Predictors of patient response to antibiotic therapy for the chronic prostatitis/chronic pelvic pain syndrome: a prospective multicenter clinical trial

Chronic inflammation in benign prostatic hyperplasia: Pathophysiology and treatment options

Benign prostatic hyperplasia, a prevalent condition in aging men, is characterized by the proliferation of prostatic epithelial and stromal cells, which leads to bladder outlet obstruction and the exacerbation of lower urinary tract symptoms. There is increasing evidence that chronic prostatic inflammation contributes to the pathogenesis and progression of benign prostatic hyperplasia. This review explores the complex relationship between chronic inflammation and benign prostatic hyperplasia, focusing on the underlying mechanisms, clinical implications, and current therapeutic approaches. The pathophysiology of benign prostatic hyperplasia is multifaceted, involving factors such as hormonal changes, hypoxia, urine reflux into prostatic ducts and stroma, autoimmune responses, and infection-induced inflammation. Inflammatory cytokines, particularly interleukin-17 and interleukin-8, may play key roles in tissue remodeling and smooth muscle contraction within the prostate, thereby influencing benign prostatic hyperplasia progression. Current therapies for benign prostatic hyperplasia include α1-blockers, phosphodiesterase 5 inhibitors, 5α-reductase inhibitors, and plant-based treatments (e.g., pollen extract). These therapies aim to alleviate symptoms by reducing prostatic inflammation, improving blood flow, and inhibiting hormonal pathways involved in prostatic enlargement. However, patients with chronic prostatic inflammation often experience more severe lower urinary tract symptoms and may be resistant to conventional treatments. This resistance has prompted the exploration of alternative therapies targeting inflammation. Chronic prostatic inflammation plays a central role in the pathogenesis and severity of benign prostatic hyperplasia. An understanding of its mechanisms will enable the development of more effective treatments to improve the quality of life among patients with benign prostatic hyperplasia.

Preliminary study of the effect of gut microbiota on the development of prostatitis

BACKGROUND

Dysbacteriosis of intestinal tract may cause systemic inflammation, making distant anatomical locations more susceptible to illness. Recent research has demonstrated that the microbiome can affect both prostatitis and the inflammation of the prostate that is linked to prostate cancer. It is still unclear, though, whether this relationship indicates causation. We conducted a Mendelian randomization investigation on two samples to fully uncover gut microbiota's potential genetic causal role in prostatitis.

METHOD

Prostatitis (1859 prostatitis cases and 72,799 controls) was utilized as the outcome, while SNPs highly linked with 196 microbial taxa (18 340 people) were chosen as instrumental factors. Random effects, inverse variance weighting, weighted medians, and MR-Egger were used to analyze causal effects. The Cochran's Q test, funnel plot, leave-one-out analysis, and MR-Egger intercept test were all used in the sensitivity analysis.

RESULTS

A causal effect in lowering the incidence of prostatitis is anticipated for five gut microorganisms (Methanobacteria, Methanobacteriaceae, Erysipelatoclostridium, Parasutterella, and Slackia; P < 0.05). Four gut bacteria, including Faecalibacterium, LachnospiraceaeUCG004, Sutterella, and Gastranaerophilales, are predicted to play a causal role in increasing the risk of prostatitis (P < 0.05). There were no discernible estimates of pleiotropy or heterogeneity.

CONCLUSION

Our investigation established the genetic links between nine gut microorganisms and prostatitis, which may offer fresh perspectives and a theoretical framework for the future prevention and management of prostatitis.

Detection of Trichomonas vaginalis Infection in Chronic Prostatitis/Chronic Pelvic Pain Syndrome Patients by Rapid Immunochromatographic Test

This study aims to evaluate associations between the immunochromatographic rapid test technique and Trichomonas vaginalis (TV) infection in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in Taiwan. All patients received post-prostate massage urine (VB3) Trichomonas rapid tests. The demographic characteristics and urogenital symptoms of CP/CPPS were recorded. Routine urinalysis of VB3 was also performed, and laboratory examination results of semen were recorded if available. A total of 29 patients with TV infection and 109 without TV infection were enrolled, which reflected that the prevalence in patients with TV infection was approximately 21%. Patients with TV infection displayed a significantly higher frequency of suprapubic/lower abdominal pain (p = 0.034), semen leukocyte > 5/high-power field (HPF) (p = 0.020), and an inflammatory type (category IIIA) (p = 0.005) than patients without TV infection. A higher prevalence of TV infection was found in patients with category IIIA (47.37%). No significant difference was found in the symptom duration and other clinical symptoms. In conclusion, the high prevalence of TV infection was revealed in CP/CPPS patients using the VB3 rapid Trichomonas test, especially in CP/CPPS patients with category IIIA. Thus, rapid TV testing might be vital for CP/CPPS patients in the hospital.

METTL3 suppresses neuropathic pain via modulating N6-methyladenosine-dependent primary miR-150 processing

Methyltransferase-like 3 (METTL3)-modulated N6-methyladenosine (m6A) was recently identified as an important epigenetic regulation type during RNA processing and contributes to multiple pathological processes. Neuropathic pain (NP) is induced by a lesion of the somatosensory nervous system, and the detailed pathways by which METTL3/m6A regulated to modulate gene dysregulation and enable NP have remained unclear. Therefore, this study investigated the function of METTL3-mediated m6A methylation on miRNA maturation, and investigated how this regulation contributes to NP progression. A rat model characterized with typical NP was established by a spared nerve-injury (SNI) method. By analyzing the expression levels of METTL3 and m6A methylation, we found that METTL3, along with m6A methylation, was dramatically downregulated in NP rats in contrast to the sham ones. Functionally, enhanced METTL3 promoted the m6A methylation in total RNAs and inhibited NP progression, whereas silencing METTL3 suppressed m6A methylation and increased NP severity. Mechanistically, METTL3 accelerated miR-150 maturation via mediating m6A methylation of primiR-150 at locus 498, cooperating with the “m6A reader” YTHDF2. Meanwhile, miR-150 could directly target brain-derived neurotrophic factor (BDNF) mRNA, and the METTL3/miR-150/BDNF regulatory pathway was finally established. Clinically, we proved that serum METTL3 mRNA was also downregulated in Shingles patients with NP, suggesting its diagnostic potential. In conclusion, we demonstrated an essential function of METTL3-regulated N6-methyladenosine during NP progression via modulating primiR-150 maturation. Serum METTL3 could effectively differentiate NP patients from healthy people, and is useful for dynamic monitoring of diseases after treatment. Therefore, the METTL3/miR-150/BDNF pathway may be a promising therapeutic target for NP patients.

