Evaluation of the cytokines interleukin 8 and epithelial neutrophil activating peptide 78 as indicators of inflammation in prostatic secretions

Cytokine profiling of prostatic fluid from cancerous prostate glands identifies cytokines associated with extent of tumor and inflammation

BACKGROUND

Cytokines are key mediators of inflammation that may relate to prostate cancer initiation and progression, and that may be useful markers of prostatic neoplasia and related inflammation. In order to better understand the relationship between cytokines and prostate cancer, we profiled cytokines in prostatic fluids obtained from cancerous prostate glands and correlated them to both cancer status and inflammatory grade.

METHODS

Prostatic fluid was collected from fresh radical prostatectomy specimens and analyzed by cytokine antibody microarray. For comparison, cases were selected from patients with either minimal or extensive cancer volume on final pathology. Among the cytokines with the greatest difference between the tumor volume groups, eight had their levels quantitated by ELISA. In addition, the grade of prostatic inflammation by neutrophils, macrophages and lymphocytes was scored for each case and examined for correlations with cytokine levels.

RESULTS

Among 174 cytokines analyzed, HGF was the most increased (6.57-fold), and along with IL18Bpa was significantly elevated in patients with extensive disease compared to those with minimal disease. IL17, GITR, and ICAM-1 were elevated in specimens with significant neutrophilic inflammation into gland lumina, and IL18Bpa, IL17, GITR, and ICAM-1 were elevated in specimens with significant lymphocytic inflammation in prostatic stroma.

CONCLUSIONS

Prostatic fluid cytokines were identified that may be useful for early cancer detection and prognostication efforts and for assessment of prostatic inflammation, particularly if they can be found not only in prostatic fluids obtained ex vivo, but in expressed prostatic secretions or urine samples from men with prostates still in situ.

Mechanisms in prostatitis/chronic pelvic pain syndrome

PURPOSE

We reviewed the current literature on mechanisms involved in the pathogenesis of prostatitis/chronic pelvic pain syndrome (CPPS).

MATERIALS AND METHODS

A literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine.

RESULTS

National Institutes of Health categories I and II prostatitis result from identifiable prostatic infections, whereas patients with category IV are asymptomatic. The majority of symptomatic cases are category III or chronic prostatitis (CP)/CPPS. The etiology of CP/CPPS is unknown. The traditional marker of inflammation, namely white blood cells in prostatic fluids, does not correlate with the predominant symptom of pelvic pain. An imbalance toward increased proinflammatory and decreased anti-inflammatory cytokines has been implicated and a few studies have shown some correlation of this with pelvic pain. The imbalance in some men may result from polymorphisms at the cytokine loci. An autoimmune process may be involved and experimental evidence indicates that this can be under hormonal influence. Recent findings include possible defects in the androgen receptor. The prostate may not even be the source of the symptoms. Pelvic pain also correlates with the neurotrophin nerve growth factor implicated in neurogenic inflammation and central sensitization. Finally, psychological stress may produce measurable biochemical changes and influence the other processes. The role of normal prostatic bacterial flora in inciting the inflammatory response has also been reconsidered.

CONCLUSIONS

The symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

Epidemiology and evaluation of chronic pelvic pain syndrome in men

Chronic pelvic pain syndrome (CPPS), formerly known as chronic abacterial prostatitis, is characterised by pelvic or perineal pain without evidence of urinary tract infection. It manifests as pain in a variety of areas including the perineum, rectum, prostate, penis, testicles and abdomen [Litwin MS, McNaughton-Collins M, Fowler Jr FJ, Nickel JC, Calhoun EA, Pontari MA, et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999;2:369-75]. It is also frequently associated with symptoms including urinary urgency, frequency, hesitancy and poor or interrupted flow. CPPS may be associated with white cells in the prostatic secretions (inflammatory) (NIH-3A), or white cell absence in the prostatic secretions (non-inflammatory) (NIH-3B) [Krieger JN, Nyberg Jr L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999;3:236-7].

Monocyte chemoattractant protein-1 and macrophage inflammatory protein-1alpha as possible biomarkers for the chronic pelvic pain syndrome

PURPOSE

The chronic pelvic pain syndrome is characterized by pelvic pain, voiding symptoms and varying degrees of inflammation within expressed prostatic secretions. We evaluated the chemokines monocyte chemoattractant protein 1 (CCL2) and macrophage inflammatory protein-1alpha (CCL3) in expressed prostatic secretions to identify marker increases associated with inflammatory (IIIA) and noninflammatory (IIIB) chronic pelvic pain syndrome. In addition, chemokine levels were correlated with clinical pain as determined by the National Institutes of Health chronic prostatitis symptom index.

MATERIALS AND METHODS

Expressed prostatic secretions were collected by digital rectal examination, and evaluated by enzyme linked immunosorbent assays for monocyte chemoattractant protein 1 and macrophage inflammatory protein-1alpha in 154 patients including controls (13), those with benign prostatic hyperplasia (54), chronic pelvic pain syndrome IIIA (37) and IIIB (50). Monocyte chemoattractant protein 1 and macrophage inflammatory protein-1alpha levels were compared between IIIA, IIIB and the control subgroups, and correlated against the chronic prostatitis symptom index and pain subscore using a Spearman test.

