Prevalence of prostatitis-like symptoms in a population based study using the National Institutes of Health chronic prostatitis symptom index

PURPOSE

The National Institutes of Health (NIH) chronic prostatitis symptom index was used to determine the prevalence of prostatitis-like symptoms among men (age 20 to 74 years) at risk in a community based study.

MATERIALS AND METHODS

The study was a cross-sectional postal survey of men age 20 to 74 years in Lennox and Addington counties, which included a large rural area, 1 major town and a suburban area with a stable population of men representative of Canadian demographics. The questionnaire collected information on 2 domains of chronic prostatitis identified in the NIH chronic prostatitis symptom index, including pain (location, severity and frequency), voiding function (irritative, obstructive), demographics, quality of life, general health and health seeking behavior. The self-reported pain score was used to identify prostatitis-like symptoms in the most discriminating domain. Based on analysis of the index final validation study comparing patients with prostatitis to normal controls and those with benign prostatic hyperplasia, the 2 questions most specific for prostatitis, including perineal and/or ejaculatory pain/discomfort, and a total pain score (0 to 21) 4 or greater were used to identify men with significant prostatitis-like symptoms.

RESULTS

A total of 2,987 eligible men received the survey, and it was completed by 868 (29%). Of the men 84 (9.7%) were identified as having chronic prostatitis-like symptoms (mean NIH chronic prostatitis symptom index pain score 9.1 +/- 0.3). The average age of the prostatitis population was 50 years compared with 52 years for men without prostatitis-like symptoms. Prevalence was 11.5% in men younger than 50 years and 8.5% in men 50 years or older. Of the sampled population 57 (6.6%) men had prostatitis-like symptoms and an index pain score 8 or greater (moderate to severe). The index voiding score (0 to 10) was 4.1 +/- 0.5 in men younger than 50 years compared with 1.5 +/- 0.1 for normal controls, and 4.7 +/- 0.4 in those 50 years or older compared with 1.9 +/- 0.1 for normal controls. Of the prostatitis group 60% sought medical help for their symptoms.

CONCLUSIONS

In our opinion this community based study using the new prostatitis symptom index confirms that chronic prostatitis-like symptoms are common.

Human interleukin-1 beta and interleukin-1 receptor antagonist secretion and velocity of tooth movement

The cytokines interleukin-1 beta (IL-1 beta) and IL-1 receptor antagonist (IL-1RA) probably play a part in orthodontic tooth movement. Here, the force magnitudes and the area of force application in the compressed periodontal ligament (PDL) were controlled and the velocity of tooth movement correlated with concentrations of IL-1 beta and IL-1RA in the gingival crevicular fluid (GCF). Seven individuals undergoing orthodontic treatment involving maxillary first premolar extractions and distal movement (bodily retraction) of the maxillary canines participated in the 84-day study. For each participant, continuous retraction forces were applied so that they received equivalent PDL stresses of 13 kPa for one canine and 4 kPa for the other. GCF cytokine concentrations from experimental and control teeth were expressed relative to total protein in the GCF and compared using an 'Activity Index' (AI)=Experimental (IL-1 beta/IL-1RA)/Control (IL-1 beta/IL-1RA). The results showed that the velocity of tooth movement in an individual was related to their AI. The correlation between AI and tooth movement was stronger from the distal (R(d)=0.78) than from the mesial (R(m)=0.65) of retracted teeth. The results demonstrate that equivalent force systems produce individual differences in cytokine production, which correlate with interindividual differences in the velocity of canine retraction.

The effect of disc thickness and trauma on disc surface friction in the porcine temporomandibular joint

The pathomechanics of osteoarthritis in the human temporomandibular joint (TMJ) are unknown. Compromised lubrication is a potential factor, but, lubrication within even the normal TMJ is not understood completely. Weeping lubrication is a concept that may be applicable to the TMJ. A characteristic of weeping lubrication is a slow increase in friction during static loading. The rate of increase in friction is related to the rate of lateral movement of synovial fluid away from the loading area. The TMJ disc is expected to be the main source of TMJ lubrication. This study tested two variables, disc thickness and magnitude of trauma to the disc, as factors that can affect the rate of flow of synovial fluid and thus alter lubrication of the disc surfaces. To test these variables, TMJ disc surface friction was measured before and after an impulse load. Before the impulse load, all discs demonstrated a gradual increase in friction during light static loading. The rate of increase in friction was inversely related to the disc thickness (R(2)=0.75). After an impulse load of known magnitude and peak force, disc surface friction was higher. The magnitude of this surface friction was correlated with the magnitude of the impulsive blow (R(2)=0.89) and the area of surface damage (R(2)=0.85). Disc thickness was a significant factor in determining the minimal impulse needed to produce higher surface friction (R(2)=0.99). These results confirm that disc thickness and trauma to the disc affect surface friction in the TMJ, and therefore may be important factors in compromised lubrication and the development of osteoarthritis.

The information required by patients with early-stage prostate cancer in choosing their treatment

OBJECTIVE

To determine the information that men diagnosed with early-stage prostate cancer think is necessary to choose their treatment (surgery, radiotherapy or 'watchful waiting').

