Prostatitis: evolving management strategies

Results of purified micronized flavonoid fraction in the treatment of categorized type III chronic pelvic pain syndrome: a randomized controlled trial

OBJECTIVES

The management of chronic pelvic pain syndrome (CPPS) is controversial because of the unclear pathogenesis of this disease. In one theory, prostatitis has been proposed to be associated with pelvic venous diseases such as varicocele and hemorrhoids, dilatation of the Santorini plexus. In this study, we investigated the effect of micronized flavonoid fraction (an agent used in venous insufficiency) in the treatment of type III CPPS.

METHODS

Patients diagnosed with type III chronic prostatitis were randomized and divided into 3 groups. Group 1 consisted of patients using antibiotics + anti-inflammatory + alpha-blocker (n = 47), Group 2 consisted of patients using antibiotics + anti-inflammatory + purified micronized flavonoid fraction (n = 45), and Group 3 consisted of patients using only purified micronized flavonoid fraction (n = 35).

RESULTS

The mean age of the patients was 32.93 ± 4.70 (range; 23-44) years. There was a statistically significant difference between the groups in terms of the 6th month NIH-CPSI (National Institute of Health Chronic Prostatitis Symptom Index) total scores (p = .000). Also, it was found that NIH-CPSI total scores at month 12 in Group 3 were significantly higher than those in Group 1 and 2 (p¹ = .000, p² = .002). NIH-CPSI total scores at month 12 in Group 2 were significantly higher than those in Group 1 (p = .000).

CONCLUSION

The use of purified micronized flavonoid will decrease prostatic inflammation occurring due to increased perineal venous return.it can also be preferred as part of multimodal therapy because of its profile with relatively less side effects and being more affordable compared with alpha-blockers.

Exploring the associations between systemic inflammation, obesity and healthy days: a health related quality of life (HRQOL) analysis of NHANES 2005-2008

Background

Obesity is positively associated with low-level chronic inflammation, and negatively associated with several indices of health-related quality of life (HRQOL). It is however not clear if obesity-associated inflammation is partly responsible for the observed negative associations between obesity and HRQOL, and also whether systemic inflammation independently affects HRQOL. We conducted an exploratory analysis to investigate the relationships between obesity, systemic inflammation and indices of HRQOL, using NHANES survey data.

Methods

Data for the variables of interest were available for 6325 adults (aged 20–75 years, BMI > 18.5 kg/m²). Demographic, body mass index (BMI), C-reactive protein (CRP), inflammatory disease status, medication use, smoking, and HRQOL data were obtained from NHANES (2005–2008) and analyzed using sampling-weighted generalized linear models. Data was subjected to multiple imputation in order to mitigate information loss from survey non-response. Both main effects and interaction effects were analyzed to evaluate possible mediation or moderation effects. Model robustness was ascertained via sensitivity analysis. Averaged results from the imputed datasets were reported in as odds ratios (OR) and confidence intervals (CI).

Results

Obesity was positively associated with poor physical healthy days (OR: 1.59, 95% CI: 1.15–2.21) in unadjusted models. ‘Elevated’ and ‘clinically raised’ levels of the inflammation marker CRP were also positively associated with poor physical healthy days (OR = 1.61, 95% CI: 1.23–2.12, and OR = 2.45, 95% CI: 1.84–3.26, respectively); additionally, ‘clinically raised’ CRP was positively associated with mental unhealthy days (OR = 1.66, 95% CI: 1.26–2.19). The association between obesity and physical HRQOL was rendered non-significant in models including CRP. Association between ‘elevated’ and ‘clinically raised’ CRP and physical unhealthy days remained significant even after adjustment for obesity or inflammation-modulating covariates (OR = 1.36, 95% CI: 1.02–1.82, and OR = 1.75, 95% CI: 1.21–2.54, respectively).

Conclusions

Systemic inflammation appears to mediate the association between obesity and physical unhealthy days. Clinically raised inflammation is an independent determinant of physical and mental unhealthy days. Importantly, elevated (but sub-clinical) inflammation is also negatively associated with physical healthy days, and may warrant more attention from a population health perspective than currently appreciated.

Electronic supplementary material

The online version of this article (10.1186/s40608-018-0196-2) contains supplementary material, which is available to authorized users.

Male accessory gland inflammation, infertility, and sexual dysfunctions: a practical approach to diagnosis and therapy

The role of urogenital inflammation in causing infertility and sexual dysfunctions has long been a matter of debate in the international scientific literature. The most recent scientific evidences show that male accessory gland infection/inflammation could alter, with various mechanisms, both conventional and biofunctional sperm parameters, and determine worst reproductive outcome. At the same time, the high prevalence of erectile dysfunction and premature ejaculation in patients with male accessory gland infection/inflammation underlines the close link between these diseases and sexual dysfunctions. The aim of this review was to provide the reader the basis for a correct diagnosis of male accessory gland infection/inflammation and a subsequent appropriate therapeutic approach, particularly in patients with infertility and/or sexual dysfunction.