RESULTS

Mean levels of monocyte chemoattractant protein 1 in the control, inflammatory benign prostatic hyperplasia, noninflammatory benign prostatic hyperplasia, inflammatory chronic pelvic pain syndrome and noninflammatory chronic pelvic pain syndrome were 599.4, 886.0, 1,636.5, 3,261.2 and 2,272.7 pg/ml, respectively. Mean levels of macrophage inflammatory protein-1alpha in the control, inflammatory benign prostatic hyperplasia, noninflammatory benign prostatic hyperplasia, IIIA chronic pelvic pain syndrome and IIIB chronic pelvic pain syndrome were 140.1, 299.4, 238.7, 1,057.8 and 978.4 pg/ml, respectively. For each cytokine both chronic pelvic pain syndrome subtypes had statistically higher levels than the control group and patients with benign prostatic hyperplasia (p = 0.0002). Receiver operating curves using monocyte chemoattractant protein 1 levels greater than 704 pg/ml and macrophage inflammatory protein-1alpha greater than 146 pg/ml identified patients with chronic pelvic pain syndrome with an accuracy of 90% from control patients. Macrophage inflammatory protein-1alpha levels (p = 0.0007) correlated with the pain subscore of the chronic prostatitis symptom index while monocyte chemoattractant protein 1 (p = 0.71) did not.

CONCLUSIONS

Monocyte chemoattractant protein 1 and macrophage inflammatory protein-1alpha within the prostatic fluid in both chronic pelvic pain syndrome subtypes provide candidate future biomarkers for chronic pelvic pain syndrome. In addition, macrophage inflammatory protein-1alpha increase in expressed prostatic secretions provides a new marker for clinical pain in chronic pelvic pain syndrome patients. Given these findings prostatic dysfunction likely has a role in the pathophysiology of this syndrome. These chemokines may serve as effective diagnostic markers and modulators against the chemokines could provide an attractive treatment strategy in individuals with chronic pelvic pain syndrome.

Pilot and feasibility study of serum chemokines as markers to distinguish prostatic disease in men with low total serum PSA

BACKGROUND

The incidence and prevalence of both benign prostatic hypertrophy (BPH) and prostate cancer (PCa) increase with the aging process. Our laboratory recently showed that the chemokines CXCL5 and CXCL12, which normally function as inflammatory mediators, are secreted at higher levels by aging prostate stromal fibroblasts and elicit proliferative responses from both prostate stromal fibroblast and epithelial cells. Because both CXCL5 and CXCL12 are secreted molecules, we hypothesized that their levels in patient serum might serve as biomarkers to distinguish between BPH and PCa.

METHODS

Serum CXCL5 and CXCL12 levels were determined using sandwich ELISAs for 51 men demonstrating low serum PSA values of < or =10 ng/ml who underwent diagnostic needle biopsy for the detection of PCa. The bivariate relationship of circulating chemokine levels, age, and disease status in the prostate was tested using the Wilcoxon rank-sum test.

RESULTS

Total serum CXCL12 levels were significantly higher for men who were biopsy positive compared to those who were biopsy negative for cancer and histological prostatitis (P = 0.050). Among men who were biopsy negative for PCa, total serum CXCL5 levels were inversely associated with prostate volume and were significantly higher in men with concomitant BPH and histological prostatitis compared to those without evidence of prostatic disease (P < 0.003).

CONCLUSIONS

The results of this pilot and feasibility study suggest that serum or plasma CXCL5 and CXCL12 levels may potentially distinguish between BPH and PCa among patients presenting with low serum PSA, and may be useful toward facilitating decisions to perform diagnostic needle biopsy in this patient population.

Abrogation of TGF beta signaling in mammary carcinomas recruits Gr-1+CD11b+ myeloid cells that promote metastasis

Aberrant TGFbeta signaling is common in human cancers and contributes to tumor metastasis. Here, we demonstrate that Gr-1+CD11b+ myeloid cells are recruited into mammary carcinomas with type II TGF beta receptor gene (Tgfbr2) deletion and directly promote tumor metastasis. Gr-1+CD11b+ cells infiltrate into the invasive front of tumor tissues and facilitate tumor cell invasion and metastasis through a process involving metalloproteinase activity. This infiltration of Gr-1+CD11b+ cells also results in increased abundance of TGF beta 1 in tumors with Tgfbr2 deletion. The recruitment of Gr-1+CD11b+ cells into tumors with Tgfbr2 deletion involves two chemokine receptor axes, the SDF-1/CXCR4 and CXCL5/CXCR2 axes. Together, these data indicate that Gr-1+CD11b+ cells contribute to TGFbeta-mediated metastasis through enhancing tumor cell invasion and metastasis.

Genetic variability in inflammation pathways and prostate cancer risk

Genetic susceptibility to prostate cancer has been consistently observed by a large number of studies. Recently, several pieces of evidence obtained from epidemiological and pathological studies support that chronic inflammation in prostate tissues may play a role in prostate cancer development. Multiple genes that play critical roles in inflammatory pathways have been associated with prostate cancer risk. In this article we review the key genetic findings of the associated genes. This includes 2 genes identified through family studies, ribonuclease L (RNASEL) and macrophage scavenger receptor 1 (MSR1), as well as a number of genes suggested by case-control studies, such as macrophage inhibitory cytokine-1 (MIC-1), interleukins (IL-8, IL-10), vascular endothelial growth factor (VEGF), intercellular adhesion molecule (ICAM), and Toll-like receptors (TLR-4, TLR-1-6-10 gene cluster). Overall, recent studies seem to suggest multiple genes work together to increase prostate risk, and this is consistent with the reality that inflammation is a very complex process. Thus, future studies are expected to place an emphasis on the study of gene-gene interactions. Advances in high throughput genotyping, data mining, and algorithm development are needed in order to produce interpretable results.