PATIENTS AND METHODS

All men diagnosed with early-stage prostate cancer in a regional urology practice in an 18-month period were surveyed. Respondents considered the treatment decision for a specific hypothetical case and judged whether each of 59 specific information items would be 'necessary' to know to make the treatment decision. Respondents provided basic demographic information (age, education and marital status).

RESULTS

Of 89 patients, 71 (80%) responded; the mean (SD, range) number of items that individual respondents identified as necessary was 32 (12, 9-58). Each item was considered necessary by 54 (18, 20-93)% of respondents. Of the 59 items, only five were necessary to > or = 80% of respondents; 23 were necessary to > or = 67% of respondents and five were not necessary to > or = 67% of respondents. Patients were divided about the remaining 31 items. There were no strong correlations (none accounted for > 20% of the variance) between the responses and demographic characteristics.

CONCLUSIONS

There appears to be large variation among patients with early-stage prostate cancer in the number of information items deemed necessary to make a treatment decision, and little agreement on the need for most individual items. Demographic characteristics were not useful as predictors of the information needs of each patient. The process of informing patients with early-stage prostate cancer (and their decision aids) needs to be flexible and able to accommodate a wide range of patients' information needs.

Interstitial cystitis. Etiology, diagnosis, and treatment

OBJECTIVE

To review current knowledge about the epidemiology, etiology, diagnosis, and treatment of interstitial cystitis, with special emphasis on management of this condition by family physicians.

QUALITY OF EVIDENCE

Articles were identified through MEDLINE and review of abstracts presented at Urology and Interstitial Cystitis meetings during the last decade. Recent reviews were further searched for additional studies and trials. Data were summarized from large epidemiologic studies. Etiologic theories were extracted from current concepts and reviews of scientific studies. Diagnostic criteria described in this review are based on clinical interpretation of National Institutes of Health (NIH) research guidelines, interpretation of data from the NIH Interstitial Cystitis Cohort Study, and recent evidence on use of the potassium sensitivity test. Treatment suggestions are based on six randomized placebo-controlled clinical treatment trials and best available clinical data.

MAIN MESSAGE

Interstitial cystitis affects about 0.01% to 0.5% of women. Its etiology is unknown, but might involve microbiologic, immunologic, mucosal, neurogenic, and other yet undefined agents. The diagnosis of interstitial cystitis is a diagnosis of exclusion. It is impossible to provide a purely evidence-based treatment strategy, but review of available evidence suggests that conservative supportive therapy (including diet modification); oral treatment with pentosan polysulfate, amitriptyline, or hydroxyzine; and intravesical treatments with heparinlike medications, dimethyl sulfoxide, or BCG vaccine could benefit some patients.

CONCLUSION

Family physicians should have an understanding of interstitial cystitis and be able to make a diagnosis and formulate an evidence-based treatment strategy for their patients.

Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention. Combined experience from three large multinational placebo-controlled trials

OBJECTIVES

We evaluated prostate volume and prostate-specific antigen (PSA) as predictors of acute urinary retention (AUR) in men with benign prostatic enlargement (BPE).

METHODS

Data were pooled from 3 identical 2-year, multinational, multicenter, non-US, placebo-controlled finasteride trials in 4,222 men with BPE and no evidence of prostate cancer.

RESULTS

The 2-year incidence of spontaneous AUR was higher in placebo patients with enlarged prostates (4.2% in men with prostate volume > or =40 ml vs. 1.6% in the <40 ml group) and higher PSA levels (3.9% in men with PSA > or =1.4 ng/ml vs. 0.5% in the <1.4 ng/ml group) at baseline. Finasteride reduced AUR incidence by 61% in men with larger prostates, by 63% in men with higher PSA levels, and by 47% in men with smaller prostates, compared with placebo.

CONCLUSIONS

BPE patients with larger prostate volumes, higher PSA levels and no evidence of prostate cancer have an increased risk of developing AUR and therefore derive the greatest benefit from the risk reduction seen with finasteride therapy.

Rat model of experimentally induced abacterial prostatitis

BACKGROUND

An experimental model in rats was developed to investigate the significance of mucosal integrity in abacterial prostatitis.

METHODS

Ethanol was instilled into the ventral prostates of male rats to reduce mucosal integrity; dinitrobenzenesulfonic acid (DNBS) was added as an irritant to induce inflammation. Controls received no treatment, ethanol only, DNBS only, or a suspension of bacteria. After various time points, rats were sacrificed, and their prostates were assayed for gross morphology, histological appearance, and cytokine levels.

RESULTS

Prostates subjected to ethanol plus DNBS showed significant inflammation, most notably after 12, 24, and 48 hr. Inflammation judged by gross and histological observations and interleukin-1beta levels correlated well at these times. Rats given only ethanol, DNBS, or no treatment, acting as negative controls, displayed little or no inflammation; rats given a bacterial suspension, acting as positive controls, showed inflammation consistent with past studies. Cytokine assays revealed raised interleukin-1beta levels in this model, while tumor necrosis factor-alpha remained at a basal level.

CONCLUSIONS

The loss of an intact mucosal surface in the prostate resulted in inflammation caused by an irritant. Interleukin-1beta appears to play a role in this inflammation, while tumor necrosis factor-alpha does not.