Poria cocos polysaccharides attenuate chronic nonbacterial prostatitis by targeting the gut microbiota: Comparative study of Poria cocos polysaccharides and finasteride in treating chronic prostatitis

Finasteride is an antiandrogenic drug used for the clinical treatment of chronic nonbacterial prostatitis (CNP). Recently, we reported the anti-CNP activity of Poria cocos polysaccharides (PPs) in a rat model. In this study, we compared the differences between PPs and finasteride in treating CNP, especially their effects on the gut microbiota. Results showed that both PPs and finasteride significantly reduced the prostate weight and prostate index of CNP rats, and improved the histological damages in the inflamed prostate. Moreover, PPs and finasteride inhibited the production of pro-inflammatory cytokines (TNF-α, IL-2 and IL-8) and androgens (dihydrotestosterone and testosterone). By 16S rDNA sequencing, PPs and finasteride were found to reprogram the gut microbiota into distinct profiles. Further analysis presented that PPs but not finasteride recovered CNP-induced changes in the gut microbiota, including Ruminococcaceae NK4A214 group, uncultured bacterium f Ruminococcaceae, Ruminiclostridium 9, Phascolarctobacterium, Coriobacteriaceae UCG-002 and Oribacterium. LDA effect size (LEfSe) analysis revealed that PPs recovered the gut microbiota by targeting Ruminococcaceae NK4A214 group. Our results suggested that PPs alleviated CNP via different mechanisms from finasteride, especially by regulating the gut microbiota, which offers therapeutic target for the treatment of CNP.

Diagnostic and Management Strategies for Patients with Chronic Prostatitis and Chronic Pelvic Pain Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common and often heterogenous condition that can have severe consequences on patient quality of life. In this review, we describe the pathophysiology, diagnostic work-up, and treatment of patients with CP/CPPS incorporating the most recent literature. Studies have demonstrated that CP/CPPS involves a complex pathophysiology, including infectious, immunologic, neurologic, endocrinologic, and psychologic etiologies, with frequent intersections between the different entities. Despite robust research assessing a variety of therapeutics targeting these etiologies, clinical trials have failed to identify an empiric treatment strategy applicable specifically to older adult male patients with CP/CPPS. As such, it can be challenging to manage older male patients with this condition. The advent of clinical phenotyping of patients with CP/CPPS has led to advances in tailored management strategies. Monomodal therapy has been largely unsuccessful because of the unclear and complex etiology of CPPS. As a result, CP/CPPS therapy has transitioned to a multimodal approach, including both pharmacologic and non-pharmacologic therapies. The best studied pharmacologic therapies include antibiotics, alpha-blockers, anti-inflammatory and immunomodulatory agents, phytotherapies, phosphodiesterase inhibitors, hormonal agents, neuromodulatory agents, and antidepressants. The best studied non-pharmacological therapies include pelvic floor physical therapy, myofascial trigger point release, acupuncture and electroacupuncture, psychological support and biofeedback, and electrocorporeal shockwave therapy and local thermotherapy.

Long Non-coding RNA LINC01119 Promotes Neuropathic Pain by Stabilizing BDNF Transcript

Neuropathic pain (NP) is caused by primary injury or dysfunction of the peripheral and the central nervous system. Long non-coding RNAs were critical regulators involved in nervous system diseases, however, the precise regulatory mechanism remains unclear. This study aims to uncover the essential role of LINC01119 in NP progression and further clarify the underlying regulatory mechanism at post-transcriptional level. LINC01119 was significantly upregulated in rats of spare nerve injury (SNI) group compared to sham group. Functionally, silencing of LINC01119 significantly alleviated the neuropathic pain-induced hypersensitivity and reduced the increase in IL-6, IL-1β, and TNF-α caused by SNI. Mechanistically, Brain-derived neurotrophic factor (BDNF) was identified as the functional target of LINC01119. Besides, an RNA binding protein, ELAVL1 could directly interact with LINC01119, and this formed LINC01119- ELAVL1 complex binds to BDNF mRNA, strengthening its RNA stability and increasing the expression level of BDNF at both transcript and protein levels. Clinically, serum LINC01119 was verified as a promising diagnostic biomarker for NP patients. LINC01119 induces NP progression via binding with ELAVL1 and increasing BDNF mRNA stability and expression level. Therefore, LINC01119 may serve as a promising diagnostic marker and therapeutic target for NP treatment.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Disease or Symptom? Current Perspectives on Diagnosis, Treatment, and Prognosis

Definitive diagnosis and selection of effective treatment for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are frustrations encountered frequently by urology care providers in their practice. Knowledge of etiology and pathophysiology is not sufficient and therapeutic guidelines have not yielded acceptable outcomes and prognoses for both patients and care providers. The authors present updated perspectives on CP/CPPS, including definition, diagnosis, treatment, and prognosis, based on literature review and clinical experience. A key point is to shift the diagnostic and therapeutic focus from a single entity of disease toward associated symptoms of CP/CPPS. An individualized multimodal treatment approach to cope with the course of the disorder is proposed. Communications and personal/family/community supports are emphasized as an important component in the therapeutic regime and rehabilitation of patients with CP/CPPS. The purpose is to improve comprehension on CP/CPPS and to help care providers and patients to achieve the goal of medical intervention-relieving associated symptoms of CP/CPPS and improving the quality of life.

Culture-independent Next Generation Sequencing of Urine and Expressed Prostatic Secretions in Men With Chronic Pelvic Pain Syndrome

OBJECTIVE

To compare standard cultures and next-generation sequencing (NGS) in men with chronic prostatitis/chronic pelvic pain syndrome (CPPS). CPPS shares clinical features with urinary tract infections, but bacteria are seldom found. NGS is more sensitive than standard cultures.

MATERIALS AND METHODS

Men diagnosed with CPPS (National Institute of Health Category III) underwent traditional cultures and NGS of their urine and expressed prostatic secretions (EPS). Characteristics between groups were compared statistically.

RESULTS

Thirty-one men with CPPS were included (mean age 44.5). All standard urine cultures were negative, and 3 EPS cultures were positive. Seventy-eight unique microbes were detected with NGS, including uropathogens in 10 of the men. There were no bacteria identified by NGS in EPS that were not also found in the urine. Men with positive NGS did not differ from those without in age, symptom severity or phenotype. Men with typical urinary tract infection symptoms (eg, dysuria, chills) were more likely to have uropathogens detected on NGS relative to men without such symptoms. Nine patients were prescribed antibiotics based on their NGS findings, but only 1 exhibited symptom improvement (11%).

CONCLUSION

NGS commonly identified bacteria in CPPS patients, but these did not localize to the prostate. NGS positivity did not correlate with symptom severity and antibiotic therapy was seldom effective. NGS detected uropathogens more frequently in those with clinical symptoms suggestive of urinary tract infection. Clinical trials are needed to examine the utility of NGS-guided antibiotics in this subpopulation.

Management of Chronic Bacterial Prostatitis

PURPOSE OF REVIEW

We conducted a review of the literature describing the most up-to-date diagnosis and treatment options of chronic bacterial prostatitis.