Spontaneous and Prostatic Steroid Binding Protein Peptide-Induced Autoimmune Prostatitis in the Nonobese Diabetic Mouse

Chronic nonbacterial prostatitis is a poorly defined syndrome of putative autoimmune origin. To further understand its pathogenesis, we have analyzed autoimmune prostatitis in the NOD mouse, a strain genetically prone to develop different organ-specific autoimmune diseases. Spontaneous development of autoimmune prostatitis in the NOD male, defined by lymphomonuclear cell infiltration in the prostate gland, is well-established by approximately 20 wk of age and is stably maintained afterward. Disease development is indistinguishable in NOD and NOR mice, but is markedly delayed in IFN-gamma-deficient NOD mice. A T cell response to the prostate-specific autoantigen prostatic steroid-binding protein (PSBP) can be detected in NOD males before development of prostate infiltration, indicating lack of tolerance to this self Ag. The intraprostatic inflammatory infiltrate is characterized by Th1-type CD4(+) T cells, which are able to transfer autoimmune prostatitis into NOD.SCID recipients. We characterize here experimental autoimmune prostatitis, detected by intraprostatic infiltrate and PSBP-specific T cell responses, induced in 6- to 8-wk-old NOD males by immunization with synthetic peptides corresponding to the C1 subunit of PSBP. Three PSBP peptides induce in NOD mice vigorous T and B cell responses, paralleled by a marked lymphomononuclear cell infiltration in the prostate. Two of these peptides, PSBP(21-40) and PSBP(61-80), correspond to immunodominant self epitopes naturally processed in NOD mice after immunization with PSBP, whereas peptide PSBP(91-111) represents a cryptic epitope. These model systems address pathogenetic mechanisms in autoimmune prostatitis and will facilitate testing and mechanistic analysis of therapeutic approaches in this condition.

Treatment of experimental autoimmune prostatitis in nonobese diabetic mice by the vitamin D receptor agonist elocalcitol

On the basis of on the marked inhibitory activity of the vitamin D receptor agonist Elocalcitol on basal and growth factor-induced proliferation of human prostate cells and on its potent anti-inflammatory properties, we have tested its capacity to treat experimental autoimmune prostatitis (EAP) induced by injection of prostate homogenate-CFA in nonobese diabetic (NOD) mice. Administration of Elocalcitol, at normocalcemic doses, for 2 wk in already established EAP significantly inhibits the intraprostatic cell infiltrate, leading to a profound reduction in the number of CD4(+) and CD8(+) T cells, B cells, macrophages, dendritic cells, and I-A(g7)-positive cells. Immunohistological analysis demonstrates reduced cell proliferation and increased apoptosis of resident and infiltrating cells. Significantly decreased production of the proinflammatory cytokines IFN-gamma and IL-17 is observed in prostate-draining lymph node T cells from Elocalcitol-treated NOD mice stimulated by TCR ligation. In addition, Elocalcitol treatment reduces IFN-gamma production by prostate-infiltrating CD4(+) T cells and draining lymph node T cells specific for an immunodominant peptide naturally processed from prostate steroid-binding protein, a prostate-specific autoantigen. Finally, CD4(+) splenic T cells from Elocalcitol-treated NOD mice show decreased ability, upon adoptive transfer into NOD.SCID recipients, to induce autoimmune prostatitis, paralleled by a reduced capacity to produce IFN-gamma in response to prostate steroid-binding protein. The results indicate that Elocalcitol is able to interfere with key pathogenic events in already established EAP in the NOD mouse. These data show a novel indication for vitamin D receptor agonists and indicate that treatment with Elocalcitol may inhibit the intraprostatic inflammatory response in chronic prostatitis/chronic pelvic pain syndrome patients.

Experimental rodent models of prostatitis: limitations and potential

Prostatitis is a polyetiological inflammation of the prostate gland in men characterized by pelvic pain, irritative voiding symptoms, and sexual dysfunction. Histologically prostatitis is characterized by poly- and mononuclear cell infiltrates (neutrophils, lymphocytes, macrophages and plasma cells) in the stromal connective tissue around the acini or ducts. Prostatitis is an important worldwide health problem in men. The pathogenesis and diagnostic criteria for the condition are obscure, with the result that the development of management programs for this condition has been hindered. Animal model(s) might be useful in elucidating mechanisms involved in the molecular pathogenesis of chronic nonbacterial prostatitis and chronic pelvic pain syndrome. Given that prostatitis might have a multifactorial etiology, several animal models with unique features may prove helpful. This review examines a number of experimental rodent models of prostatitis and evaluates their advantages and limitations.