Chronic bacterial prostatitis and irritable bowel syndrome: effectiveness of treatment with rifaximin followed by the probiotic VSL#3

This study was undertaken to evaluate the influence of treatment with rifaximin followed by the probiotic VSL#3 versus no treatment on the progression of chronic prostatitis toward chronic microbial prostate-vesiculitis (PV) or prostate-vesiculo-epididymitis (PVE). A total of 106 selected infertile male patients with bacteriologically cured chronic bacterial prostatitis (CBP) and irritable bowel syndrome (IBS) were randomly prescribed rifaximin (200 mg, 2 tablets bid, for 7 days monthly for 12 months) and probiotic containing multiple strains VSL#3 (450 × 10⁹ CFU per day) or no treatment. Ninety-five of them (89.6%) complied with the therapeutic plan and were included in this study. Group A = “6Tx/6-”: treatment for the initial 6 and no treatment for the following 6 months (n = 26); Group B = “12Tx”: 12 months of treatment (n = 22); Group C = “6-/6Tx”: no treatment for the initial 6 months and treatment in the last 6 months (n = 23); Group D = “12-”: no treatment (n = 24). The patients of Groups A = “6Tx/6-” and B = “12Tx” had the highest frequency of chronic prostatitis (88.5% and 86.4%, respectively). In contrast, group “12-”: patients had the lowest frequency of prostatitis (33.4%). The progression of prostatitis into PV in groups “6Tx/6-” (15.5%) and “6-/6Tx” (13.6%) was lower than that found in the patients of group “12-” (45.8%). Finally, no patient of groups “6Tx/6-” and “6-/6Tx” had PVE, whereas it was diagnosed in 20.8% of group “12-” patients. Long-term treatment with rifaximin and the probiotic VSL#3 is effective in lowering the progression of prostatitis into more complicated forms of male accessory gland infections in infertile patients with bacteriologically cured CBP plus IBS.

Analgesic effects of oligonol, acupuncture and quantum light therapy on chronic nonbacterial prostatitis

Background:

Chronic Nonbacterial Prostatitis (CNBP) is a condition that frequently causes long-term pain and a significant decrease in the quality of life.

Objectives:

The present study aimed to examine the analgesic effects of oligonol, acupuncture, quantum light therapy and their combinations on estrogen-induced CNBP in rats.

Materials and Methods:

This experimental study was conducted in Edirne, Turkey, using a simple randomized allocation. A total of 90 adult male Wistar rats were randomized into 9 groups of 10 rats each: Group I, control; Group II, CNBP, Group III, oligonol only, Group IV, acupuncture only; Group V, quantum only; Group VI, oligonol + quantum; Group VII, acupuncture + oligonol; Group VIII, quantum + acupuncture; Group IX, acupuncture + quantum + oligonol. Oligonol treatment was given at a dose of 60 mg/day for 6 weeks. Conceptual vessels (CV) 3 and 4, and bilaterally urinary bladder (Bl) 32 and 34 points were targeted with 1-hour acupuncture stimulation. The quantum light therapy was applied in 5-minute sessions for 6 weeks (3-times/a week). For pain measurements, mechanical pressure was applied to a point 2 cm distal to the root of the tail to elicit pain and consequent parameters (peak force, latency time of response and total length of measurement) were assessed.

Results:

Analgesic effects were observed with all treatment regimens; however, the most prominent median analgesic effect was shown in the quantum light therapy in combination with acupuncture for estrogen-induced CNBP (PF1 = 663.9, PF2 = 403.4) (P = 0.012). Furthermore, we observed that monotherapy with quantum light showed a better analgesic efficacy as compared to oligonol and acupuncture monotherapies (PF1 = 1044.6, PF2 = 661.2) (P = 0.018, P = 0.008, P = 0.018; respectively).

Conclusions:

All treatment modalities showed a significant analgesic effect on CNBP in rats, being most prominent with the quantum light therapy.

The effect of chronic bacterial prostatitis on semen quality in adult men: a meta-analysis of case-control studies

Chronic bacterial prostatitis (CBP) is caused by bacterial infection and maintains a condition of lower urinary tract infection. It may be a cause of male infertility. However, studies showed inconsistent results regarding the effect of CBP on several parameters of semen. Hence, we conducted a meta-analysis to examine the effect of CBP on basic semen parameters. A systematic review was conducted with Medline, PubMed, EMBASE, and two Chinese databases (CNKI and WANG FANG) to identify relevant studies that involved the effect of CBP on semen parameters up to July 2014. Both RevMan5.2 and STATA 12.0 software were used for the statistical analysis. Based on the inclusion and exclusion criteria, seven studies were included. The study illustrated that sperm vitality, sperm total motility, and the percentage of progressively motile sperm from CBP patients were significantly lower than controls (SMD(95%CI) −0.81[−1.14, −0.47], −1.00[−1.28, −0.73], −0.41 [−0.70, −0.12], P<0.05, respectively). However, CBP had no significant effect on semen volume, sperm concentration and the duration of semen liquefaction. In summary, our study revealed that there was a significant negative effect of CBP on sperm vitality, sperm total motility, and the percentage of progressively motile sperm. Additional, studies with larger number of subjects are needed.

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.

Antimicrobial Resistance Pattern in Enterococcus faecalis Strains Isolated From Expressed Prostatic Secretions of Patients With Chronic Bacterial Prostatitis

Purpose

Enterococcus faecalis is one of the most common pathogens linked to chronic bacterial prostatitis (CBP). Owing to a limited number of previous studies addressing this topic, we aimed to determine the drug resistance patterns of E. faecalis strains isolated from CBP patients.

Materials and Methods

One thousand twenty-one patients visited a single hospital owing to chronic prostatitis for 5 years. Culture specimens were obtained by use of a modified Meares-Stamey method. The minimal inhibitory concentrations of the antimicrobials were assessed by use of the Vitek II microbial identification system as suggested by the Clinical and Laboratory Standards Institute.