RECENT FINDINGS

Recurrence after oral antimicrobial therapy is common, due in part to the rising rates of antimicrobial resistance and inability to completely clear the offending bacteria from the prostate following prostatitis. Recent literature has described various treatment options for chronic bacterial prostatitis refractory to conventional antimicrobial agents, including the use of alternative agents such as fosfomycin, direct antimicrobial injections into the prostate, surgical removal of infected prostatic tissue, chronic oral antibiotic suppression, and an emerging novel therapy utilizing bacteriophages to target antibiotic resistant bacteria. Management of chronic bacterial prostatitis, especially recurrence after oral antimicrobial treatment, remains challenging. This review highlights an urgent need for further evidence assessing the efficacy and safety of treatment modalities for chronic bacterial prostatitis refractory to conventional oral antimicrobials.

Interventions to chronic prostatitis/Chronic pelvic pain syndrome treatment. Where are we standing and what's next?

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a frustrating syndrome. The pathogenesis and state of the art treatment of CP/CPPS are not known. A wide variety of therapies including anti-inflammatories, antibiotics, alpha-blockers, neuropathic pain modulators, and 5α-reductase inhibitors are in practice. These treatment strategies focus on alleviating symptoms in specific domains without treating root-cause and therapeutic outcome is far from satisfactory. We review the literature on current pharmacological treatments for CP/CPPS in detail and suggest future perspectives to modify the treatment strategies. We suggest that introducing novel treatment strategies such as gene editing, and T_regs expressing chimeric receptors may improve the treatment outcomes by inducing immune tolerance and controlling expression of pro-inflammatory cytokines.

Symptom Severity Following Rifaximin and the Probiotic VSL#3 in Patients with Chronic Pelvic Pain Syndrome (Due to Inflammatory Prostatitis) Plus Irritable Bowel Syndrome

This study investigated the effects of long-term treatment with rifaximin and the probiotic VSL#3 on uro-genital and gastrointestinal symptoms in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) plus diarrhoea-predominant irritable bowel syndrome (D-IBS) compared with patients with D-IBS alone. Eighty-five patients with CP/CPPS (45 with subtype IIIa and 40 with IIIb) plus D-IBS according to the Rome III criteria and an aged-matched control-group of patients with D-IBS alone (n = 75) received rifaximin and VSL#3. The primary endpoints were the response rates of IBS and CP/CPPS symptoms, assessed respectively through Irritable Bowel Syndrome Severity Scoring System (IBS-SSS) and The National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), and performed at the start of therapy (V0) and three months after (V3). In IIIa prostatitis patients, the total NIH-CPSI scores significantly (p < 0.05) decreased from a baseline mean value of 21.2 to 14.5 at V3 , as did all subscales, and in the IIIb the total NIH-CPSI score also significantly decreased (from 17.4 to 15.1). Patients with IBS alone showed no significant differences in NIH-CPSI score. At V3, significantly greater improvement in the IBS-SSS and responder rate were found in IIIa patients. Our results were explained through a better individual response at V3 in IIIa prostatitis of urinary and gastrointestinal symptoms, while mean leukocyte counts on expressed prostate secretion (EPS) after prostate massage significantly lowered only in IIIa cases.

[Structural changes of gut microbiota after gastric bypass in obese patients with type 2 diabetes]

OBJECTIVE

To investigate the structural changes inintestinal flora and metabolic changes in type 2 diabetic patients with obesity(BMI≥40 kg/m²)by sequencing the 16S rRNA genes.

METHODS

Stool samples were collected from 4 diabetic patients before and after gastric bypass surgery for extraction of the total DNA. The diversity of the intestinal flora in the samples was investigated by 16S rRNA sequencing. After surgery, the changes in glucose and lipid metabolism were evaluated in the patients, and the changesin body mass index (BMI) and waist to hip ratio were assessed at 3 month intervals.

RESULTS

After gastric bypass, the patient's BMI, waist to hip ratio, glucose metabolism and lipid metabolism gradually recovered the normal levels. The proportion of Bacteroidetesis increased and the proportions of Firmicutes and Proteobacteria decreased in the intestinal bacteria after the surgery.

CONCLUSION

Gastric bypass surgery can effectively alleviate the condition of obese patients with type 2 diabetes and improve the composition of the intestinal flora.

Comprehensive overview of prostatitis

Prostatitis is a common urinary tract syndrome that many doctors find problematic to treat effectively. It is the third most commonly found urinary tract disease in men after prostate cancer and Benign Prostate Hyperplasia (BPH). Prostatitis may account for 25% of all office visits made to the urological clinics complaining about the genital and urinary systems all over the world. In the present study, we classified prostatitis and comprehensively elaborated the etiology, pathogenesis, diagnosis, and treatment of acute bacterial prostatitis (category I), chronic bacterial prostatitis (category II), chronic pelvic pain syndrome (CPPS) (category III), and asymptomatic prostatitis (category IV). In addition, we also tried to get some insights about other types of prostatitis-like fungal, viral and gonococcal prostatitis. The aim of this review is to present the detail current perspective of prostatitis in a single review. To the best of our knowledge currently, there is not a single comprehensive review, which can completely elaborate this important topic in an effective way. Furthermore, this review will provide a solid platform to conduct future studies on different aspects such as risk factors, mechanism of pathogenesis, proper diagnosis, and rational treatment plans for fungal, viral, and gonococcal prostatitis.

A randomized controlled trial of levofloxacin, terazosin, and combination therapy in patients with category III chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVE

To explore the efficacy of levofloxacin, terazosin, and their combination in patients with category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

METHODS

A total of 115 patients with category III CP/CPPS receiving 6-week therapy were randomly divided into the levofloxacin group (n = 38), terazosin group (n = 38), and combination group (n = 39). The primary endpoint was the response rate (i.e., the change from baseline) in the total and domain scores of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). Secondary endpoints were expressed as prostatic secretion-white blood cell (EPS-WBC) and International Index of Erectile Function-5 (IIEF-5).

RESULTS

After 6 weeks, the response rate of NIH-CPSI scores was 45.1, 22.4, and 50.0 % in the levofloxacin group, terazosin group, and combination group, respectively. Furthermore, no significant difference in NIH-CPSI scores was observed between IIIA and IIIB patients in each arm. Levofloxacin alone or levofloxacin plus terazosin could significantly reduce EPS-WBC counts compared with terazosin alone. Finally, no significant difference was found between the three arms in terms of IIEF-5 scores.

CONCLUSION

A 6-week short-term treatment of levofloxacin or levofloxacin plus terazosin was more effective than terazosin alone in patients with category III CP/CPPS. Furthermore, levofloxacin treatment was not different from levofloxacin plus terazosin treatment in terms of treatment effect.

Intraprostatic injection of botulinum toxin-A in patients with refractory chronic pelvic pain syndrome: The transurethral vs. transrectal approach

OBJECTIVE

To evaluate the outcome of an intraprostatic injection of botulinum toxin-A (BTX-A) in men with refractory chronic prostatitis-associated chronic pelvic-pain syndrome (CP/CPPS) and to compare the efficacy of the transurethral and transrectal routes.