The 6-fluoro-8-methoxy quinolone gatifloxacin down-regulates interleukin-8 production in prostate cell line PC-3

Fluoroquinolones exhibit immunomodulatory effects on monocytes and macrophages, in addition to their bactericidal activities. It remains unknown even whether the quinolones act directly on the prostate. This study was based on the understanding of the molecular mechanisms of the actions of the fluoroquinolones that can be used for the treatment of chronic prostatitis/chronic pelvic pain syndrome. We investigated whether the 6-fluroro-8-methoxy quinolone gatifloxacin (GFLX) affected the production and secretion of interleukin-8 (IL-8) in the prostate cell line PC-3. GFLX decreased the level of IL-8 release from unstimulated PC-3 cells. GFLX also attenuated IL-8 secretion from PC-3 cells stimulated with peptidoglycan, Mycoplasma hominis, phorbol ester, and tumor necrosis factor alpha (TNF-alpha), indicating that GFLX exhibits an anti-inflammatory effect on the prostate cell line. However, GFLX failed to alter activation of the NF-kappaB and AP-1 elicited by these stimulants. GFLX significantly attenuated the expression of IL-8 mRNA in TNF-alpha-stimulated PC-3 cells and down-regulated the transcriptional activity of the 5'-flanking region of the IL-8 gene from -1481 to +44 bp. The deletion construct without the 5'-flanking region from -1481 to -170 bp but not the construct without the region from -1481 to -188 bp reversed the suppressive effect of GFLX on IL-8 promoter activity. These results demonstrate that GFLX suppresses IL-8 expression in the prostate cell line by decreasing the promoter activity of the IL-8 gene.

Seminal plasma cytokines and chemokines in prostate inflammation: interleukin 8 as a predictive biomarker in chronic prostatitis/chronic pelvic pain syndrome and benign prostatic hyperplasia

OBJECTIVE

This prospective study quantified cytokine and chemokine levels in seminal plasma of patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and benign prostatic hyperplasia (BPH), to evaluate inflammatory mediators as possible surrogate markers for diagnosis and treatment efficacy.

METHODS

Seminal plasma levels of eight cytokines and nine chemokines were evaluated by multiplex arrays in 83 men: 20 healthy controls and 9 men with CP/CPPS IIIA, 31 with CP/CPPS IIIB, and 23 with BPH. Prostate samples obtained by transurethral resection of the prostate from 13 patients with BPH were analysed by immunohistochemistry to detect interleukin 8 (IL-8)-producing cells and characterise inflammatory infiltrates.

RESULTS

Significantly increased levels of cytokines (IL-1alpha, IL-1beta, IL-6, IL-10, IL12p70) and chemokines (CCL1, CCL3, CCL4, CCL17, CCL22, CXCL8/IL-8) were observed in seminal plasmas from patients with CP/CPPS or BPH. However, only IL-8 was significantly elevated compared to controls (median [quartiles] 1984 [1164-2444] pg/ml), in patients with CP/CPPS IIIA (15,240 [10,630-19,501] pg/ml; p<0.0001), CP/CPPS IIIB (2983 [2033-5287] pg/ml; p=0.008), and BPH (5044 [3063-11,795] pg/ml, p<0.0001), discriminating CP/CPPS IIIA versus IIIB (accuracy=0.882+/-0.078; p=0.001). Inflammatory infiltrates were detected in prostate samples from 13 of 13 BPH patients, and IL-8-producing prostate cells in 11 of 13 samples. IL-8 concentration in seminal plasma was positively correlated with symptom score and prostate-specific antigen levels both in CP/CPPS and BPH patients.

CONCLUSIONS

IL-8 is expressed in situ by epithelial and stromal prostate cells and is functional, as shown by recruitment of cells expressing cognate receptors in BPH prostate tissue, indicating its involvement in disease pathogenesis. Among all the cytokines and chemokines analysed, IL-8 appears to be the most reliable and predictive surrogate marker to diagnose prostate inflammatory conditions, such as CP/CPPS and BPH.

Prostatitis/chronic pelvic pain syndrome

We review the diagnosis, categorization, and treatment of prostatitis/chronic pelvic pain syndrome based on the National Institutes of Health (NIH) classification. Prostatitis is an extremely common syndrome that afflicts 2%-10% of men. Formerly a purely clinical diagnosis, prostatitis is now classified within a complex series of syndromes (NIH category I-IV prostatitis) that vary widely in clinical presentation and response to treatment. Acute bacterial prostatitis (category I) and chronic bacterial prostatitis (category II) are characterized by uropathogenic infections of the prostate gland that respond well to antimicrobial treatment. In contrast, chronic prostatitis/chronic pelvic pain syndrome (category III), which accounts for 90%-95% of prostatitis cases, is of unknown etiology and is marked by a mixture of pain, urinary, and ejaculatory symptoms with no uniformly effective therapy. Asymptomatic inflammatory prostatitis (category IV) is an incidental finding of unknown clinical significance. This review describes the current status of prostatitis syndromes and explores the future prospects of new diagnostic tools and therapies.

Interleukin-8 levels in seminal plasma in chronic prostatitis/chronic pelvic pain syndrome and nonspecific urethritis

OBJECTIVE

To investigate whether a range of cytokines were detectable in the seminal plasma and urine of men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and nonspecific urethritis (NSU), and whether cytokine levels correlated with symptom severity in CP/CPPS.

PATIENTS AND METHODS

In all, 87 men participated, 33 with CP/CPPS, 31 with NSU, and 23 controls. Interleukin (IL)-1beta, IL-2, IL-6, IL-8 and IL-10 were measured in seminal plasma and first pass urine, and the results were correlated with scores for pain, urinary symptoms and quality-of-life impact using a validated symptom index, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI).

RESULTS

Seminal plasma levels of IL-8 were higher in men with CP/CPPS and NSU than in controls (P < 0.001), and the levels correlated with NIH-CPSI symptom scores in men with CP/CPPS. There were no significant differences in urinary IL-8 levels in the three groups, and no significant differences in levels of the other cytokines in either semen or urine.