Results

Forty-one samples from 41 patients who had significant E. faecalis loads for defining CBP were included in this study. The E. faecalis strains in our study were resistant to penicillin (9.7%), ampicillin (0%), ampicillin/sulbactam (0%), nitrofurantoin (0%), imipenem (0%), vancomycin (0%), teicoplanin (0%), quinupristin/dalfopristin (100%), ciprofloxacin (9.7%), levofloxacin (4.8%), norfloxacin (26.8%), erythromycin (95%), gentamicin (46.3%), tetracycline (97.5%), and trimethoprim/sulfamethoxazole (31.5%), respectively.

Conclusions

Fluoroquinolones have been the preferred antibiotics for treating CBP. Because of their low rate of drug resistance, fluoroquinolones are suitable therapeutic agents for E. faecalis strains causing CBP in Korea. Even though tetracycline, erythromycin, and trimethoprim/sulfamethoxazole have been prescribed as an empirical antimicrobial therapy for chronic prostatitis, we cannot recommend these drugs for treatment of E. faecalis isolates because of the high rates of drug resistance.

Study strategies for acupuncture treatment of chronic nonbacterial prostatitis

By retrospectively reviewing the current status of traditional Chinese medicine (TCM) and Western medicine treatments of chronic nonbacterial prostatitis (CNP), the TCM understanding of its etiologies and pathogenesis, the therapeutic principles and the mechanisms of acupuncture treatment of CNP, the clinical study strategies of acupuncture treatment for CNP were further proposed, which could provide more scientific basis and support for the definite longer-term therapeutic efficacy of acupuncture treatment of CNP. Breakthrough in the treatment of CNP will be achieved with the application of acupuncture therapy both in clinical practice and experimental research.

Therapeutic efficacy of bipolar radiofrequency thermotherapy for patients with chronic prostatitis: a retrospective analysis of 26 cases

PURPOSE

Chronic prostatitis (CP) does not yet have a universally successful therapy. Alternative treatments including thermotherapy have been adopted in the multimodal management of pain and voiding dysfunction. We retrospectively analyzed the therapeutic efficacy of bipolar radiofrequency thermotherapy for patients who were unsatisfied with conventional medication for CP.

MATERIALS AND METHODS

A retrospective study between October 2009 and September 2010 of 26 patients who were under 50 years old and diagnosed with CP (National Institutes of Health [NIH]-category III) was performed. Twenty patients were diagnosed with inflammatory CP (NIH-category IIIa) and the rest with noninflammatory CP (NIH-category IIIb). We used the Tempro system at an intraprostatic temperature of 55℃ for 50 minutes with a medium heating rate. All patients also completed the NIH-Chronic Prostatitis Symptom Index (CPSI) before and after treatment.

RESULTS

In the patients diagnosed with CP, the mean serum prostate-specific antigen (PSA) level was 0.9±0.3 ng/ml, the prostate volume was 27.1±5.5 g, and the average score for all 3 domains on the NIH-CPSI significantly decreased. The total scores decreased from 19.8±7.1 to 11.1±7.0, the pain domain decreased from 8.6±3.1 to 4.8±3.1, the voiding symptom domain decreased from 5.1±1.8 to 2.9±1.8, and the effect on the quality of life decreased from 6.1±2.2 to 3.4±2.2 (p<0.05).

CONCLUSIONS

Bipolar radiofrequency thermotherapy for patients with CP intractable to conventional medication can provide significant improvement in the NIH-CPSI. Large, randomized controlled trials will also be required to confirm the efficacy of this therapy.

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.

Sexual dysfunction in type III chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) observed in Turkish patients

AIM

Chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is a common disabling condition that is primarily associated with pain in the urogenital region and disturbances in urinary and sexual function. Chronic pelvic pain symptoms are the most common presentation, especially perineal, lower abdominal, testicular, penile as well as ejaculatory pain. Other genitourinary tract complaints include voiding disorders and sexual dysfunction. We aimed in the study at examining the prevalence rates of premature ejaculation and erectile dysfunction in patients with chronic pelvic pain syndrome and comparing these rates with those of healthy control subjects.

MATERIALS AND METHODS

Between November 2006 and January 2008, 85 patients with the diagnosis of CP/CPPS were chosen for the study; 30 patients without regular sexual activity and 12 patients without inclusion criteria were excluded from the study. A total of 43 patients were included in the study. Twenty healthy volunteers without prostatitis-like syndromes were used as a control group. The sexual function of the patients and the healthy volunteers were evaluated using Arizona Sexual Function Questionary Form and International Index of Erectile Function (IIEF). Erectile dysfunction (ED), ejaculatio precox (EP) and pain on ejaculation (PEP) were investigated as sexual dysfunction.

RESULTS

The mean age of the patients was 33.7 (22-48) years; the mean symptom period was 37.7 (6-120) months, while the mean age of the control group was 32.4 (24-48) years. The mean NIH-CPSI score of the patient group was 26.1 (16-34). Patient group was classified as CPPS type IIIa and CPPS type IIIb. Mild and moderate erectile dysfunction (ED) was found in [9] 23.2% patients at the patient group and [2] 10% at the control group (P: 0.185). Severe erectile dysfunction was not found in both groups. Ejaculatio Precox (EP) was found at (29) 67.4% of the patient group and [7] 40% of the control group. Pain on ejaculation (PEP) was detected in [15] 37.2% of the patient group, while none of the control group had pain on ejaculation. More than one sexual dysfunction was found in [17] 41.8% of the patient group and none of the control group. Comparing patient group versus control group, ejaculation disorders (EP and PEP) and more than one sexual dysfunction disorder were statistically significant. According to ED, there is no statistical difference between the groups (P > 0.05).