PATIENTS AND METHODS

In an uncontrolled randomised clinical trial conducted in men with refractory CP/CPPS, the patients were classified into two groups according to the route of BTX-A injection; transurethral (group 1, 28 patients) and transrectal ultrasonography-guided (group 2, 35 patients). The chronic prostatitis symptom index (CPSI), maximum urinary flow rate (Q max) and white blood cell (WBC) count in expressed prostatic secretion (EPS) were measured before and at 3, 6 and 12 months after the injection. A significant clinical improvement (SCI, defined as a reduction of 4 points or a 25% decrease in total CPSI score) was correlated with patient age, prostate volume and symptom duration.

RESULTS

In group 1, the pain and quality-of-life domain scores improved, but statistically significantly only at 6 months. The voiding score improved at all follow-up visits. In group 2 there was a significant improvement in all the CPSI domain scores at all follow-up visits, except for pain, which was insignificantly improved by 12 months. The SCI ratings in groups 1 and 2 were 36%, 79% and 57%, and 49%, 89% and 74% in group 2 at the three follow-up visits, respectively. The Q max was significantly improved in both groups during the follow-up (except at 12 months in group 1). There was a significant reduction in the mean WBC count in the EPS in patients with inflammatory prostatitis. Both prostate volume and symptom duration were significantly associated with a lower SCI rating.

CONCLUSION

BTX-A is an available treatment option for patients with refractory CP/CPPS. It is more effective in patients with a small prostate and short symptom duration. The transrectal route provided better results than the transurethral route. More prospective longer term studies are needed.

Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome

Prostatitis comprises of a group of syndromes that affect almost 50% of men at least once in their lifetime and makeup the majority of visits to the Urology Clinics. After much debate, it has been divided into four distinct categories by National Institutes of Health namely (1) acute bacterial prostatitis; (2) chronic bacterial prostatitis; (3) chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) which is further divided into inflammatory and non-inflammatory CP/CPPS; and (4) asymptomatic inflammatory prostatitis. CP/CPPS has been a cause of great concern for both patients and physicians because of the lack of presence of thorough information about the etiological factors along with the difficult-to-treat nature of the syndrome. For the presented manuscript an extensive search on PubMed was conducted for CP/CPPS aimed to present an updated review on the evaluation and treatment options available for patients with CP/CPPS. Several diagnostic criteria’s have been established to diagnose CP/CPPS, with prostatic/pelvic pain for at least 3 mo being the major classifying symptom along with the presence of lower urinary tract symptoms and/or ejaculatory pain. Diagnostic tests can help differentiate CP/CPPS from other syndromes that come under the heading of prostatitis by ruling out active urinary tract infection and/or prostatic infection with uropathogen by performing urine cultures, Meares-Stamey Four Glass Test, Pre- and Post-Massage Two Glass Test. Asymptomatic inflammatory prostatitis is confirmed through prostate biopsy done for elevated serum prostate-specific antigen levels or abnormal digital rectal examination. Researchers have been unable to link a single etiological factor to the pathogenesis of CP/CPPS, instead a cluster of potential etiologies including atypical bacterial or nanobacterial infection, autoimmunity, neurological dysfunction and pelvic floor muscle dysfunction are most commonly implicated. Initially monotherapy with anti-biotics and alpha adrenergic-blockers can be tried, but its success has only been observed in treatment naïve population. Other pharmacotherapies including phytotherapy, neuromodulatory drugs and anti-inflammatories achieved limited success in trials. Complementary and interventional therapies including acupuncture, myofascial trigger point release and pelvic floor biofeedback have been employed. This review points towards the fact that treatment should be tailored individually for patients based on their symptoms. Patients can be stratified phenotypically based on the UPOINT system constituting of Urinary, Psychosocial, Organ-specific, Infectious, Neurologic/Systemic and symptoms of muscular Tenderness and the treatment algorithm should be proposed accordingly. Treatment of CP/CPPS should be aimed towards treating local as well as central factors causing the symptoms. Surgical intervention can cause significant morbidity and should only be reserved for treatment-refractory patients that have previously failed to respond to multiple drug therapies.

Clinical significance of national institutes of health classification in patients with chronic prostatitis/chronic pelvic pain syndrome

Purpose

We determined the effects of alpha-blockers and quinolone in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) classified by National Institute of Health (NIH) consensus group.

Materials and Methods

Data from a total of 111 patients who were diagnosed with CP/CPPS between June 2010 and June 2012 were analyzed retrospectively. The patients were classified into group 1 (category IIIA, n=40) and group 2 (category IIIB, n=71). Treatment using alfuzosin and levofloxacin was given to both groups for 6 weeks. International Prostate Symptom Score (IPSS) and NIH Chronic Prostatitis Symptom Index were measured before and after therapy.

Results

Group 1 had a significant decrease in total IPSS score, CPSI pain score, CPSI quality of life (QoL) score, and total CPSI score (p=0.043, p=0.006, p=0.015, and p=0.006, respectively). Group 2 had a significant decrease in IPSS voiding symptom score, IPSS storage symptom score, total IPSS, CPSI pain score, CPSI voiding score, CPSI QoL score, and total CPSI score (p=0.002, p=0.004, p=0.001, p=0.001, p=0.006, p=0.001, and p=0.001, respectively). The CPSI score was reduced by 6 points or more in 50.0% of patients (n=18) in group 1 and in 51.6% of patients (n=32) in group 2. However, there was no statistically significant difference between the changes in IPSS and CPSI scores across the 2 groups.

Conclusions

Although combination treatment reduced the CPSI score in both groups, there was no significant difference between the groups after combination treatment. We suggest that factors other than inflammation also contribute to symptoms associated with CP/CPPS.

Prostatitis and chronic prostatitis/chronic pelvic pain syndrome

The prevalence of prostatitis is extremely high, with up to 16% of men diagnosed with prostatitis at some point throughout their lifetime. However, the etiology appears to be multifactorial and standard treatment regimens have been altered significantly in recent years. The purpose of this review is to examine the changing scientific views on the causes and treatment of prostatitis, chronic prostaitis and chronic pelvic pain syndrome. We review the infectious and noninfectious etiology of the disease, examining the role of antimicrobial treatment in eradicating infection as well as ameliorating symptoms. Current NIH classifications, which stratify prostatitis into four categories, are discussed, as is the NIH Chronic Prostatitis Symptom Index, the primary tool used to assess symptomatology. Diagnostic examinations are studying the need for the four-glass test and its practical replacement by the two-glass test. Multimodal treatment therapy is then discussed, including recent data on biofeedback and evaluation of the role of pelvic floor dysfunction in prostatitis.