CONCLUSION

Semen IL-8 levels correlate with subjective symptoms in men with CP/CPPS. IL-8 might contribute to the pathophysiology of CP/CPPS and NSU, and elevated levels might be a useful marker of the condition.

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.

Mechanisms in prostatitis/chronic pelvic pain syndrome

PURPOSE

We reviewed the current literature on mechanisms involved in the pathogenesis of prostatitis/chronic pelvic pain syndrome (CPPS).

MATERIALS AND METHODS

A literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine.

RESULTS

National Institutes of Health categories I and II prostatitis result from identifiable prostatic infections, whereas patients with category IV are asymptomatic. The majority of symptomatic cases are category III or chronic prostatitis (CP)/CPPS. The etiology of CP/CPPS is unknown. The traditional marker of inflammation, namely white blood cells in prostatic fluids, does not correlate with the predominant symptom of pelvic pain. An imbalance toward increased proinflammatory and decreased anti-inflammatory cytokines has been implicated and a few studies have shown some correlation of this with pelvic pain. The imbalance in some men may result from polymorphisms at the cytokine loci. An autoimmune process may be involved and experimental evidence indicates that this can be under hormonal influence. Recent findings include possible defects in the androgen receptor. The prostate may not even be the source of the symptoms. Pelvic pain also correlates with the neurotrophin nerve growth factor implicated in neurogenic inflammation and central sensitization. Finally, psychological stress may produce measurable biochemical changes and influence the other processes. The role of normal prostatic bacterial flora in inciting the inflammatory response has also been reconsidered.

CONCLUSIONS

The symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.

NIDDK-sponsored Chronic Prostatitis Collaborative Research Network (CPCRN) 5-year data and treatment guidelines for bacterial prostatitis

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a disabling condition that is poorly understood. The National Institutes of Diabetes and Digestive and Kidney Diseases-sponsored Collaborative Research Network has developed a symptom index, formed a cohort study, a case control study, a full-scale randomised clinical trial, a resource utilisation study and clinical trials, as well as basic research studies, in an effort to better understand and manage patients with this condition. Cohort, case control and resource utilisation studies have confirmed the substantial impact of CP/CPPS. Clinical trials in basic research suggest that anti-inflammatory therapy and alpha-blocker therapy may be effective. The minority of patients with acute or chronic bacterial prostatitis continues to respond favourably to oral fluoroquinolone therapy.

Chronic prostatitis/chronic pelvic pain syndrome in elderly men: toward better understanding and treatment

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common of the prostatitis syndromes. It is characterised by pelvic pain, with or without voiding symptoms. CP/CPPS accounts for 2 million office visits in the US alone. Recent epidemiological studies have shown that CP/CPPS can affect men at any age, including those in their 80s. The aetiology is unknown but proposals include infectious, autoimmune, neurologic and psychiatric causes. Men with CP/CPPS are much more likely to have had a past medical history of cardiovascular, neurologic, psychiatric or infectious disease (particularly sinusitis) as compared with asymptomatic individuals. Although leucocytes are commonly found in the prostatic fluid of these men, they do not correlate with the symptoms. The clinical evaluation now includes a validated, self administered symptom score, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), which was designed as an outcome measure for treatment trials. This can aid in diagnosis and follow-up of patients' response to therapy. Treatment for CP/CPPS is empiric and limited by a lack of randomised, placebo-controlled clinical trials. Antimicrobials are commonly used to treat the symptoms of CP/CPPS. However, the finding that asymptomatic men have equal or greater numbers of bacteria which localise to the prostatic fluid, compared with men with CP/CPPS, has raised doubts about the contribution of infection to the symptoms. Other commonly used drugs include alpha-adrenoceptor antagonists, anti-inflammatory drugs, tricyclic antidepressants and anticholinergic agents. The adverse effects of these medications are a concern in older men with CP/CPPS. Other therapies available include minimally invasive procedures such as microwave thermotherapy and transurethral needle ablation, and now neuromodulation devices.Although much progress has been made, particularly in the last 7 years, considerable work still remains to be done to determine the aetiology and pathogenesis of CP/CPPS, and to develop mechanism based therapy that is shown to be effective in controlled trials.

Antiproliferative factor, heparin-binding epidermal growth factor-like growth factor, and epidermal growth factor in men with interstitial cystitis versus chronic pelvic pain syndrome

OBJECTIVES

To determine whether men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) have urine markers previously described for patients with interstitial cystitis (IC; presence of antiproliferative factor [APF] activity, decreased levels of heparin-binding epidermal growth factor-like growth factor [HB-EGF], and increased levels of epidermal growth factor).

METHODS

Clean catch urine specimens were collected from 41 symptomatic patients with CP/CPPS, 36 asymptomatic men without bladder disease who served as the control group, and 24 men with IC. APF activity was determined by (3)H-thymidine incorporation into primary normal adult human bladder epithelial cells. HB-EGF and epidermal growth factor levels were determined by enzyme-linked immunosorbent assay.

RESULTS

Men with CP/CPPS did not differ significantly from asymptomatic controls for any of the three markers tested (P >0.49). In contrast, APF activity was present significantly more often and HB-EGF levels were significantly lower in the urine specimens from men with IC than in the specimens from controls or patients with CP/CPPS (P <0.00001 for all four comparisons). Although the epidermal growth factor levels also tended to be higher in the urine from patients with IC than in the urine from controls, the difference did not reach statistical significance (P = 0.06).

