A search for infectious agents in chronic abacterial prostatitis using ultrasound guided biopsy

The International Consensus Classification of Mature Lymphoid Neoplasms: a report from the Clinical Advisory Committee

Since the publication of the Revised European-American Classification of Lymphoid Neoplasms in 1994, subsequent updates of the classification of lymphoid neoplasms have been generated through iterative international efforts to achieve broad consensus among hematopathologists, geneticists, molecular scientists, and clinicians. Significant progress has recently been made in the characterization of malignancies of the immune system, with many new insights provided by genomic studies. They have led to this proposal. We have followed the same process that was successfully used for the third and fourth editions of the World Health Organization Classification of Hematologic Neoplasms. The definition, recommended studies, and criteria for the diagnosis of many entities have been extensively refined. Some categories considered provisional have now been upgraded to definite entities. Terminology for some diseases has been revised to adapt nomenclature to the current knowledge of their biology, but these modifications have been restricted to well-justified situations. Major findings from recent genomic studies have impacted the conceptual framework and diagnostic criteria for many disease entities. These changes will have an impact on optimal clinical management. The conclusions of this work are summarized in this report as the proposed International Consensus Classification of mature lymphoid, histiocytic, and dendritic cell tumors.

Mycoplasma genitalium: A new superbug

Mycoplasma genitalium (MG) is an emerging sexually transmitted pathogen. It is an important cause of nongonococcal urethritis in men and is associated with cervicitis and pelvic inflammatory disease in women, putting them at risk of infertility. Multiple factors that aid pathogenesis of MG include its ability of adhesion, gliding motility, and intracellular invasion by means of the tip organelle. Through intracellular localization and antigenic variation, MG could result in treatment-resistant chronic infection. There are limited data on the prevalence of MG in Indian patients with urogenital syndromes. Recently, a high prevalence of extra genital infection with MG has been reported. Molecular assays are the major diagnostic techniques of MG infection. Antimicrobial agents such as macrolides, along with fluoroquinolones, are the treatment of choice for MG infections. The issue of drug resistance to azithromycin and fluoroquinolones in MG is rising globally. As molecular tests are becoming available for MG, both for the diagnosis and the detection of antimicrobial resistance, any patient with MG infection should then be tested for antimicrobial resistance. Consideration of MG as a cause of sexually transmitted disease in the Indian population is crucial in diagnostic algorithms and treatment strategies. The purpose of this review is to understand the prevalence of MG in different clinical scenarios, molecular mechanisms of pathogenesis, current status of antimicrobial resistance, and its impact on MG treatment.

The presence of Chlamydia trachomatis infection in men with chronic prostatitis

Introduction

The aim of the study was to evaluate the frequency of occurrence of Chlamydia trachomatis (C.t.) DNA in the prostate material in the group of individuals with the chronic prostatitis.

Material and methods

The study included 65 males aged between 47 and 68 years of age, reporting for transrectal prostate biopsy because of the elevated serum prostate-specific antigen concentration and/or abnormalities detected in prostate palpation per rectum. The urethral smear collection was performed in all the patients in order to detect C.t. DNA. After that, the transrectal prostate biopsy was performed (histopathology tests, C.t. DNA). Additionally, the levels of anti-C.t. IgG antibodies and anti-C.t. IgA antibodies were checked in the serum. The DNA isolation from prostate specimens was conducted with the use of the Chelex method, while the C.t. DNA detection - with the ligase chain reaction. Specific antibodies were detected with the use of the ELISA method.

Results

C.t. DNA in the prostate gland was found in 7 out of 65 men (10.8%). In urethral smear, C.t. was found in none of the individuals. Anti-C.t. IgA antibodies were detected in the serum of 16/65 (24.6%), while anti-C.t. IgG antibodies in 6/65 (9.2%) of the examined males. IgA antibodies were found in two and IgG in one out of the 7 men who had C.t. infection in the prostate.

Conclusions

The presence of C.t. DNA in the prostate gland may be indicative of the role of chlamydia in the development of chronic prostatitis.

Current Knowledge of the Potential Links between Inflammation and Prostate Cancer

Inflammation is inherent in prostatic diseases and it is now accepted that it may facilitate cellular proliferation in both benign and malignant conditions. The strong relationship between prostatic inflammation and pathogenesis of benign prostatic hyperplasia (BPH) is supported by epidemiologic, histopathologic and molecular evidence. Contrariwise, the role of inflammation in prostate carcinogenesis is still controversial, although current data indicate that the inflammatory microenvironment can regulate prostate cancer (PCa) growth and progression. Knowledge of the complex molecular landscape associated with chronic inflammation in the context of PCa may lead to the introduction and optimization of novel targeted therapies. In this perspective, evaluation of the inflammatory component in prostate specimens could be included in routine pathology reports.