Influence of infection on the distribution patterns of NIH-Chronic Prostatitis Symptom Index scores in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a complex condition for which the etiological determinants are still poorly defined. To better characterize the diagnostic and therapeutic profile of patients, an algorithm known as UPOINT was created, addressing six major phenotypic domains of CP/CPPS, specifically the urinary (U), psycho-social (P), organ-specific (O), infection (I), neurological/systemic (N) and muscular tenderness (T) domains. An additional sexual dysfunction domain may be included in the UPOINT(S) system. The impact of the infection domain on the severity of CP/CPPS symptoms is a controversial issue, due to the contradictory results of different trials. The aim of the present retrospective study was to further analyze the extent to which a positive infection domain of UPOINTS may modify the pattern of CP/CPPS symptom scores, assessed with the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI). In a cohort of 935 patients that was divided on the basis of the presence or absence of prostatic infection, more severe clinical symptoms were shown by the patients with infection (median NIH total score: 24 versus 20 points in uninfected patients; P<0.001). Moreover, NIH-CPSI score distribution curves were shifted towards more severe symptoms in patients with a positive infection domain. Division of the patients into the six most prominent phenotypic clusters of UPOINTS revealed that the ‘prostate infection-related sexual dysfunction’ cluster, including the highest proportion of patients with evidence of infection (80%), scored the highest number of NIH-CPSI points among all the clusters. To assess the influence of the infection domain on the severity of patients’ symptoms, all subjects with evidence of infection were withdrawn from the ‘prostate infection-related sexual dysfunction’ cluster. This modified cluster showed symptom scores significantly less severe than the original cluster, and the CPSI values became comparable to the scores of the five other clusters, which were virtually devoid of patients with evidence of infection. These results suggest that the presence of pathogens in the prostate gland may significantly affect the clinical presentation of patients affected by CP/CPPS, and that the infection domain may be a determinant of the severity of CP/CPPS symptoms in clusters of patients phenotyped with the UPOINTS system. This evidence may convey considerable therapeutic implications.

Eliminating sedimentation for the treatment of chronic pelvic pain syndrome

The aim of this study was to evaluate the curative effects of eliminating sedimentation inside the prostate via manipulation for the treatment of chronic pelvic pain syndrome (CPPS) using the National Institutes of Health (NIH)-chronic prostatitis symptom index (CPSI) scores. According to the prostatitis classification standard of the NIH, 721 patients with CPPS were divided into groups IIIA and IIIB by prostatic fluid routine examination (EPSRt) and treated using manipulation. The treatment was performed once per 3 days for 3–5 min and 10 treatments were considered to be a period. The EPSRt and NIH-CPSI scores were tested before and at the end of each period following treatment. After 3 treatment periods, the effectiveness and total effectiveness rates of the IIIA group were 72.3 and 15.9%, respectively and those of the IIIB group were 71.8 and 16.3%, respectively. Statistical analysis showed no significant differences between the curative effects in the two groups (P>0.05). The NIH-CPSI scores of the two groups were significantly improved following each treatment period (P<0.01). Eliminating sedimentation using manipulation dispersed the blockage, discharged the turbidity and cleared the gland, leading to the elimination of sedimentation and the relief of sinus hyperemia around the prostate, which significantly improved the clinical symptoms of CPPS and the quality of life of the patients.

Management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): the studies, the evidence, and the impact

INTRODUCTION

The development of an accepted clinical definition, classification system and validated outcome questionnaire for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has led to a flurry of clinical trial activity over the last 15 years.

METHODS

Twenty-four of these studies enrolled a homogeneous population of CP/CPPS patients, were prospective randomized placebo or sham controlled, and employed the National Institutes of Health chronic prostatitis symptom index (CPSI) as an outcome parameter.

RESULTS

This review of the evidence and clinical impact from these studies suggests that physician's strict adherence to a rigid evidence-based approach for the treatment of a CP/CPPS patient will result in disappointed patients as well as disappointed physicians.

CONCLUSIONS

There is no one particular treatment that shows significant clinical efficacy to be recommended as a mono-therapy for CP/CPPS. Therefore, the physician must adapt his knowledge and interpretation of the evidence from randomized placebo- and sham-controlled trials to determine what therapy or therapies are best indicated for each individual patient.

Safety and efficacy of levofloxacin versus ciprofloxacin for the treatment of chronic bacterial prostatitis in Chinese patients

Levofloxacin is a synthetic fluoroquinolone that is usually used to treat chronic bacterial prostatitis. We investigated the safety and efficacy of levofloxacin compared with ciprofloxacin for the treatment of chronic bacterial prostatitis in Chinese patients. This was a multicenter, open-label, randomized controlled non-inferiority trial. Four hundred and seventy-one patients with clinical symptoms/signs were enrolled into the study, and 408 patients were microbiologically confirmed chronic bacterial prostatitis, who were randomized to either oral levofloxacin (500 mg q.d.) or ciprofloxacin (500 mg b.i.d.) for 4 weeks. Bacterial clearance rate, clinical symptoms/signs, adverse reactions and disease recurrence were assessed. The clinical symptoms and signs (including dysuria, perineal discomfort or pain) and bacteria cultures in 209 patients treated with levofloxacin and 199 patients treated with ciprofloxacin were similar. The most common bacteria were Escherichia coli and Staphylococcus aureus. One to four weeks after the end of 4 weeks treatment, the bacterial clearance rate (86.06% vs. 60.03%; P<0.05) and the clinical efficacy (including clinical cure and clinical improvement(93.30% vs. 71.86%; P<0.05)) were significantly higher in the levofloxacin-treated group than in the ciprofloxacin-treated group. The microbiological recurrence rate was significantly lower in the levofloxacin-treated group than in the ciprofloxacin-treated group (4.00% vs. 19.25%; P<0.05). Rates of adverse events and treatment-related adverse events were slightly lower in the levofloxacin-treated group than in ciprofloxacin-treated group. Levofloxacin showed some advantages over ciprofloxacin in terms of clinical efficacy and disease recurrence, with a low rate of adverse events, for the treatment of chronic bacterial prostatitis in Chinese patients.

Effect of prostatitis on lower urinary tract symptoms: retrospective analysis of prostate biopsy tissue

Purpose

Most patients, even some urologists, assume that prostate volume is the most important prognostic factor for lower urinary tract symptoms (LUTS). In some cases, however, prostatic inflammation is a more important factor in LUTS than is prostate volume. For this reason, comparison of the impact on LUTS of inflammation and prostate volume is an attractive issue.

Materials and Methods

From January 2000 to May 2009, 1,065 men aged between 47 and 91 years (who underwent transrectal ultrasound-guided prostate needle biopsy and transurethral prostatectomy) were retrospectively investigated. Components such as age, serum prostate-specific antigen (PSA) level, prostate volume, and the presence of prostatitis were investigated through independent-sample t-tests, chi-square tests, and univariate and multivariate analyses.