CONCLUSION

Sexual function disorders, especially ejaculation disorders (EP and PEP), are frequently seen in CP/CPPS patients versus normal population. Age, symptoms period, symptom score and CP/CPPS subgroups are not risk factors for sexual function disorders. Patients with the diagnosis of CP/CPPS should be evaluated for sexual function disorders.

Prevalence of prostatitis-like symptoms in Japanese men: Population-based study in a town in Hokkaido

AIM

To determine the prevalence of prostatitis-like symptoms in Japanese men living in one town.

METHODS

A cross-sectional and population-based study was performed in a town that had 6385 men aged from 20 to 79 years. We sent two questionnaires, the validated Japanese version of the National Institutes of Health Chronic Prostatitis Symptom Index and the International Prostate Symptom Score (I-PSS) with questions about individual medical information, to 1424 randomly selected community-indwelling men. Subjects were defined as having prostatitis-like symptoms if they complained of perineal and/or ejaculatory pain or discomfort and their total pain score was four or greater.

RESULTS

A total of 512 men (36%) responded completely to the questionnaires. Of the 512 responders, 25 men (4.9%) were identified as having prostatitis-like symptoms. Prevalence of symptoms was the same in men aged younger than 50 years (5.0%) as those 50 years and older (4.8%). The I-PSS score was 10.8 in men with prostatitis-like symptoms, which was higher than in those without symptoms.

CONCLUSIONS

Prevalence of prostatitis-like symptoms was 4.9% in randomly selected men. International comparison of prevalence of the symptoms may contribute to further understanding of chronic prostatitis.

A placebo-controlled comparison of the efficiency of triple- and monotherapy in category III B chronic pelvic pain syndrome (CPPS)

OBJECTIVES

To perform a prospective, placebo-controlled study to examine the efficacy of alpha-blocker compared with triple therapy (alpha-blocker, anti-inflammatory, and muscle relaxant) in the treatment of Category IIIB chronic pelvic pain syndrome (Category IIIB CPPS).

MATERIALS AND METHODS

The study was conducted between September 2004 and December 2005, and included 90 treatment naïve patients, aged 22-42 yr (mean age: 29.1+/-5.2) with Category IIIB CPPS, who were randomized into three groups: group 1, alpha-blocker; group 2, combination of alpha-blocker, anti-inflammatory, and muscle relaxant; group 3, placebo once daily. The patients were treated for 6 mo and were followed up for a further 6 mo. Changes from baseline in the total and domain scores of the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) were evaluated. The primary criterion for response was scoring <or=2 on the NIH-CPSI quality of life item. The secondary criterion for response was >50% reduction in NIH-CPSI pain score.

RESULTS

The NIH-CPSI initial and sixth-month total scores were 23.1 and 10.7, respectively, in group 1, and 21.9 and 9.2, respectively, in group 2. The initial and sixth-month scores remained stable in group 3 (22.9 and 21.9, respectively). There was no statistically significant difference between two treatment arms with respect to efficiency of treatment (p>0.05). The responses in groups 1 and 2 were found durable at the end of 12 mo.

CONCLUSIONS

We found that alpha-blocker monotherapy was as effective and safe as triple therapy in the treatment of Category IIIB CPPS.

Catastrophizing and Pain-Contingent Rest Predict Patient Adjustment in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Cognitive/behavioral and environmental variables are significant predictors of patient adjustment in chronic pain. Using a biopsychosocial template and selecting several pain-relevant constructs from physical, cognitive/behavioral, and environmental predictors, outcomes of pain and disability in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were explored. Men (n = 253) from a North American multi-institutional NIH-funded Chronic Prostatitis Cohort Study in 6 US and 1 Canadian centers participated in a survey examining pain and disability. Measures included demographics, urinary symptoms, depression, pain, disability, catastrophizing, control over pain, pain-contingent rest, social support, and solicitous responses from a significant other. Regressions showed that urinary symptoms (beta = .20), depression (beta = .24), and helplessness catastrophizing (beta = .29) predicted overall pain. Further, affective pain was predicted by depression (beta = .39) and helplessness catastrophizing (beta = .44), whereas sensory pain was predicted by urinary symptoms (beta = .25) and helplessness catastrophizing (beta = .37). With regard to disability, urinary symptoms (beta = .17), pain (beta = .21), and pain-contingent rest (beta = .33) were the predictors. These results suggest cognitive/behavioral variables (ie, catastrophizing, pain-contingent rest) may have significant impact on patient adjustment in CP/CPPS. Findings support the need for greater research of such pain-related variables in CP/CPPS.

PERSPECTIVE

This article explores predictors of patient adjustment in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Cognitive/behavioral variables of catastrophizing and pain-contingent rest respectively predicted greater pain and disability. Catastrophic helplessness was a prominent pain predictor. These findings inform clinicians and researchers on several new variables in CP/CPPS outcomes and suggest future research.

[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.

Preliminary experience with a terpene mixture versus ibuprofen for treatment of category III chronic prostatitis/chronic pelvic pain syndrome

To evaluate the efficacy of a terpene mixture (rowatinex) compared to ibuprofen, patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) were randomly selected to either receive rowatinex 200 mg t.i.d. or ibuprofen 600 mg t.i.d. After a 6-week treatment, the decrease in the mean total NIH-CPSI score was significant in both groups from 21.4 to 15.3, (6.1 (p < 0.01) and from 21.2 to 16.8, (4.4 (p = 0.04) in the rowatinex and ibuprofen group, respectively. The rate of definite improvement as defined as 25% improvement in the total score was superior (p = 0.04) in the rowatinex group (68%) versus the ibuprofen group (40%). Judging from these results, rowatinex gave significant symptomatic relief and may be of benefit for many men diagnosed with CP/CPPS. Further, including the placebo-controlled studies are necessary to define its role in the management of this difficult to treat disease.