Stress-field translation in the healthy human temporomandibular joint

Movement over the surface of the temporomandibular joint (TMJ) disc produces tractional forces. These forces potentially increase the magnitude of shear stresses and contribute to wear and fatigue of the disc. Theoretically, tractional forces in all synovial joints are the result of frictional forces, due to rubbing of the cartilage surfaces, and plowing forces, due to translation of the stress-field through the cartilage matrix as the joint surface congruency changes during motion. For plowing forces to occur in the TMJ, there must be mediolateral translation of the stress-field as the condyle moves dorsoventrally during jaw function. To test whether mediolateral stress-field translation occurs in the intact TMJ, we measured stress-field position and translation velocities in ten normal individuals during rhythmic jaw opening and closing. Magnetic resonance imaging and jaw tracking were combined to animate the three-dimensional position of the stress-field between the articulating surfaces. This allowed for mediolateral translation velocity measurements of the centroid of the stress-field. The results showed that during jaw opening and closing at 0.5 Hz, the average peak mediolateral translation velocity was 35 +/- 17 mm/sec. When opening and closing increased to 1.0 Hz, the average peak velocity was 40 +/- 19 mm/sec. Theoretical model estimates of the work done during such translation ranged from 6 to 709 mJ between the individual joints studied. The potential clinical importance of this measure is that long-term exposure of the TMJ disc to high work may result in fatigue failure of the TMJ disc.

Prostatitis: the last frontier

Prostatitis, the neglected third disease (after benign prostatic hypertrophy and prostate cancer) is the last frontier of prostate disease. Innovative new research and clinical initiatives have revived urologists' interest in this difficult and frustrating disease. New funding initiatives, industry interest and powerful patient lobby groups have put this long-neglected syndrome back on the urologic agenda. Presented here is an inventory of what is and is not known about prostatitis. It is based on a review of the literature, undisputed facts, solid hypotheses, and common sense. Also offered is a series of personal challenges to the urologic community. As we enter the twenty-first century we must develop a rational management strategy for patients who present with symptoms of prostatitis.

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.

Treatment of refractory interstitial cystitis

Interstitial cystitis is the most therapeutically frustrating condition of the urinary tract. The vast array of treatments available clearly indicates that none is particularly effective. As the majority of patients fail to experience a significant and prolonged response to standard treatments, new options are frequently being developed. These include the oral administration of cimetidine, the intravesical use of hyaluronic acid and BCG, and total cystectomy with the formation of a continent urinary diversion. Unfortunately, the acceptance of many new treatments is based on incomplete evaluation, and this has resulted in a confusing array of disparate alternatives. Effective and durable treatment will not be available until the nature of the disease is better understood and the mechanisms of action of current therapies are elucidated.

Human tooth movement in response to continuous stress of low magnitude

Conventional orthodontic therapy often uses force magnitudes in excess of 100 g to retract canine teeth. Typically, this results in a lag phase of approximately 21 days before tooth movement occurs. The current project was undertaken to demonstrate that by using lower force magnitudes, tooth translation can start without a lag phase and can occur at velocities that are clinically significant. Seven subjects participated in the 84-day study. A continuous retraction force averaging 18 g was applied to 1 of the maxillary canines, whereas a continuous retraction force averaging 60 g was applied to the other. The magnitude was adjusted for each canine to produce equivalent compressive stresses between subjects. Estimated average compressive stress on the distal aspect of the canine teeth was 4 kPa or 13 kPa. The moment-to-force ratios were between 9 and 13 mm. Tooth movement in 3 linear and 3 rotational dimensions was measured with a 3-axis measuring microscope and a series of dental casts made at 1- to 14-day intervals. The results showed a statistical difference in the velocity of distal movement of the canines produced by the 2 stresses (P =.02). The lag phase was eliminated and average velocities were 0.87 and 1.27 mm/month for 18 and 60 g of average retraction force. Interindividual velocities varied as much as 3 to 1 for equivalent stress conditions. It was concluded that effective tooth movement can be produced with lower forces and that because loading conditions were controlled, cell biology must account for the variability in tooth velocities measured in these subjects.

What questions do patients with curable prostate cancer want answered?

PURPOSE

To determine the questions that recently diagnosed early-stage prostate cancer patients think should be addressed with patients like themselves.

STUDY POPULATION

56 patients diagnosed as having early-stage prostate cancer within the previous year.

METHODS

Surveys distributed to the patients included 93 questions that might be considered important. Respondents judged the importance (essential/desired/no opinion/avoid) of addressing each question, and indicated why those "essential" or "desired" were important.

RESULTS

38 patients (68%) responded. Agreement on question importance, overall, was rather poor (mean 41.6%, kappa 0.17). There were, however, 20 questions that at least 67% of the respondents agreed were essential to address and 12 that they agreed were not essential. No question was relevant to the treatment decisions of more than 50% of respondents, but 91 questions were relevant to at least one respondent's decision.

CONCLUSIONS

Although there was enough agreement to define a core set of questions that should be addressed with most patients, each of the remaining questions was also considered essential to some people. The core set, therefore, would not be adequate to satisfy any one patient's essential information needs. Whereas most questions would be needed to cover all patients' decision needs, only some are needed for any given patient. Such variability in information needs means that the subjective standard is the only viable legal standard for judging the adequacy of provision of information for the treatment decision.