Results

Chi-square tests between prostatitis, prostate volume, serum PSA, and severe LUTS showed that prostate volume (R=0.173; p=0.041) and prostatitis (R=0.148; p<0.001) were related to LUTS. In particular, for a prostate volume under 50 ml, prostatitis was a stronger risk factor than was prostate volume. Among the multivariate predictors, prostatitis (odds ratio [OR]: 1.945; p<0.001) and prostate volume (OR, 1.029; p<0.001) were found to be aggravating factors of LUTS.

Conclusions

For patients with prostate volume less than 50 ml, prostatitis was found to be a more vulnerable factor for LUTS. For those with prostate volume over 50 ml, on the other hand, the volume itself was a more significant risk factor than was prostatitis. In conclusion, the presence of prostatitis is one of the risk factors for LUTS with increased prostate volume.

Tamsulosin Monotherapy versus Combination Therapy with Antibiotics or Anti-Inflammatory Agents in the Treatment of Chronic Pelvic Pain Syndrome

Purpose

Chronic pelvic pain syndrome (CPPS) is treated by use of various protocols. We compared tamsulosin monotherapy with tamsulosin in combination with antibiotics or anti-inflammatory agents and evaluated the efficacy of these treatments in patients with CPPS.

Methods

Patients (n=107) who were younger than 55 years and diagnosed with CPPS were randomly assigned to treatment with tamsulosin at 0.2 mg (group A), tamsulosin at 0.2 mg plus anti-inflammatory drugs (group B) or tamsulosin at 0.2 mg plus antibiotics (group C) daily. We applied the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostate Symptom Score (IPSS) to evaluate 100 patients who were treated for 12 weeks (7 withdrew). Scores of the three groups were compared by analysis of variance and we also evaluated subscores, which included pain, voiding and quality of life (QoL).

Results

All three groups showed statistically significant decreases in NIH-CPSI score, IPSS and subscore scores (P<0.05). There were no statistically significant differences between the groups except for the QoL domain of the IPSS (group A vs. C; P<0.01).

Conclusions

Tamsulosin monotherapy for 12 weeks was effective for treating patients with CPPS, compared with combination therapy with antibiotics or anti-inflammatory drugs.

Phenotypic approach to the management of the chronic prostatitis/chronic pelvic pain syndrome

• Our traditional approach to managing the chronic prostatitis (CP) syndromes has not been very successful for many of our patients. • Our developing understanding of CP/chronic pelvic pain syndrome (CP/CPPS) as a heterogeneous syndrome rather than a homogenous disease has allowed us to develop treatment strategies based on individual patient characteristics. • By considering each patient as a unique individual and tailoring treatments to a specific patient's clinical 'phenotype' we improve our therapeutic outcomes.

Pharmacotherapy strategies in chronic prostatitis/chronic pelvic pain syndrome management

IMPORTANCE OF THE FIELD

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is one of the most common diagnoses arising out of urologic office visits. It is a costly problem and sufferers compare the effect of this syndrome on quality of life as being similar to the effects of diabetes mellitus and myocardial infarction. The syndrome is variable in presentation and symptom management and efficacy will vary between inflicted men.

AREAS COVERED IN THIS REVIEW

CP/CPPS is not highly responsive to therapy. As such, it is often a waxing and waning illness with symptoms in multiple domains, including urinary symptoms, pain and ejaculatory dysfunction. The pharmacotherapeutic options and management strategies for CP/CPPS presented in this review are based on the published literature from September 1989 to January 2010. When available, randomized, placebo-controlled studies were reviewed to aid in making definitive recommendations for treatment strategies.

WHAT THE READER WILL GAIN

The reader will be familiarized with the commonly used classes of pharmaceutical and non-pharmaceutical therapies. Readers will then use the efficacy data to inform treatment decisions for patients with disparate symptomatology. This will be crystallized in the author's treatment algorithm and summary statement.

TAKE HOME MESSAGE

Many practitioners use antimicrobials as a first-line agent, particularly a fluoroquinolone, such as levofloxacin. Trimethoprim/sulfamethoxazole is another medication alternative, with comparable response rates. Many afflicted men will have significant improvement on a 4- to 6-week regimen of a fluoroquinolone antibiotic. Second-line pharmacotherapy includes alpha-blockers, 5-alpha reductase inhibitors and anti-inflammatories for men with urinary symptoms or pain as a predominant symptom domain. Other pharmacotherapy includes steroids, glycosaminoglycans and phytotherapy. Surgical options are generally not recommended for CP/CPPS. Despite the lack of curative therapies, effective symptom management can be achieved with knowledge of the classes of pharmacotherapy. Therapeutic decisions can be based on the symptoms of the patient. Pelvic floor physical therapy is a useful second-line therapy in the author's opinion, but randomized controlled trials and standardization of technique for CP/CPPS are needed before recommendations can be substantiated.

Loss of Nkx3.1 expression in bacterial prostatitis: a potential link between inflammation and neoplasia

NKX3.1 is a homeodomain protein that functions as a dosage sensitive prostate-specific transcription factor. Diminished NKX3.1 expression is associated with prostate epithelial cell proliferation in vitro and with increasing Gleason grade in patient samples. Mouse Nkx3.1 also functions as a negative regulator of prostate cell growth in prostate cancer models. Identifying biological and environmental factors that modulate NKX3.1 accumulation is therefore central to efforts aimed at elucidating prostate growth control mechanisms. To determine the effect of inflammation on Nxk3.1 accumulation, bacterial prostatitis was induced by intraurethral inoculation of a uropathogenic E. coli strain in mice. Nkx3.1 expression was profoundly reduced in infected prostate lobes and correlated with increased expression of a proliferation marker. Androgen receptor levels were also reduced in concert with Nkx3.1, and a marked increase in the basal cell marker p63 was observed. Analyses of the inflammatory infiltrate revealed a classic acute inflammatory response that attained characteristics of a chronic state within fourteen days postinoculation. Comparison of the four prostate lobes revealed clear differences in the extent of inflammation. These data demonstrate that acute inflammation in response to a bacterial agent in the prostate is associated with a significant diminution in the level of a key regulator of prostate cell proliferation. These observations provide a plausible mechanism whereby prostate inflammation may establish a local environment conducive to epithelial cell growth.

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.

Chronic prostatitis: management strategies

The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this review involves a 4- to 6-week course of antibacterials, which may be repeated if the initial course provides relief. Pain and urinary symptoms can be ameliorated with anti-inflammatories and alpha-blockers. If the relief is not significant, then patients should be referred for biofeedback. Minimally invasive surgical options should be reserved for treatment-refractory patients.