Epidemiologic risk factors for chronic prostatitis

Chronic prostatitis/chronic pelvic pain syndrome is a multifactorial problem, which affects men of all ages and in all demographics. Recent studies have shown that the prevalence of prostatitis is approximately 2-10% among unselected men in North America, Europe and Asia. This data clearly indicates that chronic prostatitis constitutes an important problem in international health care. Nevertheless, the aetiology and pathogenesis of chronic prostatitis have yet to be clearly delineated, despite the numerous efforts which have been made, with regard to both basic and clinical research. In fact, factors other than leucocytes and bacteria have been shown to contribute to the symptoms typically associated with prostatitis. Studies of the epidemiology and determinants of prostatitis risk factors may also provide clues to the general aetiology of prostatitis. Other epidemiological data appears to indicate that certain as-yet-unknown factors might be associated with an increased tendency towards the development of chronic prostatitis. However, findings from most studies are considered to represent only preliminary data, because of the small sample sizes or lack of generalizability inherent to most of the studies. The identification and characterization of these relevant risk factors might accelerate or augment the development of preventive, diagnostic, and therapeutic strategies for the treatment of these syndromes.

The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III

Recent studies suggest that the symptoms of chronic non-bacterial prostatitis (CP) or Chronic Pelvic Pain Syndrome (CPPS) may be due to or associated with pelvic floor muscle dysfunction. Therapies aimed to improve relaxation and proper use of the pelvic floor muscles such as biofeedback physical therapy and pelvic floor re-education are expected to give symptom improvement. The objective of this study was to evaluate the effect of biofeedback physical therapy on the symptoms of men with CPPS.

MATERIALS AND METHODS

Between March 2000 to March 2004, 33 consecutive men were diagnosed with CP/CPPS based on history including the NIH-CPSI questionnaire and physical examination including pelvic floor muscle tonus, urinalysis, uroflowmetry with residual urine measurement and transrectal ultrasonography of the prostate. All patients participated in a pelvic floor biofeedback re-educating program. A rectal EMG probe was used to measure resting tone of the pelvic floor muscles and was helpful for instruction pelvic floor muscles contraction and relaxation.

RESULTS

Two of the 33 men dropped out. In the remaining 31 men, mean age 43.9 years (range 23-70), the mean total Chronic Prostatitis Symptom Index (NIH-CPSI) changed from 23.6 (range 11-34) at baseline to 11.4 (range 1-25) after treatment (p<0.001). The mean value of the pelvic floor muscle tonus was 4.9 at diagnosis (range 2.0-10.0) and decreased to 1.7 (range 0.5-2.8) after treatment (p<0.001).

CONCLUSIONS

Our study clearly demonstrates a significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS patients, leading to a significant improvement of the symptom score. The correlation between the pelvic muscle tonus results with NIH-CPSI score is highly suggestive that the pelvic floor plays an important role in the pathophysiology of CP/CPPS.

EAU Guidelines on Chronic Pelvic Pain

OBJECTIVES

On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of chronic pelvic pain patients were established.

METHOD

Guidelines were compiled by a working group and based on current literature following a systematic review using MEDLINE. References were weighted by the panel of experts.

RESULTS

The full text of the guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article is a short version of this text and summarises the main conclusions from the guidelines on management of chronic pelvic pain.

CONCLUSION

A guidelines text is presented including chapters on prostate pain and bladder pain syndromes, urethral pain, scrotal pain, pelvic pain in gynaecological practice, role of the pelvic floor and pudendal nerve, general treatment of chronic pelvic pain and neuromodulation. These guidelines have been drawn up to provide support in the management of the large and difficult group of patients suffering from chronic pelvic pain.

In Vitro Activity of Fluoroquinolones, Azithromycin and Doxycycline against Chlamydia Trachomatis Cultured from Men with Chronic Lower Urinary Tract Symptoms

INTRODUCTION

Little is known about chlamydia survival in the presence of fluoroquinolones in patients with chronic prostatitis syndrome (CPS). In vitro activities of four fluoroquinolones, azithromycin and doxycycline against C. trachomatis in patients with CPS being not treated with antibiotics earlier were investigated and compared.

MATERIAL AND METHODS

Chlamydia survival in 304 patients with CPS being not treated with antibiotics earlier was analysed and compared. Infection by C. trachomatis was determined in the urethra and expressed prostatic secretion by cell culture test.

RESULTS

Azithromycin and ofloxacin were found to be the most active antichlamydial agent with ciprofloxacin and doxycycline being least active.

CONCLUSION

Ofloxacin can be recommended as the primary drug in the treatment of chlamydia-infected patients with CPS. The decision on the prescription of other fluoroquinolones should be made individually. The investigation of chlamydia survival in the presence of antibiotics in patients with CPS and C. trachomatis prior to treatment is recommended.

Failure of a monotherapy strategy for difficult chronic prostatitis/chronic pelvic pain syndrome

PURPOSE

We determined the effect of a best evidence based monotherapeutic strategy for patients diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) referred to a specialized prostatitis clinic.

MATERIALS AND METHODS

Patients with CP/CPPS referred by urologists after failure of prescribed therapy for evaluation and treatment at Queen's University prostatitis research clinic were extensively evaluated, aggressively treated following a standardized treatment algorithm and followed for 1 year using a validated prostatitis specific symptom and quality of life instrument, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). All patients underwent a standardized protocol for CP/CPPS including a history, physical examination, standard 4-glass test, plus urethral swab and semen for microscopy and culture, uroflowmetry and residual urine determination. Treatment followed a best evidence based strategy with a standardized monotherapy based algorithm.