Asymptomatic inflammation and/or infection in benign prostatic hyperplasia

OBJECTIVE

To determine the extent, pattern and clinical significance of asymptomatic histological inflammation and latent infection (National Institute of Health Category IV prostatitis) in benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

The study included 80 patients (from a cohort of 100 consecutive potentially eligible subjects) with a diagnosis of BPH, but no history or symptoms of prostatitis. Histological sections were obtained from specimens collected prospectively at transurethral resection of the prostate (TURP), immunostained for leukocyte common antigen and scanned using a computerized image-analysis system. Foci of inflammation were categorized as glandular, periglandular, stromal or peri-urethral, and the inflammatory cell density graded from 1 to 3. Relationships and correlations were calculated between the volume, degree and type of inflammation, presence and type of bacteria (culture of deep prostatic biopsies), the use of catheters and prostate specific antigen (PSA) levels.

RESULTS

Inflammation was identified in all patients but the mean tissue surface area involved was only 1.1% of the total specimen, with periglandular inflammation being the predominant pattern (0.5%). Of the prostate specimens, 44% showed bacterial growth (in 67% of the catheterized patients and 28% of those uncatheterized; 42% of patients were catheterized before TURP). There was no significant difference between any combination of inflammation pattern, volume or grade of inflammation in those catheterized or not (P=0.15) or culture-positive (pathogenic or not) and culture-negative cases (P=0.06). Neither total PSA or PSA density was significantly correlated (P>0.05) with the amount, degree or distribution of inflammation.

CONCLUSION

Prostatic inflammation is an extremely common histological finding in patients with symptoms of BPH who have no symptoms of prostatitis. There was no correlation between the degree and pattern of inflammation, catheterization, presence of bacteria, serum PSA or PSA density. The clinical significance of asymptomatic Category IV chronic prostatitis associated with BPH has yet to be determined.

Prostatitis: evolving management strategies

Concepts regarding the etiology, diagnosis, and management of prostatitis have changed more in the last 3 years than they have in the last 3 decades. Urologists (and all physicians) no longer need to avoid patients with this disease. It is hoped that the new management strategies that are evolving will eventually benefit the majority of patients sustaining prostatitis.

Specific mucosal immunity in the pathophysiology of bacterial prostatitis in a rat model

Mucosal immunity was established in the rat prostate by stimulating the common mucosal system through serosal exposure of formalin-killed Escherichia coli. Immunized but not sham-immunized rats developed bacterial specific IgG and IgA in prostatic fluid, and IgA in urine. Immunized (n = 21) and sham-immunized control rats (n = 30) were challenged by transurethral injection of E. coli into the prostate ducts. Mortality, gross and microscopic pathology, tissue bacterial counts, bacterial associated immunoglobulins, and antibody titers in serum and urine were assessed at 7 days following the challenge. Increased E. coli specific immunoglobulin titers were seen in immunized rats, and E. coli, but not Proteus, found in the prostates of immunized animals were coated with IgG and IgA. Immunization protected against toxaemia and septicemia, seen as a rare complication of acute prostatitis, but did not protect against acute prostatitis, nor alter the degree of tissue damage seen in the rat model.Key words: prostatitis, mucosal immunity, rat model.

Specific mucosal immunity in the pathophysiology of bacterial prostatitis in a rat model

Mucosal immunity was established in the rat prostate by stimulating the common mucosal system through serosal exposure of formalin-killed Escherichia coli. Immunized but not sham-immunized rats developed bacterial specific IgG and IgA in prostatic fluid, and IgA in urine. Immunized (n = 21) and sham-immunized control rats (n = 30) were challenged by transurethral injection of E. coli into the prostate ducts. Mortality, gross and microscopic pathology, tissue bacterial counts, bacterial associated immunoglobulins, and antibody titers in serum and urine were assessed at 7 days following the challenge. Increased E. coli specific immunoglobulin titers were seen in immunized rats, and E. coli, but not Proteus, found in the prostates of immunized animals were coated with IgG and IgA. Immunization protected against toxaemia and septicemia, seen as a rare complication of acute prostatitis, but did not protect against acute prostatitis, nor alter the degree of tissue damage seen in the rat model.

Repetitive prostatic massage therapy for chronic refractory prostatitis: the Philippine experience

