatitis were treated with transperineal brachytherapy. Four of the patients received a single i.v. dose of ciprofloxacin (500 mg) intraoperatively. Postimplant antibiotics were not given. The pretreatment biopsy slides were reviewed.

RESULTS

Two of the five patients developed postimplant urinary retention requiring short-term catheterization, and both resolved spontaneously. One patient developed what appeared to be an exacerbation of his chronic prostatitis.

CONCLUSION

We continue to recommend prostate brachytherapy for the treatment of clinically organ-confined cancer, with no concern about prior clinical or pathologic evidence of prostatitis.

[Bacterial content of the enucleated prostate gland]

OBJECTIVE

To determine the prevalence of prostatic colonization or infection in patients undergoing prostatic surgery for obstructive symptoms due to benign hyperplasia of the prostate (BPH), to identify and quantitate the microorganisms isolated in quantitative bacterial tissue cultures, and to determine the influence of open surgery vs endoscopy on the microbiological findings.

METHODS

A prospective study was conducted on 175 patients undergoing surgery for BPH. All patients were entered into a study protocol that included quantitative bacterial cultures of prostatic tissue. Data of previously defined variables were entered into a data base for subsequent analysis comprised of redefinition of the variables and descriptive and analytical studies.

RESULTS

44 of the 175 patients (25.1%) had a positive bacterial culture of prostatic tissue. Histological lesions indicating prostatitis associated with BPH were found in 68 of the 175 patients (38.9%), regardless of the presence or absence of bacteria. Of these 68 patients with histologically demonstrated prostatic inflammation, only 19 (27.9%) had a positive prostatic tissue culture. The incidence of granulomatous prostatitis was 1.1%.

CONCLUSIONS

The presence of bacteria was demonstrated in prostates of a significant number of patients (25.1%) undergoing prostatectomy for BPH. The microorganisms most frequently isolated in the quantitative bacterial cultures were, by order of frequency, coagulase negative Staphylococci, Escherichia coli and Enterococcus faecalis, which were present in concentrations of at least 10(4) CFU/Gm in prostatic tissue of 79.6% of the cases. No differences were found between the type of procedure the patient underwent and the presence or absence of prostatic infection.

Relevance of male accessory gland infection for subsequent fertility with special focus on prostatitis

Infections of the male genitourinary tract may contribute to infertility to a various extent depending on the site of inflammation. Especially in prostatitis, the exact classification of the infection contributes to its impact on changes in the ejaculate. Similarly, in urethritis, epididymitis and orchitis, only a clear clinical diagnosis allows a rational approach to altered sperm parameters. Several inflammatory and reactive alterations of sperm quality seem to be proven; nevertheless, the impact of these findings on male fertility remains in many cases unclear. Even therapeutic trials do not provide more insights into the association of male genital infections and impaired fertility, although the efficacy of antibiotic trials seems to be proven. For the future, it may be decisive to evaluate inflammatory changes in the ejaculate not only on the basis of standard but also on functional parameters, thus providing new definitions of the interactions between male urogenital tract infection and disturbances of male fertility.

High-grade inflammation in prostate cancer as a prognostic factor for biochemical recurrence after radical prostatectomy. Pathologist Multi Center Study Group

OBJECTIVES

To assess the prognostic value of prostatic stromal inflammation in surgically treated localized prostate carcinoma for biochemical recurrence-free survival.

METHODS

Stromal prostatic inflammation grading was studied in 161 patients who underwent radical prostatectomy for prostate cancer without involvement of the lymph nodes and who did not receive preoperative or postoperative radiotherapy or hormonal therapy until recurrence occurred. Inflammation was graded as high-grade inflammation if confluence of inflammatory cell infiltrate and/or glandular epithelium disruption associated with interstitial inflammatory infiltrate were present and as low-grade inflammation otherwise. Each specimen was graded separately first in the stroma surrounding nonmalignant glands and second in the stroma surrounding malignant glands. Biochemical recurrence based on serum prostate-specific antigen (PSA) level was defined as two successive PSA measurements greater than 1 ng/mL.

RESULTS

Malignant tissue was significantly less involved in high-grade inflammation than benign adjacent tissue (9.3% and 19.9%, respectively; P <0.01). In a univariate Kaplan-Meier analysis, the 5-year recurrence-free survival rate for patients with high-grade and low-grade classified prostates was 61.0% and 66.7% in benign tissue and 27.0% and 65.3% in malignant tissue, respectively, with a significant difference between grades only in malignant tissue (P <0.02). In a multivariate analysis controlling for Gleason grade, preoperative serum PSA, pathologic stage, and inflammation grade in malignant tissue, the latter factor remained significantly predictive of biochemical recurrence (P = 0.03).

CONCLUSIONS

Patients with high-grade inflammation surrounding malignant glands in radical prostatectomy specimens had significantly more postoperative biochemical recurrence than patients with low-grade inflammation.

[Male urogenital amicrobial phlogosis: effects of the treatment with amtolmetin guacyl on some sperm parameters]

To examine if some inflammation-related sperm abnormalities were influenced by leucocytospermia (sWBC) alone, WBC-specific Radical oxygen species (WBC-ROS) over-production, and/or by different infected sexual gland sites and if these abnormalities were possibly reversible following treatment with an antiphlogistic drug, a total of 43 infertile male patients with amicrobial male accessory gland infections (MAGI) associated with prostatitis (P, n = 16), prostato-vesiculitis (PV, n = 14) or prostato-vesiculo-epididymitis (PVE, n = 13) as confirmed by ultrasound, were studied. The patients were then further subdivided into two subsets: one of the subsets (P, n = 10; PV, n = 8; PVE, n = 7) was administered amtolmetina guacyl (Eufans) 600 mg once daily for 14 consecutive days per month, for a 2-months period. The second subset (six patients for each category) received no treatment (matched-control). Mean outcome measures included a follow-up of sperm analysis with assessment of sperm forward motility (M), sperm viability (V). In addition, sWBC as well as basal and maximal fMLP-mediated WBC-ROS production were also carried out by conventional immunocytochemistry staining and chemiluminescence analysis respectively. In the pre-treatment, in all patients (treated and not treated subsets) median values of the sperm M and V were significantly different among categories (P > PV > PVE), and necrozoospermia (sperm viability < 25%) were present in the 70% out of group P patients and in all (100%) patients from groups PV and PVE. Median sWBC concentrations, elevated (values > 1 mil/ml) in all groups, in the PV and PVE groups were significantly higher compared to those found in the group P. Furthermore, PVE group generated baseline and fMLP-stimulated ROS productions from low density 45% Percoll fraction (Pc45), significantly higher than those found in P or PV groups. Sperm outcome measures were significantly different compared with the matched-controls (exhibiting 0% case-responders), in a time- and infected gland site-dependent manner. Thus, either in terms of median values and percentages of responders (defined as parameters ensued within the conventional normal range) sperm M and V percentages, as well as sWBC improved after the first (T1) antiphlogistic course in the group P only, but after the second (T2) antiphlogistic course in the other groups (PV or PVE). Moreover, treated patients of each group had amounts of generated basal and fMLP-stimulated ROS signals significantly reduced, with values ensued within a fertile control range at T2, in 80, 62.5 and 42.8% out of the P, PV and PVE groups respectively. We concluded that long-term amtolmetina-guacyl administration demonstrated efficacy and safety in the treatment of amicrobial MAGI, exhibiting a positive impact on all sperm parameters studied and no side-effects.