CONCLUSIONS

These findings indicate that at least two of the urine biomarkers previously identified in women with IC (presence of APF activity and decreased levels of HB-EGF) are also found in men with IC, but not in men with CP/CPPS. This finding suggests that IC and CP/CPPS may be two different disorders with distinct pathophysiologies. It also confirms the utility of the presence of APF activity and HB-EGF levels as markers for IC in men, as well as in women, with this disorder.

Etiology and management of chronic pelvic pain syndrome in men

Prostatitis results in >2 million physician office visits annually. Characterized by pelvic pain and voiding symptoms, chronic pelvic pain syndrome (CPPS) is poorly defined. The Chronic Prostatitis Collaborative Research Network (CPCRN) has put forward a uniform set of classifications for chronic prostatitis based on pain being the primary symptom. The CPCRN has also created a valid instrument for measuring symptoms: the Chronic Prostatitis Symptom Index. After nonbacterial prostatitis has been diagnosed, treatment of patients should be individualized. The condition may be caused by bladder, prostate, pelvic side wall, or seminal vesicle pathology. In addition to currently used treatments, several new therapies are being investigated after promising pilot studies. Despite the multiple approaches to management of CPPS, no hard and fast guidelines have been developed. This review provides an overview of assessment techniques and management options for men with CPPS.

Counting leukocytes in expressed prostatic secretions from patients with chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

The evaluation of WBCs in EPS is recommended for classifying patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) but no agreement has been reached on the optimal method. We sought to determine the relationship between the expressed prostatic secretions (EPS) leukocyte (WBC) count per high-power field (evaluated by a more quantitative wet mount method and the traditional gram-stained smear method used in clinical microbiology laboratories) and the EPS WBC concentration to determine whether quantitative methods are necessary for accurate patient classification.

METHODS

EPS collected from 94 patients with CP/CPPS were evaluated by gram-stained smear, a standardized wet mount, and a hemocytometer method.

RESULTS

The gram-stained smear detected EPS WBCs in 21 (22%) of 94 subjects compared with 78 (83%) by the standardized wet mount and 57 (60%) by the hemocytometer method. The gram-stained EPS WBC count correlated poorly with the WBC concentration by hemocytometer (R(2) = 0.051, P = 0.03). Although the standardized EPS WBC count correlated better with the concentration by hemocytometer, the correlation coefficient remained low (R(2) = 0.244, P <0.0001).

CONCLUSIONS

The standardized wet mount proved superior to the gram-stained smear, but both methods lacked precision. Quantitative determination of the EPS WBC concentration by a counting chamber method proved to be the superior evaluation for research studies of CP/CPPS.

Chronic pelvic pain syndrome: a non-prostatocentric perspective

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common urological diagnosis affecting young and middle aged men. Symptoms of genital or pelvic pain associated with voiding or sexual dysfunction were historically attributed to an inflamed prostate gland. A review of urological and non-urological literature pertaining to CPPS was conducted in order to devise a plausible alternative description of this syndrome. Due to publisher's criteria, only select articles are included and cited for this purpose. Evidence of a bacterial etiology is non-existent, while evidence of prostatic inflammation is conflicting and non-specific. More plausible causes of prostatitis-like symptoms include musculoskeletal pain, pelvic floor muscular dysfunction, myofascial pain syndromes or functional somatic syndromes. Thorough evaluation and appropriate therapy for patients has been seriously hindered by decades of a prostatocentric approach to CP/CPPS. The following article introduces an alternative perspective.

Chronic prostatitis

PURPOSE OF REVIEW

This review covers recent developments in the classification, epidemiology, aetiology, diagnosis and treatment of patients diagnosed with chronic prostatitis (NIH classification types II, IIIa/IIIb and IV prostatitis) in the period of review (2001-2002).

RECENT FINDINGS

Recent studies highlight some of the problems with the 1995 NIH classification. Epidemiological studies have confirmed that "prostatitis" is common, with a prevalence of 10-15%. Associations of prostatitis include benign prostatic hyperplasia, sexually transmitted disease, lower urinary tract symptoms, stress, and reduced sunlight exposure. Elevated levels of cytokines in the seminal plasma and prostatic secretions have been detected in men with chronic prostatitis compared with normal individuals, suggesting an active inflammatory process in the male genital tract. This inflammatory reaction may be mediated by an adaptive immune response directed against a genital tract antigen(s) (autoimmunity). Increased levels of bacterial 16S ribosomal DNA in the prostates of men with chronic prostatitis compared with controls are compatible with the notion that a bacterial inflammatory event initiates an auto-immune process; however, the role of bacteria in the continuation of symptoms is unknown.

SUMMARY

The aetiology of chronic pelvic pain syndrome is still not certain, although an auto-immune process is favoured. Further research is required to determine the putative auto-antigen, the immune responses of patients, the role of bacteria in the inflammatory process, and the patients' pain response to genitourinary insults. As yet no diagnostic tests (other than to eliminate other pathology) and few treatments for chronic prostatitis can be recommended on the basis of scientific evidence.

Prevalence of prostatitis-like symptoms in a community based cohort of older men

PURPOSE

We describe a community based study to estimate the prevalence of prostatitis-like symptoms using questions similar to the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI).

MATERIALS AND METHODS

Study subjects were a randomly selected sample of Olmsted County, Minnesota white men 40 to 79 years old in January 1990 who participated in a longitudinal study of lower urinary tract symptoms. Subjects were evaluated biennially using self-administered questionnaires. In 2000 questions similar to the NIH-CPSI were incorporated into the questionnaire and questionnaire responses were used to categorize men as having prostatitis-like symptoms.