Patients frustrated with failure of traditional therapy for prostatitis have traveled to the Philippines and elsewhere for repetitive prostatic massage combined with antibiotic therapy. The aim of our study was to evaluate prospectively the response of patients who traveled to Manila to undergo this treatment. Twenty-six patients consented and were registered by the Prostatitis Foundation (B.H.) and subsequently evaluated (J.C.N., J.D.) prior to and following treatment (A.E.F.). Evaluation at baseline and after treatment consisted of standardized history and previously validated prostatitis-specific Symptom Frequency Questionnaire (SFQ) and Symptom Severity Index (SSI), International Prostate Symptom Score (I-PSS) and Quality of Life (QoL) questionnaire, the O'Leary Sexual Function Inventory (SFI), and a Subjective Global Assessment (SGA). Treatment in Manila consisted of triweekly prostatic massage combined with specific culture directed and/or empirical antimicrobial therapy for 6 to 12 weeks. Twenty-two patients completed at least one follow-up assessment and 12 patients completed 2-year assessment (average follow-up of 17 months in 22 patients). There was a significant decrease in average symptom severity (SSI) by 4 months that continued for 2 years, but less improvement in symptom frequency (SFQ) and quality of life (QoL), and no significant improvement in voiding symptoms (I-PSS) or sexual function (SFI) at time of last assessment. Forty-six percent of the 22 evaluable patients had >60% decrease (significant improvement) in symptom severity (SSI), whereas 27% had similar significant improvement in frequency of symptoms (SFQ) when last assessed. Thirty-three percent reported marked subjective improvement (SGA) at last evaluation. Of the 12 patients who completed the 2-year follow-up, 5 of the original 26 had a significant and sustainable improvement in objective and subjective measurements of frequency and severity of symptoms. The combination of prostatic massage and antibiotics for treating difficult refractory cases of prostatitis may be promising, but its ultimate value needs to be confirmed. Studies in patients with less refractory and shorter duration disease may allow us to predict who will respond to this therapeutic approach.

The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network

PURPOSE

Chronic abacterial prostatitis is a syndrome characterized by pelvic pain and voiding symptoms, which is poorly defined, poorly understood, poorly treated and bothersome. Research and clinical efforts to help men with this syndrome have been hampered by the absence of a widely accepted, reliable and valid instrument to measure symptoms and quality of life impact. We developed a psychometrically valid index of symptoms and quality of life impact for men with chronic prostatitis.

MATERIALS AND METHODS

We conducted a structured literature review of previous work to provide a foundation for the new instrument. We then conducted a series of focus groups comprising chronic prostatitis patients at 4 centers in North America, in which we identified the most important symptoms and effects of the condition. The results were used to create an initial draft of 55 questions that were used for formal cognitive testing on chronic prostatitis patients at the same centers. After expert panel review formal validation testing of a revised 21-item draft was performed in a diverse group of chronic prostatitis patients and 2 control groups of benign prostatic hyperplasia patients and healthy men. Based on this validation study, the index was finalized.

RESULTS

Analysis yielded an index of 9 items that address 3 different aspects of the chronic prostatitis experience. The primary component was pain, which we captured in 4 items focused on location, severity and frequency. Urinary function, another important component of symptoms, was captured in 2 items (1 irritative and 1 obstructive). Quality of life impact was captured with 3 items about the effect of symptoms on daily activities. The 9 items had high test-retest reliability (r = 0.83 to 0.93) and internal consistency (alpha = 0.86 to 0.91). All but the urinary items discriminated well between men with and without chronic prostatitis.

CONCLUSIONS

The National Institutes of Health chronic prostatitis symptom index provides a valid outcome measure for men with chronic prostatitis. The index is psychometrically robust, easily self-administered and highly discriminative. It was formally developed and psychometrically validated, and may be useful in clinical practice as well as research protocols.

Research guidelines for chronic prostatitis: consensus report from the first National Institutes of Health International Prostatitis Collaborative Network

OBJECTIVES

The National Institutes of Health (NIH) organized the first International Prostatitis Collaborative Network workshop (November 5 and 6, 1998, Washington, DC) to address the confusion surrounding the diagnostic and treatment strategies in chronic prostatitis.

METHODS

A panel of North American and international urologic researchers, interested physicians, medical industry representatives, and patients were invited to participate and reviewed current definitions, classification systems, and recent epidemiologic and both published and "in progress" treatment studies.

RESULTS

A general concensus was developed for adoption of the following criteria for clinical studies in chronic prostatitis/chronic pelvic pain syndrome: (a) the NIH definition of chronic prostatitis/chronic pelvic pain syndrome; (b) the 1995 NIH Classification System; (c) the eligibility (inclusion/exclusion) criteria developed by the NIH Chronic Prostatitis Clinical Research Network; (d) the NIH Chronic Prostatitis Symptom Index. It was agreed that clinical treatment trials involving presently available, experimental, and theoretical therapeutic modalities be prioritized according to maximum potential benefits and that regulatory authorities (ie, Food and Drug Administration in the United States) consider major changes in the approval process for treatment modalities in chronic prostatitis.

CONCLUSIONS

Chronic prostatitis is a major health care issue. Standardization of definitions, classification, study design, and outcome parameters will promote rational and comparative evaluation of diagnostic and therapeutic strategies.

Impact of a shared decision-making program on patients with benign prostatic hyperplasia

OBJECTIVES

To determine patient views about the Shared Decision-Making Program (SDP), an interactive videodisk program designed to inform patients with benign prostatic hyperplasia (BPH) about their condition and treatment options and to determine its impact on perceived knowledge and treatment preference.

METHODS

Six hundred seventy-eight patients with symptomatic BPH from eight Canadian centers viewed the SDP. Before and after viewing the video, patients answered questionnaires designed to assess treatment preference, knowledge gained, and satisfaction with this educational format. A 1-year follow-up survey was also conducted.

RESULTS

Most patients showed a high desire for information and high satisfaction with the SDP; this satisfaction persisted at 1 year. Patients' self-reported knowledge increased significantly (P <0.0001). However, the SDP did not alter initial treatment preferences among those with already formed preferences, although it aided almost half of those initially undecided in forming a preference. Viewing the SDP also appeared to enhance the physician-patient relationship.