Treatment of chronic prostatitis in Chinese men

The aim of this study is to assess the status of treatment of chronic prostatitis (CP) in Chinese men. A population-based cross-sectional survey was performed, in which 15 000 men aged between 15 and 60 years were randomly selected to receive a questionnaire designed to assess National Institutes of Health Chronic Prostatitis Symptoms Index (NIH-CPSI) status, therapeutic efficacy and 28 other items. A total of 12 743 men (84.95%) completed the questionnaire, of whom 1 071 (8.4%) were identified as having prostatitis-like symptoms and 517 (4.5%) were diagnosed with CP according to NIH-CPSI criteria and prostatitis-like symptomatology. Of the CP patients, 372 (65%) underwent long-term routine treatment 12 times per year. Additionally, 217 (72.8%) patients received antibiotic therapy and 215 (79.3%) men showed therapeutic effects. The treatment cost USD 1 151 (8 059 yuan) per person per year on average. Most CP patients received routine treatment, in most cases with antibiotics. Treatment was costly and most CP patients were not satisfied with its effectiveness. Antibacterial treatment might have been effective primarily in patients with bacterial disease.

Excessive antibiotic use in men with prostatitis

BACKGROUND

Prostatitis accounts for 2 million outpatient visits annually. The majority of prostatitis cases fit the definition of chronic pelvic pain syndrome, for which routine antibiotic use is not indicated.

METHODS

Inpatient, outpatient, and pharmacy datasets from the Veterans Health Administration were used to quantify the magnitude of antibiotic use attributable to chronic pelvic pain syndrome. Specifically, men with a diagnosis of infectious/acute prostatitis or a urinary tract infection were excluded, and the remaining men with a diagnosis of prostatitis were defined as having chronic pelvic pain syndrome.

RESULTS

The annual prevalence of chronic pelvic pain syndrome was 0.5%. Prescriptions for fluoroquinolone antibiotics were filled in 49% of men with a diagnosis of chronic pelvic pain syndrome compared with 5% in men without chronic pelvic pain syndrome. Men with chronic pelvic pain syndrome were more than 7 times more likely to receive a fluoroquinolone prescription independently of age, race/ethnicity, and comorbid conditions. Increased use of other antibiotics also was observed. High use was similar in men with either infectious/acute prostatitis or chronic pelvic pain syndrome.

CONCLUSION

Despite evidence that antibiotics are not effective in the majority of men with chronic pelvic pain syndrome, they were prescribed in 69% of men with this diagnosis. Some increased use is probably due to uncontrolled confounding by comorbid conditions or inaccurate diagnostic coding. However, a 7-fold higher rate of fluoroquinolone usage suggests that strategies to reduce unnecessary antibiotic use in men with prostatitis are warranted.

Treatment for chronic prostatitis/chronic pelvic pain syndrome: levofloxacin, doxazosin and their combination

INTRODUCTION

We performed a prospective, randomized study to examine the efficacies of levofloxacin and doxazosin alone and as a combination therapy in patients with National Institutes of Health (NIH) category III chronic prostatitis/chronic pelvic pain syndrome.

PATIENTS AND METHODS

Men with a NIH diagnosis of category III chronic prostatitis/chronic pelvic pain syndrome and who had experienced pelvic pain for more than 3 months during the last 6 months were enrolled. All patients underwent treatment for 6 weeks. The patients were assessed at baseline and after 2 and 6 weeks by using the NIH Chronic Prostatitis Symptom Index. Eighty-one men (average age 40.1 years) were randomized to either the levofloxacin group (n = 26), the doxazosin group (n = 26), or the combination group (n = 29).

RESULTS

The average baseline NIH Chronic Prostatitis Symptom Index total scores were 22.6, 22.4, and 24.1, respectively. At 6 weeks, the total scores were 11.2 (response rate 50.3%), 17.7 (response rate 21.1%), and 13.1 (response rate 45.6%), respectively. The levofloxacin group showed a higher response rate than the doxazosin group, not at 2 weeks but at 6 weeks (p < 0.001).

CONCLUSIONS

For a 6-week short-term treatment levofloxacin is more effective than doxazosin for chronic prostatitis/chronic pelvic pain syndrome. In addition, levofloxacin monotherapy was also more effective when compared with the combination therapy.

A molecular analysis of prokaryotic and viral DNA sequences in prostate tissue from patients with prostate cancer indicates the presence of multiple and diverse microorganisms

BACKGROUND

Inflammation, both acute and chronic, is a common feature of prostate histology. While inflammation has been proposed to play an important role in both benign and malignant growth of the prostate, the stimuli for this inflammation remain poorly characterized. Infectious pathogens are potential stimuli for prostatic inflammation.

METHODS

Universal eubacterial PCR was used to test 170 prostate tissue core samples from 30 cancer patients for 16S rDNA gene sequences. Positive PCR products (n=64, 37%) were cloned and sequenced. For comparison, tissue samples from 30 patients were cultured using standard clinical microbiological techniques. DNA samples from 200 additional patients were tested by organism-specific PCR for the presence of Chlamydia trachomatis, Propionibacterium acnes, Trichomonas vaginalis, BK virus, Epstein-Barr virus, human cytomegalovirus, human papillomavirus, and xenotropic murine leukemia-related virus.

RESULTS

16S sequencing results indicated the presence of 83 distinct microorganisms. Microbiological culture isolated markedly fewer species. In general, organism-specific PCR failed to detect multiple organisms previously reported as common in the prostate. There was no significant association between the presence of particular species of bacteria and histologic evidence of acute or chronic inflammation.

CONCLUSIONS

Most prostates from men undergoing prostatectomy (87%) contain bacterial DNA from one or more species. However, the majority of individual tissue core samples were negative, suggesting regional heterogeneity in the presence of bacteria and a lack of a generalized or ubiquitous prostatic flora. Culture results suggest either the "unculturable" nature of species present in the prostate or that 16S rDNA sequences were derived from non-viable bacteria.

Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis

BACKGROUND

There is currently a lack of consensus for the diagnosis, investigations and treatments of acute bacterial prostatitis (AP).

METHODS

The symptoms, investigations and treatments of 371 inpatients diagnosed with AP were analyzed through a retrospective study conducted in four departments - Urology (U), Infectious Diseases (ID), Internal Medicine (IM), Geriatrics (G) - of two French university hospitals.

RESULTS

The cause of admission, symptoms, investigations and treatments depended markedly on the department of admission but not on the hospital. In U, patients commonly presented with a bladder outlet obstruction, they had a large imaging and functional check-up, and received alpha-blockers and anti-inflammatory drugs. In ID, patients were febrile and received longer and more appropriate antibiotic treatments. In G, patients presented with cognitive disorders and commonly had post-void urine volume measurements. In IM, patients presented with a wide range of symptoms, and had very diverse investigations and antibiotic regimen.Overall, a 3:1 ratio of community-acquired AP (CA-AP) to nosocomial AP (N-AP) was observed. Urine culture isolated mainly E. coli (58% of AP, 68% of CA-AP), with venereal agents constituting less than 1%. The probabilistic antibiotic treatments were similar for N-AP and CA-AP (58% bi-therapy; 63% fluoroquinolone-based regimen). For N-AP, these treatments were more likely to be inadequate (42% vs. 8%, p < 0.001) and had a higher rate of bacteriological failure (48% vs. 19%, p < 0.001). Clinical failure at follow-up was more common than bacteriological failure (75% versus 24%, p < 0.001). Patients older than 49 had more underlying urinary tract disorders and a higher rate of clinical failure (30% versus 10%, p < 0.0001).