RESULTS

Of 1,541 men 182 (12%) had at least 1 urogenital pain symptom. Pubic (76 men, 4.9%) and testicular (73, 4.7%) pain were the most frequent pain symptoms. A total of 34 men with prostatitis-like symptoms (2.2%) had higher mean pain (6.7 versus 0.5), urinary symptom (3.5 versus 2.1) and quality of life impact (3.7 versus 1.9) scores compared to men who did not (all p <0.001). Pain frequency (OR 39.2, 95% CI 18.8, 81.9) and pain intensity (OR 21.5, 95% CI 8.7, 52.9) were more strongly associated with prostatitis-like symptoms than urinary symptom score (OR 2.8, 95% CI 1.4, 5.6) or quality of life impact score (OR 4.5, 95% CI 1.9, 10.7).

CONCLUSIONS

Although urogenital pain is common among community dwelling men, prostatitis-like symptoms based on the modified questions from the NIH-CPSI are less common. While pain measures may be useful in distinguishing between men with and without prostatitis-like symptoms, the urinary symptom and quality of life impact scores could partly reflect benign prostatic hyperplasia.

Overview summary statement. Diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

Members of the Chronic Prostatitis Collaborative Research Network (CPCRN) met in a 1-day symposium to review recent findings and to debate unanswered issues in the diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The meeting was focused on producing an overview summary statement that would, as nearly as possible, represent the consensus views of the attendees. As discussed below, the participants agreed that a history, physical examination, and urinalysis/urine culture are mandatory for the evaluation of all patients presenting with CP/CPPS, with other assessments categorized as recommended or optional, depending on the history and physical findings. Observations and suggestions regarding first- and second-line therapies are also offered, with the recognition that randomized, placebo-controlled trials to guide selection of therapies for chronic nonbacterial prostatitis are currently lacking.

Inflammation and anti-inflammatory therapy in chronic prostatitis

Anti-inflammatory medications have been used for the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), given that inflammation and pain are traditionally associated with this condition. The National Institutes of Health (NIH) classification divides category III into (1) category IIIA--patients with white blood cells (WBCs) in their expressed prostatic secretions, post-prostate massage urine (voided bladder urine-3 [VB3]) or semen; and (2) category IIIB--those without WBCs. However, recent studies indicate that the ability of WBC count alone to distinguish men with symptoms from those without appears limited. Other markers of inflammation, such as cytokines, may correlate better with clinical findings. The mechanisms of inflammation continue to be investigated, including contributions from reactive oxygen species, autoimmune response, neurogenic inflammation, and even endocrine dysfunction. There have been few controlled studies of anti-inflammatory therapy for chronic prostatitis. In the only randomized double-blind placebo-controlled trial, the NIH-Chronic Prostatitis Symptom Index (CPSI) total, domain, and pain scores significantly decreased from baseline in all groups, but the difference was not statistically significant. Other medications that have some theoretic anti-inflammatory properties have shown promising early results. Further study of currently available anti-inflammatory medications may be warranted, especially in longer trials, which may allow resolution of the significant placebo effect commonly seen in the short term in men with CPPS. Further discussion is needed to either validate, modify, or abolish the distinction between category IIIA and IIIB in the NIH classification.

Phytotherapy in chronic prostatitis

Chronic prostatitis is a very common condition that is poorly understood and has a significant impact on quality of life. Given the lack of proven efficacy of conventional therapies, such as antibiotics, it is not surprising that patients have turned with increasing frequency to phytotherapy and other alternative treatments. Although alternative therapies are plentiful, few have been subjected to scientific scrutiny and prospective controlled clinical trials. This review will cover phytotherapies commonly used in prostatitis patients and focus in detail on those with published data. These treatments include zinc, cernilton (bee pollen), quercetin, and saw palmetto. Although many of these therapies appear promising in small preliminary studies, phytotherapy requires the same scientific criteria for validation and acceptance as do conventional medical therapies.

CXCL8((3-73))K11R/G31P antagonizes the neutrophil chemoattractants present in pasteurellosis and mastitis lesions and abrogates neutrophil influx into intradermal endotoxin challenge sites in vivo

The ELR(+) CXC chemokines are critical for protective neutrophil responses to most bacterial infections, but nevertheless can contribute importantly to the pathogenic effects of many inflammatory responses. We recently engineered a series of high affinity CXCL8/IL-8 antagonists, one of which, CXCL8((3-73))K11R/G31P, binds very strongly to neutrophils via the CXCR1 and CXCR2. Herein we show in competitive 125I-ligand binding assays that bovine CXCL8((3-73))K11R/G31P has an affinity for neutrophils that is 2-3 orders of magnitude higher than that of CXCL8/IL-8. Furthermore, when used at approximately 0.5 nM, CXCL8((3-73))K11R/G31P inhibited by 50% the chemotactic responses of neutrophils to 129 nM CXCL8/IL-8, but it also blocked chemotactic responses to the alternate ELR-CXC chemokines CXCL1/GRO alpha and CXCL5/ENA-78. Furthermore, CXCL8((3-73))K11R/G31P could inhibit by 93-97% the spectrum of neutrophil chemotactic activities present within wash fluids from clinical bacterial pneumonia or experimental endotoxin-induced mastitis lesions. Finally, intramuscular or subcutaneous application of CXCL8((3-73))K11R/G31P (75 micro g/kg) reduced by up to 97% neutrophil infiltration into intradermal endotoxin challenge sites in cattle, and prevented their circulating neutrophils from responding to CXCL8/IL-8 or ENA-78 in vitro. This data thus encourages further investigation of the potential impact of this novel antagonist on ELR-CXC chemokine-driven inflammatory disorders.