CONCLUSIONS

Patients saw the SDP as an effective method for teaching patients about BPH and the risks and benefits of various treatments, clarifying particular areas about which many patients appear to have a desire for more information than is often provided. Patients were enthusiastic about the educational value of the program, and their active participation in the decision-making process may actually enhance the physician-patient relationship. Contrary to other studies, we found no significant alterations in treatment preferences. Problems relating to the cost and timely updating of the software need to be addressed for these kinds of programs to realize their full potential.

Prostatitis unplugged? Prostatic massage revisited

Repetitive prostatic massage is not a new tool in the urologists' armatarium. Once the most popular therapeutic maneuver used to treat prostatitis, it was abandoned as primary therapy almost 3 decades ago. Based on experience reported outside North America and anecdotal experiences of some patients and their physicians, it may be making a comeback. Unfortunately, there are almost no prospective data that would substantiate a claim as to its effectiveness. This article discusses the historic aspects of prostatic massage, suggests possible mechanisms of action, and describes the opinions of North American urologists who are associated with academic clinical research centers and are universally acknowledged as experts in the diagnosis and treatment of prostatitis. At this time, the science of prostatic massage must rely on anecdotal experiences, small, uncontrolled studies, and perhaps somewhat biased opinions of the major thought leaders in the field of chronic prostatitis/chronic pelvic pain syndrome.

Medical therapy for BPH: expanding our treatment paradigm?

Medical therapy for relief of symptoms of benign prostatic hyperplasia (BPH) is now a clinical reality. The challenge for urologists treating BPH with medical therapy is how to rationally employ the two proven classes of medications,the alpha blockers and finasteride, in their practice. To accomplish this, we must critically examine the results of multiple important clinical BPH trials published over the last decade and examine the short and long term effect of the various available medical therapies on symptoms, objective progression and consequences of the disease process and whether evidence based indicators will allow us to choose appropriate therapies. It appears that we can rationalize our medical therapy decisions, taking into consideration severity of disease, prostate size (and perhaps PSA) and most importantly, the patients' longterm expectations for treatment outcome. But first physicians must decide for themselves whether to expand their treatment paradigm beyond short term symptom relief to encompass long term durability and even prevention of the consequences of the long term progression of BPH.

Perplexing problem of persistently painful prostatitis

Chronic prostatitis has been a perplexing problem for urologists for decades. This review explores the perils and pitfalls urologists encounter with epidemiology, etiology, classification, diagnosis, and treatment of this syndrome. The major question involves the problem of developing rational treatment plans for patients with a medical condition associated with genitourinary pain, variable voiding, and sexual dysfunction but no obvious and accepted etiology. Exciting, innovative, ongoing research does offer some solutions and management strategies that urologists can even now incorporate into their practice while waiting for the fundamental questions to be answered.

Diagnosis and treatment of prostatitis in Canada

OBJECTIVES

There is a general consensus among physicians that the present management of chronic prostatitis is dismal. We undertook a survey of Canadian primary care physicians (PCPs) and urologists to determine the degree and source of frustration and to analyze present practice patterns in this disease.

METHODS

Five thousand PCPs and all 545 Canadian urologists were asked to complete a comprehensive computer-assisted telephone survey that explored practice characteristics, attitudes, and diagnostic and treatment strategies in the management of prostatitis. Randomization of attribute banks, adherence to questionnaire routing, validation by on-site monitoring, and possible bias were addressed.

RESULTS

Completed interviews were obtained from 10% of PCPs and 28% of urologists. PCPs see on average 3.5 (median 2) patients with prostatitis per month and urologists see on average 21.8 (median 11) patients with prostatitis per month. All physicians experience significantly more frustration in treating prostatitis than they do in treating patients with benign prostatic hyperplasia (BPH) and prostate cancer, and they perceive that prostatitis affects patients' quality of life significantly more than BPH and almost as much as prostate cancer. The degree of frustration and unhappiness in dealing with prostatitis is driven by a lack of confidence and comfort in their ability to accurately diagnose and subsequently rationalize treatment. Most PCPs and urologists continue to employ steps in addition to history and physical examination to establish a diagnosis but only a few PCPs and a third of urologists use specific lower urinary tract cultures. Physicians tend to use trimethoprim or trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone as their usual first line therapy for chronic prostatitis. The most commonly used therapeutic strategy (40%) for chronic prostatitis was TMP-SMX as first line therapy and a fluoroquinolone as second line therapy.

CONCLUSIONS

There is widespread frustration, discomfort, and lack of confidence in both PCPs' and urologists' perceived ability to manage prostatitis. Physicians have expressed a desire for a better understanding of this disease, simpler and clearer diagnostic guidelines, and more rational treatment strategies.

What prostate cancer patients should know: variation in professionals' opinions

PURPOSE

This study was designed to determine what questions health-care professionals think should be addressed with curable prostate cancer patients before treatment decisions are made.

METHOD

A survey was distributed to radiation oncologists, urologists, medical oncologists, nurses and radiation therapy technologists (RTTs) involved in treating prostate cancer patients. Participants were asked to judge the importance of addressing each of 78 questions (essential/important/no opinion/avoid) with a described hypothetical patient prior to the treatment decision. Eighty participants were later selected at random for a retest.

