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

Chronic Prostatitis/Chronic Pain Pelvic Syndrome and Male Infertility

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is defined as urologic pain or discomfort in the pelvic region, associated with urinary symptoms and/or sexual dysfunction, lasting for at least 3 of the previous 6 months. The rate of symptoms related to prostatitis has a mean prevalence of 8-8.2%. CP/CPPS is most frequent in men younger than 50 years, among whom it is the most common urologic diagnosis. In the last decades, many studies have been published on CP/CPPS and its association with male infertility. The pathophysiologic relation between CP/CPPS and male infertility involves several aspects, which are not well studied yet. A reduction in semen parameters has been demonstrated in patients with CP/CPPS, and several mechanisms have been proposed to represent putative pathophysiological links between CP/CPPS and infertility, including male accessory gland inflammation, metabolic syndrome, inflammatory bowel disease, HPV co-infection and autoimmunity. In light of this evidence, a multidisciplinary approach is advocated for patients with known CP/CPPS, and particular attention is needed for male patients of infertile couples in order to evaluate male accessory glands correctly. In addition, it is advisable that future studies dealing with the treatment of CP/CPPS take into consideration all the different pathophysiological aspects implicated.

Antimicrobial therapy for chronic bacterial prostatitis

BACKGROUND

Chronic bacterial prostatitis (CBP) is frequently diagnosed in men of fertile age, and is characterized by a disabling array of symptoms, including pain in the pelvic area (for example, perineum, testicles), voiding symptoms (increased frequency and urgency, also at night; pain or discomfort at micturition), and sexual dysfunction. Cure of CBP can be attempted by long-term therapy with antibacterial agents, but relapses are frequent. Few antibacterial agents are able to distribute to the prostatic tissue and achieve sufficient concentrations at the site of infection. These agents include fluoroquinolones, macrolides, tetracyclines and trimethoprim. After the introduction of fluoroquinolones into clinical practice, a number of studies have been performed to optimize the antimicrobial treatment of CBP, and to improve eradication rates and symptom relief.

OBJECTIVES

To assess and compare the efficacy and harm of antimicrobial treatments for chronic bacterial prostatitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE, other national or international databases and abstracts from conference proceedings on 8 August 2012.

SELECTION CRITERIA

We included all randomized controlled comparisons of one antimicrobial agent versus placebo or one or more comparator antimicrobial agents, combined or not with non-antimicrobial drugs. We also included trials comparing different doses, treatment durations, dosing frequencies, or routes of administration of antimicrobial agents. We excluded studies in which patients were not diagnosed according to internationally recommended criteria, or were not subjected to lower urinary tract segmented tests.

DATA COLLECTION AND ANALYSIS

Study data were extracted independently by two review authors. Study outcomes were microbiological efficacy (pathogen eradication), clinical efficacy (symptom cure or improvement, or symptom scores) at test-of-cure visits or at follow-up, or both, and adverse effects of therapy. Secondary outcomes included microbiological recurrence rates.Statistical analysis was performed using a fixed-effect model for microbiological outcomes and a random-effects model for clinical outcomes and adverse effects. The results were expressed as risk ratios for dichotomous outcomes (with 95% confidence intervals) or as standardized mean differences for continuous or non-dichotomous variables.

MAIN RESULTS

We identified 18 studies, enrolling a total of 2196 randomized patients. The oral fluoroquinolones ciprofloxacin, levofloxacin, lomefloxacin, ofloxacin and prulifloxacin were compared. There were no significant differences in clinical or microbiological efficacy or in the rate of adverse effects between these fluoroquinolones. In chlamydial prostatitis, (i) azithromycin showed improved eradication rates and clinical cure rates compared to ciprofloxacin, with no significant differences regarding adverse effects; (ii) azithromycin was equivalent to clarithromycin, both microbiologically and clinically; (iii) prulifloxacin appeared to improve clinical symptoms, but not eradication rates, compared to doxycycline. In ureaplasmal prostatitis, the comparisons ofloxacin versus minocycline and azithromycin versus doxycycline showed similar microbiological, clinical and toxicity profiles.