RESULTS

A total of 100 consecutive patients with CP/CPPS (average age 42.2 years, range 20 to 70 and average symptom duration 6.5 years, range 0.5 to 39) had 1-year followup after initial evaluation. Patients were prescribed treatment based on documentation of "failed," "successful" and "never tried" therapies based on a standardized treatment algorithm. Patients treated successfully were continued on the prescribed therapy, while therapy was discontinued and new therapy instituted (based on algorithm) in those in whom the initially prescribed therapy failed. At 1 year there was a statistically significant decrease in total NIH-CPSI (23.3 to 19.5, p = 0.0004), pain (11.0 to 9.4, p = 0.03) and quality of life (7.7 to 6.1, p <0.001), but not voiding (4.6 to 4.0, p = 0.12). A perceptible 25% decrease in total NIH-CPSI symptom score was noted in 37% and the greatest improvement was in the quality of life domain (43% of patients had greater than 25% improvement in quality of life). Of the patients 35% had a significant decrease of greater than 6 points in total NIH-CPSI. A clear, clinically significant improvement in total NIH-CPSI (greater than 50% decrease) was noted in 19%.

CONCLUSIONS

Approximately a third of patients with treatment refractory CP/CPPS undergoing extensive evaluation and therapy based on a sequential monotherapy treatment strategy in a specialized prostatitis clinic had at least modest improvement in symptoms during 1 year. This study confirms that a treatment strategy based on the sequential application of monotherapies for patients with a long history of severe CP/CPPS remains relatively poor.

Azithromycin treatment follow-up: antibacterial susceptibility of Chlamydia trachomatis in patients with chronic prostatitis

The antibacterial susceptibility of Chlamydia trachomatis in 138 patients with chronic prostatitis (CP) and clinical failures after antibacterial treatment with azithromycin (AZI) were investigated. Azithromycin was not found to be top-of-the-line drug in the follow-up treatment, showing only average results in vitro. The investigation of the susceptibility of chlamydia to antibiotics in causes of chronic prostatitis is highly recommended.

Minimally invasive therapies for prostatitis

A plethora of reports describe a number of promising new minimally invasive treatment modalities available to patients with chronic prostatitis. This article reviews these studies, with most evaluating treatments using heat or intraprostatic injection. The results are difficult to compare because of the inconsistencies in study design, modalities of treatment, and outcome measures. Standard criteria for assessing symptom severity in chronic prostatitis recently have been developed and prospective clinical trials are underway to evaluate minimally invasive therapies for this debilitating condition. Until definitive data from these trials are available, minimally invasive therapies most likely will continue to be empirical and not a standard of care.

Treatment of chronic prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial

PURPOSE

We compared the efficacy of tamsulosin with placebo for the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

MATERIALS AND METHODS

In a double blind phase II trial, 58 patients 55 years old or younger with moderate to severe CP/CPPS were randomized to receive 0.4 mg tamsulosin or placebo for 6 weeks. Patients were assessed on days -14 and -1 during a 2-week washout, and on days 15 and 45. The primary end point was the change from baseline in total National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score on day 45. Secondary end points were the change from baseline in total NIH-CPSI score on day 15 and the change from baseline in pain, urinary symptoms and quality of life/impact domains of the NIH-CPSI on days 15 and 45. Analyses of responders were performed post hoc.

RESULTS

On day 45 the treatment effect (difference between treatment groups in change from baseline) was -3.6 (p = 0.04) in favor of tamsulosin. The overall effect of tamsulosin was a function of the baseline total NIH-CPSI score. Treatment effect increased significantly as the baseline score increased (for total NIH-CPSI p <0.01). Tamsulosin efficacy was superior to placebo at the 75th percentile of baseline score for the total NIH-CPSI score (-8.3, p <0.01), the pain domain (-2.9, p = 0.02), the urinary symptoms domain (-2.3, p <0.01) and the impact/quality of life domain (-2.1, p = 0.02). The efficacy of tamsulosin increased with time (no significant treatment difference at 15 days) and tamsulosin was well tolerated.

CONCLUSIONS

Tamsulosin was superior to placebo in providing symptomatic relief in men with CP/CPPS, particularly in those with more severe symptoms.

Single-drug or combined antibacterial therapy in the treatment of patients with chronic prostatitis and Chlamydia trachomatis?

The efficacy of antibacterial combinations as compared with single-drug treatment in 57 patients with chronic prostatitis and Chlamydia trachomatis was investigated in this study.

Acute prostatitis in middle-aged men: a prospective study

OBJECTIVES

To determine the clinical outcome of middle-aged men with acute prostatitis, the optimum time for re-assessing their prostate-specific antigen (PSA) levels, and to detect any possible echotextural and vascular changes that remain as a consequence of acute inflammation.

PATIENTS AND METHODS

Persistent fever prompted a re-evaluation for prostatic abscess formation in 28 middle-aged men, using transrectal ultrasonography (TRUS) colour Doppler imaging, undertaken at the 3-, 6- and 12-month visits. The results of TRUS were compared with laboratory data and clinical outcome.

RESULTS

Two abscesses were detected; 19 (68%) of the patients remained infection-free at the 3-month visit. Serum PSA levels were elevated in 11 (39%) of the patients at this visit; three prostate carcinomas were diagnosed. Increased intraprostatic colour flow was detected in 68% and there were hypoechoic areas in 46% of the patients.