RESULTS

The overall response rate was 55% (284/518) on the initial survey and 56% (45/80) on the retest. The relative importance of the various questions was similar across groups (r(76) ranged from 0.75 to 0.91, all P<0.001). Despite the between-group similarity, opinions within each group varied widely. For example, among oncologists, the number of questions deemed essential by individual respondents ranged from five to 69, with >90% respondent agreement on only 15 of the 78 questions. The extent of agreement was similar in the other groups. The retest showed that essential and important responses were reasonably stable, i.e. 92% of questions judged essential at one time were judged either essential (58%) or important (34%) at the other time.

CONCLUSIONS

Although the relative importance of addressing the various questions appears similar across the professional groups involved in the care of prostate patients, within each profession there seems to be little agreement. The lack of agreement includes both how many questions are essential to address and whether or not most individual questions are essential.

Effective office management of chronic prostatitis

Chronic prostatitis does not have to be a frustrating urologic office encounter. The empathetic urologist who is equally committed to all patients (including those with prostatitis), can achieve realistic improvement in symptoms with a simple and straightforward diagnostic and therapeutic strategy.

Transurethral radiofrequency hot balloon thermal therapy in chronic nonbacterial prostatitis

There is no universally successful therapy for chronic nonbacterial prostatitis. Successful outcomes of treatment have been independently reported with transurethral heat therapy and balloon dilation. The THERP transurethral "hot balloon" uses balloon dilation of the prostatic urethra and radiofrequency heating of the prostate. Patients with refractory chronic nonbacterial prostatitis were assessed with validated prostatitis-specific symptom indices prior to, 3, and 6 months after 900 seconds of THERP treatment. Although early results appeared promising the long-term results in four patients led to early termination of the study. Although one patient did have improvement at 6 months, no patient reported improvement at 9 months, and the adverse events (urinary retention, retrograde ejaculation, hematuria, urethral stricture, worsening of symptoms) of this treatment in prostatitis patients was significant. This study demonstrated no sustainable efficacy and substantial adverse effects for the use of combination balloon dilation and heat therapy for patients with chronic nonbacterial prostatitis.

Relative efficacy of various exogenous glycosaminoglycans in providing a bladder surface permeability barrier

PURPOSE

To investigate the relative efficacy of heparin (H), pentosanpolysulfate (PPS) and hyaluronic acid (HA) in preventing the absorption of 14C labeled urea in protamine pretreated bladders compared with saline pretreated control bladders.

MATERIALS AND METHODS

Control Group - Rabbit bladders were pretreated with phosphate buffered saline (PBS) followed by instillation of 14C-urea. Radioactivity was determined in blood, bladder and fluid drained from the bladder. Protamine Group - Bladders were pretreated with of PBS followed by protamine sulfate. The bladders were then treated with 14C-urea and radioactivity determined as above. GAG Groups - Bladders were pretreated with saline and protamine as described above followed by instillation of: Group 3A - HA, Group 3B - H and Group 3C - PPS. The bladders were then treated with 14C-urea and radioactivity determined as described above.

RESULTS

Protamine treated bladders demonstrated significantly more radioligand uptake in bladder tissue compared with control bladders. There was no significant difference in radioligand uptake in bladders treated with PPS and H compared with control. While not significantly different, there was considerably more radioligand concentration in the blood of rabbits with bladders treated with protamine and protamine-HA compared with those of control rabbits and those treated with protamine-PPS and protamine-H.

CONCLUSIONS

Exogenous GAG's are effective in providing an epithelial permeability barrier in protamine pretreated bladders. There is a difference in the relative efficacy of the various GAG's in producing this effect.

Long-term implications of medical therapy on benign prostatic hyperplasia end points

There is a progression over time of relevant measurable benign prostatic hyperplasia (BPH) end points including symptoms, flow rates, prostate size, complications such as acute urinary retention (AUR), and surgical rates. Only two classes of medical therapy, the alpha-blockers and a 5-alpha-reductase inhibitor, have shown unequivocal and consistent efficacy over placebo in 1-year studies. Both of these classes of medications have demonstrated relative long-term safety. Finasteride has been shown in three large, 2-year, randomized, controlled studies to be superior to placebo, and both finasteride and the alpha-blockers have demonstrated long-term efficacy and safety in open-label studies. The efficacy of finasteride is significantly enhanced when it is used in patients with large prostates. Long-term finasteride therapy also results in a significant reduction in the incidence of AUR and the need for surgery. Long-term medical therapy for BPH is effective and safe. Data are now available that allow clinicians to analyze the long-term risks and benefits of the various medical options and subsequently rationalize long-term therapy for individual patients.

Placebo therapy of benign prostatic hyperplasia: a 25-month study. Canadian PROSPECT Study Group

OBJECTIVE

To analyse the efficacy, correlations and adverse-event profile of placebo therapy from the initial placebo run-in period to beyond 2 years of treatment.

PATIENTS AND METHODS

The effects of placebo therapy on prostate size, maximum urinary flow rate (Qmax) and symptoms were analysed, and adverse drug experiences documented, for a period of 25 months in 303 patients randomized to the placebo arm of a controlled trial evaluating finasteride in the treatment of BPH (the Canadian PROSPECT study).