CONCLUSION

This study highlights the difficulties encountered on a daily basis by the physicians regarding the diagnosis and management of acute prostatitis.

Treatment of chronic prostatitis/chronic pelvic pain syndrome

Acceptance of the National Institutes of Health definition of Category III Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) and the development and validation of the Chronic Prostatitis Symptom Index has stimulated significant research into treatment of this condition. Evidence-based suggestions for treatment include the following. (i) Antimicrobials cannot be recommended for men with longstanding, previously treated CP/CPPS. (ii) Alpha-blockers can be recommended as first-line medical therapy, particularly in alpha-blocker-naïve men with moderately severe symptoms who have relatively recent onset of symptoms. (iii) Alpha-blockers cannot be recommended in men with longstanding CP/CPPS who have tried and failed alpha-blockers in the past. And (iv) anti-inflammatory therapy, finasteride and pentosan polysulfate are not recommended as primary treatment; however, they may have a useful adjunctive role in a multimodal therapeutic regimen. Early data on herbal therapies, particularly quercetin and cernilton, are intriguing, but larger multicentre, randomised, placebo-controlled trials are required before a high level of evidence recommendation can be made on its use. At this time, surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.

Sexual dysfunction and prostatitis

Despite a large number of reports exploring the links between diseases of the prostate and effects on sexuality, the relationship between prostatitis and sexual dysfunction has not been as thoroughly investigated. A number of reports have focused on the adverse effects of prostatitis on quality of life, with resultant indirect effects on sexuality. More detailed studies are available on the links between ejaculation and the chronic prostatitis/chronic pelvic pain syndrome subgroup of prostatitis. Improvement of sexual dysfunction following treatment of prostatitis has been reported in a few studies, most notably in association with alpha-blocker therapy. This review addresses some of the more relevant reported links between prostatitis and sexual function.

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.

[Classification, etiology, diagnosis and treatment of prostatitis. Other types of prostatitis. Acute and chronic prostatitis]

Prostatitis is a highly prevalent nosologic entity and hence has an enormous financial impact on health systems as well as negative repercussions on patients' quality of life. The symptoms are ambiguous, diagnostic methods are controversial and treatments are long and produce inconsistent results; consequently, although not life-threatening, prostatitis has become one of those diseases that is difficult both for the patient and for the physician who attempts to help, sometimes without success. Although an infectious etiology is accepted in most cases, there are major controversies about both the diagnostic methods used and their interpretation. Recently the National Institutes of Health in the USA has proposed a new classification of this disease to substitute that used for the last twenty years. This new classification may provide a more effective approach to the diagnosis and treatment of this insidious disease.

Chronic prostatitis: Charlottesville to Seattle

PURPOSE

Since few men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) have culturable bacteria by traditional approaches, we used sensitive molecular methods to determine presence of fastidious microorganisms.

MATERIALS AND METHODS

We evaluated 135 men with CP/CPPS by standardized clinical evaluation, and by lower tract localization cultures and chamber counts of expressed prostatic secretions of leukocytes. We excluded from study patients with bacteriuria, bacterial prostatitis, urethritis or positive urethral cultures. Prostate biopsy was obtained using a double-needle technique to limit contamination. We chose molecular approaches because previous studies had used culture antigen detection in urine, urethral swabs and expressed prostatic secretions. However, interpretation of such studies is complicated because urogenital samples often acquire bacteria while passing through the urethra. We used specific and broad-spectrum polymerase chain reaction (PCR) assays.

RESULTS

Only 10 (8%) of the 135 subjects had positive specific PCR assays, including Mycoplasmia genitalium, Chlamydia trachomatis and Trichomonas vaginalis. Our findings suggested that C. trachomatis, T. vaginalis and M. genitalium may be identified in some patients with CP/CPPS, even among men with no evidence of urethritis and with negative urethral cultures and other assays. The broad-spectrum PCR assays provided the most provocative findings. DNA encoding tetracycline resistance was identified in 25% of subjects, and 77% of subjects had evidence of 16S rDNAs. The white blood cell concentration in the prostatic secretions correlated with identification of 16S rDNAs in prostate tissue (p <0.01).

CONCLUSIONS

Delineating the precise role of these organisms in the etiology of CP/CPPS may help define better diagnostic and treatment algorithms.

The management of chronic prostatitis in men with HIV

Prostatitis is a common urologic diagnosis. Although treatment algorithms are available for this poorly understood entity, several adaptations must be made in order to accommodate the therapeutic needs of HIV-positive patients. The most important consideration when treating HIV-infected patients for prostatitis is their current immune status, whether they are immunocompromised or not (non-progressive disease or reconstituted with highly active antiretroviral therapy). A treatment algorithm for those with chronic bacterial prostatitis (Category II), chronic nonbacterial prostatitis (Category IIIA), and prostatodynia (Category IIIB) is presented in this article. In the HIV-positive patient population, there is a greater likelihood for atypical pathogens including fungi, tuberculosis, anaerobes, and viruses. Because the HIV-infected patient is at increased risk for the development of prostatic abscess and urosepsis than the general population, increased monitoring and evaluation and longer-term appropriately directed antimicrobial therapy are required.

More effects of extracorporeal magnetic innervation and terazosin therapy than terazosin therapy alone for non-inflammatory chronic pelvic pain syndrome: a pilot study

The objective of this study was to evaluate whether extracorporeal magnetic innervation (ExMI) combined with alpha-blocker therapy is more effective than alpha-blocker monotherapy for patients with non-inflammatory chronic prostatitis (CP)/chronic pelvic pain syndrome (CPPS), category IIIB. Patients were randomized to either terazosin monotherapy (group 1, n=21) or terazosin combined with ExMI therapy (group 2, n=19). Patients in group 2 had 12 treatment sessions of ExMI twice a week during 6 weeks. None of the patients experienced any side effects from treatment. The changes in each domain of the National Institutes of Health (NIH)-Chronic Prostatitis Symptom Index (CPSI) measured on week 6 were not significantly different between the groups. However, the difference (median, 25-75th percentiles) between the two groups in total NIH-CPSI scores was -4 (-11.5, -2) for group 1 and -12 (-17.3, -2.3) for group 2, respectively (P=0.047). At 6 weeks, 47.6% (10 of 21) of group 1 had a >25% decrease in total NIH-CPSI compared with 78.9% (15 of 19) of group 2 (P=0.041). Also, more patients in group 2 (78.9%) were rated as responders with a 6-point decrease in NIH-CPSI compared with group 1 (47.6%) (P=0.041). The early results suggest that ExMI combined with alpha-blocker therapy has better effect than alpha-blocker monotherapy for the treatment of CP/CPPS.