CONCLUSION

The re-evaluation for abscess formation should not be postponed for > 48 h. Patients with acute prostatitis tend to have persistent infection. PSA levels could be high even up to 3 months after an acute episode. Middle-aged men with carcinoma could be missed during the acute phase of inflammation. PSA and TRUS monitoring are strongly recommended.

Where do we stand with chronic prostatitis? An update

Chronic prostatitis remains a difficult management problem, which reflects the fact that its aetiology remains incompletely understood. It is a common condition that is characterized by protracted symptoms and high morbidity. Although lacking a reliable diagnostic test, antibiotic therapy remains the mainstay of treatment in the majority of cases.

Questionnaire survey of Japanese urologists concerning the diagnosis and treatment of chronic prostatitis and chronic pelvic pain syndrome

OBJECTIVES

We performed a questionnaire survey to investigate various issues in the diagnosis and treatment of chronic prostatitis/chronic pelvic pain syndrome by Japanese urologists and to clarify the circumstances surrounding prostatitis in Japan.

METHODS

Japanese urologists (n = 1869) were surveyed by mail using a 17-item questionnaire to determine current diagnostic and treatment practices for prostatitis/chronic pelvic pain syndrome.

RESULTS

Only 1.5% (11/739) of urologists diagnosed chronic prostatitis/chronic pelvic pain syndrome using the 4-glass test, while most did so using the 2-glass test (voided bladder [VB]2 and VB3, or VB2 and expressed prostatic secretion [EPS]). Approximately half (55.2%; 412/746) did not perform urine cultures to differentiate chronic bacterial prostatitis from chronic abacterial prostatitis/chronic pelvic pain syndrome. Approximately half (46%; 343/746) did not count the number of leukocytes in VB2 or VB3/EPS to differentiate chronic abacterial prostatitis from chronic pelvic pain syndrome. Although many urologists (63.8%; 459/720) thought that chronic abacterial prostatitis/chronic pelvic pain syndrome was not an infectious disease, many chose antimicrobial agents as the primary treatment. More than half (52.2%; 384/735) of all urologists felt pessimistic about dealing with chronic prostatitis/chronic pelvic pain syndrome compared to treating benign prostatic hypertrophy or prostate cancer, because of the high number of complaints by patients and their own lack of confidence in diagnosing and treating the condition.

CONCLUSION

There is much confusion and frustration among Japanese urologists about chronic prostatitis/chronic pelvic pain syndrome. Further studies are needed to elucidate its etiology and pathogenesis, and to establish guidelines for its diagnosis and treatment.

Transrectal prostatic ultrasonography in acute bacterial prostatitis: findings and clinical implications

To evaluate the role of transrectal ultrasonography (TRUS) in the diagnosis of acute bacterial prostatitis (ABP) and to analyse the possible relationship between sonographic findings and clinical presentation and evolution, a prospective study using TRUS in patients with ABP was conducted. 45 patients (aged 58.2 +/- 14.6 y; mean +/- SD) with a clinical diagnosis of ABP admitted to a university hospital were studied prospectively. Clinical, analytical and microbiological data were recorded. TRUS was performed on admission and after 1 month of antibiotic therapy. Findings were correlated with clinical and evolutive data. The mean prostatic volume on admission was 40.5 +/- 17.9 ml. 21 patients (46.6%) had sonographically demonstrable lesions in peripheral prostatic lobules. One month later, when treatment had ended, lesions had disappeared or improved in 61.1% of patients, and the mean prostatic volume was 24.3 +/- 10.5 ml (p < 0.0005). Clinical, analytical and microbiological data and evolution of ABP were not significantly different in patients with or without sonographically demonstrable lesions. TRUS does not need to be performed in every patient with suspicion of ABP; the only indication for TRUS in ABP is the exclusion of prostatic abscess.

A randomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis

PURPOSE

We determine the effects of treatment with rofecoxib and placebo in patients with chronic prostatitis.

MATERIALS AND METHODS

Patients diagnosed with chronic nonbacterial prostatitis were randomized to 6 weeks of 25 or 50 mg., rofecoxib or placebo in a double-blind multicenter study with a 1-week run in of placebo. End points included the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) (average pain score item 4 primary end point), and patient global assessment questions of pain, disease activity and response to therapy.

RESULTS

A total of 161 patients were randomized in the study. The NIH-CPSI total, domain and pain scores significantly decreased from baseline in all groups and, although the mean scores numerically favored the rofecoxib groups, the difference was not significantly different among groups. There was a trend for the percentage of patients with a 25% (or 6 point) improvement in total score being superior on rofecoxib versus placebo with the difference being significantly different (p <0.05) for the 50 mg. rofecoxib group. Patient global assessment of pain, response to therapy and disease activity also favored rofecoxib over placebo (p <0.05, p = 0.07, p = 0.06, respectively). Of the patients 79% on 50 mg. rofecoxib versus 59% on placebo reported no or mild pain, and 56% of patients on 50 mg. rofecoxib versus 27% on placebo experienced significant improvement in quality of life (p <0.005). Rofecoxib was generally well tolerated.

CONCLUSIONS

To our knowledge this study is the first to evaluate rofecoxib versus placebo in patients with prostatitis and the first large multicenter treatment study to use the NIH-CPSI. Subjective assessment with patient global questions may be more sensitive to change than the NIH-CPSI and, therefore, may be a better tool to use in future therapeutic trials. Although 6 weeks of rofecoxib treatment appear to benefit many men diagnosed with chronic prostatitis/chronic pelvic pain syndrome further studies are needed.