RESULTS

For all variables, the values during follow-up were significantly different from baseline (P < or = 0.001). Transrectal ultrasonography confirmed a progressive increase in prostate volume over 25 months (+8.4%) but Qmax improved for the first 5 months (to 1.4 mL/s over baseline) and remained 1.0 mL/s more than baseline at 25 months. The total symptom score improved by -2.9 points in the first 2 months on placebo and was ultimately 2.3 points below baseline at 25 months. The extent of the placebo response for symptoms (r=0.08, P=.180) and Qmax (r=0.04, P=0.550) was independent of age, but the response correlated with the initial severity of symptoms (r= -0.394, P < or = 0.001) and initial Qmax (r= -0.134, P=0.023). Patients with a prostate of < or = 40 mL had a clinically more important placebo response than those with larger prostates. In all, 246 patients (81.2%) reported adverse events thought to be secondary to placebo therapy. The most common complaint was urogenital (40.3%), specifically impotence (6.3%) and decreased libido (6.3%); 13.2% of patients discontinued placebo therapy because of significant adverse reactions.

CONCLUSIONS

Placebo therapy rapidly produces a significant improvement in Qmax and symptoms of BPH but also causes clinically important adverse effects. The beneficial effect fades but remains after 2 years.

Prostatitis: myths and realities

OBJECTIVES

To explore the myths surrounding the enigmatic syndrome that the urologic community has labeled as prostatitis and to determine the actual realities associated with this disease.

METHODS

A critical evaluation of the syndrome of prostatitis based on examination of the recent world literature, undisputed scientific facts, solid hypotheses, common sense, and the author's personal opinion.

RESULTS

The most common myths surrounding the importance, etiology, diagnosis, classification, and treatment of prostatitis are in fact merely myths. Recent research has led to a new awareness of the importance of prostatitis, new insights into its pathogenesis, improved disease classification and symptom assessment, and will ultimately lead to more rational diagnostic and treatment strategies.

CONCLUSIONS

The introduction of a new more rational classification system, the development and validation of reliable symptom assessment instruments, new funding initiatives by granting agencies and the pharmaceutical industry, and an awakening appeal for intellectual examination of this common prostate disease by academic urologists guarantees that prostatitis will find an important place on the urologic agenda as we enter the next millennium.

The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group

BACKGROUND

Finasteride is known to improve urinary symptoms in men with benign prostatic hyperplasia, but the extent to which the benefit is sustained and whether finasteride reduces the incidence of related events, including the need for surgery and the development of acute urinary retention, is not known.

METHODS

In this double-blind, randomized, placebo-controlled trial, we studied 3040 men with moderate-to-severe urinary symptoms and enlarged prostate glands who were treated daily with 5 mg of finasteride or placebo for four years. Symptom scores (on a scale of 1 to 34), urinary flow rates, and the occurrence of outcome events were assessed every four months in 3016 men. Prostate volume was measured in a subgroup of the men. Complete data on outcomes were available for 2760 men.

RESULTS

During the four-year study period, 152 of the 1503 men in the placebo group (10 percent) and 69 of the 1513 men in the finasteride group (5 percent) underwent surgery for benign prostatic hyperplasia (reduction in risk with finasteride, 55 percent; 95 percent confidence interval, 41 to 65 percent). Acute urinary retention developed in 99 men (7 percent) in the placebo group and 42 men (3 percent) in the finasteride group (reduction in risk with finasteride, 57 percent; 95 percent confidence interval, 40 to 69 percent). Among the men who completed the study, the mean decreases in the symptom score were 3.3 in the finasteride group and 1.3 in the placebo group (P<0.001). Treatment with finasteride also significantly improved urinary flow rates and reduced prostate volume (P<0.001).

CONCLUSIONS

Among men with symptoms of urinary obstruction and prostatic enlargement, treatment with finasteride for four years reduces symptoms and prostate volume, increases the urinary flow rate, and reduces the risk of surgery and acute urinary retention.

What the prostate cancer patient should know: variations in urologists' opinions

OBJECTIVES: To determine the questions that treating Ontario urologists think should be addressed with patients who have curable prostate cancer before treatment decisions are made. METHODS: All Ontario (Canada) urologists (179) were given a scenario describing a case of curable prostate cancer and asked to judge the importance, using one of four categories (essential/important/no opinion/avoid), of addressing each of 78 questions. RESULTS: Ninety-seven (54%) of urologists completed the survey. The questions identified most frequently as "essential" to address were: treatment-related incontinence rates (76%), cure rates (74%), treatment-related impotence rates (73%), right of refusal (71%), and mortality from watchful waiting (63%). The questions identified most frequently to "avoid" related to searching for the first medical centre (29%) and the number of prostate cancer patients cured by the physicians (16%). There was little agreement among the urologists on the importance of addressing most of the remaining questions (Average agreement 40.7%). CONCLUSIONS: Most urologists assign great importance to addressing questions related to major treatment morbidity and success rates. Beyond these few major categories, there is widespread disparity among urologists about what information the patient should know. This "information gap" presents an identifiable dilemma in our adherence to the ethical principles underpinning informed consent in patients with potentially curable prostate cancer.