Leukocyte and bacterial counts do not correlate with severity of symptoms in men with chronic prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study

PURPOSE

We examine whether leukocytes and bacteria correlate with symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS

All 488 men screened into the National Institutes of Health Chronic Prostatitis Cohort Study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, were used to measure symptoms. Urethral inflammation was defined as white blood cell (WBC) counts of 1 or more (1+) in the first voided urine. Participants were classified as category IIIa based on WBC counts of 5 or more, or 10 or more (5+, 10+) in the expressed prostatic secretion, or 1+ or 5+ either in the post-expressed prostatic secretion urine (voided urine 3) or semen. Uropathogens were classified as localizing if the designated bacterial species were absent in voided urine 1 and voided urine 2 but present in expressed prostatic secretion, voided urine 3 or semen, or present in expressed prostatic secretion, voided urine 3 or semen at 2 log concentrations higher than at voided urine 1 or 2. Associations between symptoms, and inflammation and infection were investigated using generalized Mantel-Haenszel methods.

RESULTS

Of all participants 50% had urethral leukocytes and of 397 with expressed prostatic secretion samples 194 (49%) and 122 (31%) had 5+ or 10+ WBCs in expressed prostatic secretion, respectively. The prevalence of category IIIa ranged from 90% to 54%, depending on the composite set of cut points. None of the index measures were statistically different (p >0.10) for selected leukocytosis subgroups. Based on prostate and semen cultures, 37 of 488 men (8%) had at least 1 localizing uropathogen. None of the index measures were statistically different (p >0.10) for selected bacterial culture subgroups.

CONCLUSIONS

Although men with chronic prostatitis routinely receive anti-inflammatory and antimicrobial therapy, we found that leukocytes and bacterial counts as we defined them do not correlate with severity of symptoms. These findings suggest that factors other than leukocytes and bacteria also contribute to symptoms associated with chronic pelvic pain syndrome.

Theories of prostatitis etiology

Prostatitis reflects a broad spectrum of prostatic infections, both acute and chronic. Chronic prostatitis, known as National Institutes of Health category III or chronic pelvic pain syndrome, broadly defines a disease that is still poorly understood, and as a consequence, difficult to treat. Typical symptoms include pelvic pain and voiding dysfunction. Infection is often cited as the cause of this condition, despite frequent negative cultures. A close look at the local prostatic microenvironment may yield clues. The role of inflammatory mediators and what stimulates them can point to potential sites of prevention. A genetic link or relationship to other diseases may prove to be part of the cause. Furthermore, a neurologic source, whether anatomic or psychologic, has been strongly debated. Ultimately, it may become clear that chronic prostatitis represents the final common result of a disease that originates from a cascade of multiple stimuli.

Bacteria in the chronic prostatitis-chronic pelvic pain syndrome: molecular approaches to critical research questions

PURPOSE

There is a pressing need to determine the causes and consequences of, and optimal therapy for the chronic prostatitis-chronic pelvic pain syndrome.

MATERIALS AND METHODS

New data suggest that bacterial infection may be critical in some patients. We examined the rationale for and technical approaches to hypothesis driven studies of bacteria in the chronic prostatitis-chronic pelvic pain syndrome.

RESULTS

The first hypothesis was that patients with the chronic prostatitis-chronic pelvic pain syndrome have prostatic bacteria that distinguish them from controls. In pilot studies patients with inflamed expressed prostatic secretions were more likely to have bacterial DNAs, that is 16S ribosomal DNAs. Current goals are to clone, sequence and compare ribosomal DNAs from patients and controls to determine which bacteria are most specific to the chronic prostatitis-chronic pelvic pain syndrome and which should be targeted in clinical trials. The second hypothesis was that bacterial viability correlates with the severity of the chronic prostatitis-chronic pelvic pain syndrome. Quantitative assays for bacterial elongation factor messenger RNA (tufA messenger RNA) provide tools to correlate bacterial viability with patient characteristics, will provide insights into the potential value of antimicrobial therapy and identify characteristics that distinguish patients most likely to respond. The third hypothesis was that patients with prostatic bacteria have similar bacteria in expressed prostatic secretions or on seminal fluid analysis and, furthermore, these bacteria differ from bacteria in controls. These studies would determine whether expressed prostatic secretions or seminal fluid analysis can be used to identify prostatic bacteria and may result in clinical methods for noninvasive diagnosis of prostatic infection.

CONCLUSIONS

These studies should provide important insights into the causes of the chronic prostatitis-chronic pelvic pain syndrome and may elucidate optimal clinical evaluation and treatment in patients.

Involvement of chemokines in pain

It is well established that neuroinflammation plays an important role in neurodegenerative diseases like Alzheimer's disease, stroke, traumatic brain- and spinal cord injury and demyelinating diseases. Likewise, it has been suggested that neuroinflammation plays an important role in nociception and hyperalgesia. Most research concerning inflammatory aspects of pain has concerned the effects of proinflammatory cytokines, prostaglandins and growth factors. Recently, it has been suggested that chemokines play a role in inflammatory pain. Chemokines do not only attract blood leukocytes to the site of injury but also contribute directly to nociception.