Management of prostatitis

Prostatitis is a common clinical entity with a prevalence rate of 5-9% and accounts for over 2 million hospital visits annually in the USA. It is traditionally classified into acute bacterial, chronic bacterial, abacterial prostatitis and prostatodynia. The recent consensus conference of the US National Institute of Diabetes and Digestive and Kidney Diseases in 2000 resulted in renewed interest in the prevalence, etiology, pathogenesis and treatment of the prostatitis syndromes. In this review, we present the contemporary knowledge and experience regarding the etiology, classification, evaluation and treatment of this condition including the role of transurethral microwave hyperthermia and transurethral needle ablation.

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.

Psychological problems in young men with chronic prostatitis-like symptoms

OBJECTIVE

To take a different perspective in assessing young men with chronic prostatitis-like symptoms, this study was designed since few prospective studies are available to survey a population of young men.

MATERIAL AND METHODS

One hundred and fifty men aged 20 years dwelling in the community were randomly selected. Chronic prostatitis-like symptoms were measured by the National Institutes of Health-Chronic Prostatitis Symptom Index and the selfreported scores for pain and urinary symptoms were used to identify chronic prostatitis-like symptoms. The psychological methods used were the Beck Depression Inventory, the State-Trait Anxiety Inventory, and the Bem Sex Role Inventory. A total of 87 men (a response rate 58%) completed self-administered questionnaires.

RESULTS

As the scores for pain and urinary symptoms increased, those for depression increased (p < 0.001 and p = 0.01, respectively). However, the mean scores for state and trait anxiety were not different according to the scores for pain and urinary symptoms. The mean masculinity scores were not different according to the scores for pain but those were significantly different according to the scores of urinary symptoms (p = 0.042). The mean femininity scores were not different according to the scores of pain and urinary symptoms.

CONCLUSIONS

Our findings suggest that psychological factors, especially depression and weak masculine identity may be associated with an early stage of chronic prostatitis-like symptoms. Young men with chronic prostatitis-like symptoms also have psychological problems.

National institutes of Health Chronic Prostatitis Symptom Index for Japanese men

OBJECTIVES

To establish a Japanese version of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and to determine its validity and applicability in patients with chronic prostatitis, comparing the results with those from patients with benign prostatic hyperplasia (BPH) and normal men.

METHODS

The study included 103 patients with chronic prostatitis, 60 with BPH, and 87 normal men who agreed to respond to a self-administered questionnaire of the Japanese version of the NIH-CPSI (JPN-NIH-CPSI). Testing-retesting was done to confirm the reliability of the index in 23 patients with chronic prostatitis, with a 2-week interval between tests.

RESULTS

Pain or discomfort was more prominent in the prostatitis group than in the BPH and normal groups. Overall, quality of life in the prostatitis group was impaired more severely than that in the other two groups. The scores of three domains (pain, urinary symptoms, and quality-of-life impact) in the prostatitis group were clearly higher than those in the BPH and normal groups, except for those of urinary symptoms in the BPH group. The test-retest analysis showed good reliability and internal consistency for the JPN-NIH-CPSI, with a Cronbach's alpha coefficient of more than 0.8.

CONCLUSIONS

The JPN-NIH-CPSI can be reliably used for evaluation of Japanese patients with prostatitis, as is the NIH-CPSI for English-speaking men.

Nerve growth factor and chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

To investigate whether the pain experienced by patients with chronic prostatitis/chronic pelvic pain syndrome (CPPS) may be related to the expression of nerve growth factor (NGF), induced by inflammation and tissue injury experienced as a result of chronic inflammation. CPPS is a disease of unknown pathogenesis.

METHODS

We measured the levels of NGF and the pro-inflammatory cytokine interleukin (IL)-6 and compared these with the levels of IL-8, interferon-gamma, IL-2, and IL-10 in the seminal plasma of 31 patients with CPPS and 14 controls using enzyme-linked immunosorbent assay technology. Results were correlated with health-related quality of life as measured by the multidimensional pain inventory, the McGill pain questionnaire, and the International Prostate Symptom Score.

RESULTS

The cytokines analyzed were detectable in the seminal plasma from the patients with CPPS and controls. NGF correlated directly with pain severity (P <0.01) and IL-10 levels (P <0.04), and IL-6 correlated inversely with pain severity (P <0.03).

CONCLUSIONS

These results suggest that NGF and cytokines that regulate inflammation (IL-6 and IL-10) may play a role in the pain symptoms experienced by patients with CPPS.

Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study

OBJECTIVES

To compare ultrasonography and abdominal radiography with intravenous urography in the investigation of urinary tract infection in men.

DESIGN

Prospective study in two hospital departments. Radiological procedures and urological assessments performed on different days by different clinicians

SETTING

District general hospital.

PARTICIPANTS

Consecutive series of men (n=114) referred to the department of urology for investigation of proved urinary tract infection.

INTERVENTIONS

Ultrasonography and intravenous urography of renal tract and assessment of urinary flow rate. Clinical assessment, cystoscopy, urodynamic studies, and transrectal ultrasonography with biopsy.

MAIN OUTCOME MEASURES

Sensitivity and specificity of ultrasonography and abdominal radiography compared with intravenous urography.

RESULTS

Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being a poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder and ultrasonography detected more abnormalities than intravenous urography alone. No important abnormality was missed by this combination (sensitivity 100% and specificity 93%).

CONCLUSIONS

Ultrasonography with abdominal radiography is as accurate as intravenous urography in detecting important urological abnormalities in men presenting with urinary tract infection. This combination is safer than intravenous urography and should be the initial investigation for such patients. Additional determination of urinary flow rate is useful for the assessment of an incompletely emptying bladder.