AUTHORS' CONCLUSIONS

The microbiological and clinical efficacy, as well as the adverse effect profile, of different oral fluoroquinolones are comparable. No conclusions can be drawn regarding the optimal treatment duration of fluoroquinolones in the treatment of CBP caused by traditional pathogens.Alternative antimicrobial agents tested for the treatment of CBP caused by traditional pathogens are co-trimoxazole, beta-lactams and tetracyclines, but no conclusive evidence can be drawn regarding the role of non-fluoroquinolone antibiotics in the treatment of CBP caused by traditional pathogens.In patients with CBP caused by obligate intracellular pathogens, macrolides showed higher microbiological and clinical cure rates compared to fluoroquinolones.

Clinical courses following acute bacterial prostatitis

Purpose:

There are few studies about clinical courses following acute bacterial prostatitis (ABP). We evaluated the progression rates of chronic bacterial prostatitis (CBP) and inflammatory chronic pelvic pain syndrome (CPPS) after ABP treatment. Also evaluated the characteristics of the patients who developed CBP and inflammatory CPPS after ABP treatment.

Methods:

Total 437 patients compatible with a confirmed diagnosis of ABP from 5 urological centers between 2001 and 2010 were enrolled to study. We defined chronic infection (CI) as a progression to CBP and inflammatory CPPS after treatment of ABP in admission periods when followed up at 3 months or more. Results were analyzed between two groups: recovered without CI (group A, n=385) and developed to CI (group B, n=52).

Results:

Of the 437 ABP patients, 1.3% (6/437) progressed to CBP and 10.5% (46/437) progressed to inflammatory CPPS. The progression rate of CI was 11.8% (52/437). The patients who developed to CI were higher in alcohol consumption rate, diabetes, voiding symptoms, prior manipulation rate, enlarged prostate volume, catheterization history rate and short duration of antibiotic treatment (P<0.05).

Conclusions:

The identification and characterization of these factors may accelerate the development of preventive, diagnostic and therapeutic strategies for the treatment of CI from ABP.

Mechanisms of action and clinical application of macrolides as immunomodulatory medications

Macrolides have diverse biological activities and an ability to modulate inflammation and immunity in eukaryotes without affecting homeostatic immunity. These properties have led to their long-term use in treating neutrophil-dominated inflammation in diffuse panbronchiolitis, bronchiectasis, rhinosinusitis, and cystic fibrosis. These immunomodulatory activities appear to be polymodal, but evidence suggests that many of these effects are due to inhibition of extracellular signal-regulated kinase 1/2 (ERK1/2) phosphorylation and nuclear factor kappa B (NF-kappaB) activation. Macrolides accumulate within cells, suggesting that they may associate with receptors or carriers responsible for the regulation of cell cycle and immunity. A concern is that long-term use of macrolides increases the emergence of antimicrobial resistance. Nonantimicrobial macrolides are now in development as potential immunomodulatory therapies.

New treatments for chronic prostatitis/chronic pelvic pain syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common condition among men of a wide age range, with detrimental effects on quality of life. The etiology, pathogenesis, and optimal treatment of CP/CPPS remain unknown, although progress has been made in these domains in recent years. A wide variety of pharmacologic and nonpharmacologic therapies have been studied in clinical trials, but most have shown limited efficacy in symptom alleviation. CP/CPPS is increasingly viewed as a condition that involves variable degrees of neuropathic pain. Medications such as gabapentin, pregabalin, memantine, and tricyclic antidepressants are often used in other neuropathic pain conditions and, therefore, are considered potential treatments for CP/CPPS. Few studies of these agents in patients with CP/CPPS have been reported, but future clinical trials should help to determine their utility and to characterize the pathogenetic mechanisms of pain in CP/CPPS. Combining treatment trials with biomarker, genomic, and imaging studies, in addition to epidemiologic and symptom-based assessments, will maximize the ability to probe disease etiology and pathogenesis, as well as identify effective treatment.

Efficacy and safety of gatifloxacin for urinary tract infection in nonspecialized Korean urologic practice

To investigate the efficacy and safety of gatifloxacin (400mg/day) on chronic prostatitis or cystitis, 453 patients with prostatitis (NIH category II or IIIa) (N=149, mean 45.8+/-13.3 years) and cystitis (N=304, mean 53.8+/-14.3 years) were enrolled. Total NIH CPSI score and symptom score for cystitis decreased from 20.3 to 9.9 (response rate 86.7%, 95% CI 80.2-93.2%) and from 6.2 to 1.8 (response rate 83.2%, 95% CI 78.7-87.7%), respectively. In the overall clinical efficacy, 71.2% and 88.4% of the patients with prostatitis and cystitis were responders, respectively. Of the patients, 15.7% reported insignificant adverse events. These results suggest that gatifloxacin was well tolerated and improved the clinical outcomes in patients with chronic prostatitis or cystitis.

Pelvic pain in women and men: recent findings

PURPOSE OF REVIEW

All Pubmed-listed articles generated by the search terms 'pelvic' and 'pain' from the year 2004 (plus or minus 6 months) were examined for relevance to pain management therapeutics. An emphasis was given to clinical studies related to chronic pain disorders.

RECENT FINDINGS

Use of the descriptive diagnosis 'pelvic pain', traditionally limited to gynecological pains, has now been generalized to include male populations with similar symptom complexes arising from organs of reproduction and other pelvic organ systems such as the gastrointestinal tract and urological structures. Clinical studies have sought to refine or test existing 'standard' therapies for current pain groupings, and have frequently obtained frustrating results because many therapies appear to be effective in only a subset of patients. Notably, the same therapeutics appear to be effective in similar subsets of patients with other protean disorders.

SUMMARY

A commonality of symptoms suggests a commonality of pathophysiology, although this has not proved to be globally true. The success of therapeutic options appears to depend upon a stratification of previous pain groupings into overlapping subsets each with their effective treatment. Current studies are still defining these subsets and finding monotherapies to be inadequate for whole populations.

Predictors of Symptom Severity in Patients With Chronic Prostatitis and Interstitial Cystitis

PURPOSE

Numerous studies have been performed to identify potential risk factors for CP/CPPS and IC. However, few studies have been done to identify predictors of disease severity.

MATERIALS AND METHODS

A total of 174 men with CP/CPPS and 111 women with IC completed questionnaires to quantify symptom severity and identify demographic, medical and psychosocial characteristics. Symptom severity was assessed with the National Institutes of Health CPSI in men, and the O'Leary-Sant ICSI and problem index in women. Univariate and multivariate analyses were performed to identify characteristics predictive of worse symptoms.

RESULTS

The mean National Institutes of Health CPSI score in men was 15.32, and the mean O'Leary-Sant ICSI and problem index in women was 19.17. The most commonly reported comorbidities were allergies, sinusitis, erectile dysfunction and irritable bowel syndrome in men, and allergies, urinary incontinence, sinusitis and irritable bowel syndrome in women. In the 2 sexes self-reported urinary frequency and urgency, worse depression scores and lower education level were independent predictors of worse symptom severity. In men additional independent predictors were self-reported pelvic pain, fibromyalgia and previous heart attack, and in women an additional independent predictor was postmenopausal status.

CONCLUSIONS

There are several common medical conditions associated with urological pelvic pain syndromes in men and women. Few of them were predictive of symptoms severity in this analysis. Self-reported pelvic pain symptoms, education and depression severity were the factors most strongly predictive of symptom severity in patients with CP/CPPS and IC.

Prostatitis: epidemiology of inflammation

Approximately 8 million prostatitis-related outpatient visits per year have been reported worldwide. Only a small percentage presents with bacterial prostatitis. Chronic pelvic pain syndrome/prostatodynia is a frustrating disease for patients and caregivers. This paper is an attempt to analyze causes and types of inflammation and to determine if inflammation may have an impact on treatment and outcome. Is inflammation even a relevant factor in the diagnosis of chronic pelvic pain syndrome? Do we need to begin to look for different factors involved in the development of this often crippling disease?