Immune mediators of chronic pelvic pain syndrome

The cause of chronic pelvic pain syndrome (CPPS) has yet to be established. Since the late 1980s, cytokine, chemokine, and immunological classification studies using human samples have focused on identifying biomarkers for CPPS, but no diagnostically beneficial biomarkers have been identified, and these studies have done little to deepen our understanding of the mechanisms underlying chronic prostatic pain. Given the large number of men thought to be affected by this condition and the ineffective nature of current treatments, there is a pressing need to elucidate these mechanisms. Prostatitis types IIIa and IIIb are classified according to the presence of pain without concurrent presence of bacteria; however, it is becoming more evident that, although levels of bacteria are not directly associated with levels of pain, the presence of bacteria might act as the initiating factor that drives primary activation of mast-cell-mediated inflammation in the prostate. Mast cell activation is also known to suppress regulatory T cell (Treg) control of self-tolerance and also activate neural sensitization. This combination of established autoimmunity coupled with peripheral and central neural sensitization can result in the development of multiple symptoms, including pelvic pain and bladder irritation. Identifying these mechanisms as central mediators in CPPS offers new insight into the prospective treatment of the disease.

Immunohistochemical analysis of inflammatory cells in benign and precancerous lesions and carcinoma of the prostate

OBJECTIVE

Inflammation is an important cause of tumorigenesis in various types of malignancy. Mediators derived from inflammatory cells are associated with cancer proliferation, angiogenesis, and DNA damage. In the present study, we immunohistochemically examined the infiltration patterns of inflammatory cells in benign glands including glandular hyperplasia, and in prostatic intraepithelial neoplasia and adenocarcinoma.

METHODS

Formalin-fixed, paraffin-embedded tissues were obtained from 100 patients with prostate cancer. All patients underwent radical prostatectomy. We assessed the number of infiltrating T cells (CD3(+)), B cells (CD20(+), CD79alpha(+)), and macrophages (CD68(+), CD204(+)) in benign and malignant prostate tumors.

RESULTS

CD68(+) macrophages infiltrated benign glands to a higher extent than those of adenocarcinoma. In contrast, the number of CD204(+) cells was higher in malignant glands than in benign glands. There was no significant difference in the number of infiltrating T cells between benign and malignant tumors; however, the number of infiltrating B cells was significantly reduced in malignant glands.

CONCLUSIONS

Inflammation of the prostate may act on prostate carcinomas; particularly that involving M2 macrophage infiltration may play a significant role in prostate carcinogenesis.

Mycoplasma genitalium: from Chrysalis to multicolored butterfly

The history, replication, genetics, characteristics (both biological and physical), and factors involved in the pathogenesis of Mycoplasma genitalium are presented. The latter factors include adhesion, the influence of hormones, motility, possible toxin production, and immunological responses. The preferred site of colonization, together with current detection procedures, mainly by PCR technology, is discussed. The relationships between M. genitalium and various diseases are highlighted. These diseases include acute and chronic nongonococcal urethritis, balanoposthitis, chronic prostatitis, and acute epididymitis in men and urethritis, bacterial vaginosis, vaginitis, cervicitis, pelvic inflammatory disease, and reproductive disease in women. A causative relationship, or otherwise strong association, between several of these diseases and M. genitalium is apparent, and the extent of this, on a subjective basis, is presented; also provided is a comparison between M. genitalium and two other genital tract-orientated mollicutes, namely, Mycoplasma hominis, the first mycoplasma of human origin to be discovered, and Ureaplasma species. Also discussed is the relationship between M. genitalium and infertility and also arthritis in both men and women, as is infection in homosexual and immunodeficient patients. Decreased immunity, as in HIV infections, may enhance mycoplasmal detection and increase disease severity. Finally, aspects of the antimicrobial susceptibility and resistance of M. genitalium, together with the treatment and possible prevention of mycoplasmal disease, are discussed.

A prospective, randomized, double-blind trial to evaluate the role of a short reducing course of oral corticosteroid therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome

OBJECTIVES

To assess the validity of our observational experience that a short course of oral prednisolone therapy might be of value in the management of symptoms of chronic pelvic pain syndrome (CPPS) in men.

PATIENTS AND METHODS

Twenty-one men with CPPS (inflammatory or non-inflammatory) for > or =6 months, and who had failed to improve with standard antibiotic therapy, were randomized to receive either a 1-month reducing course of oral prednisolone (nine) or an equivalent placebo regimen (12 men). The outcome measures used were the McGill Pain Questionnaire, the Hospital Anxiety and Depression Scale (HADS), General Health Questionnaire-30 (GHQ-30) and the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), which were completed at baseline and 3 months.

RESULTS

Outcomes were analysed for the 18 patients (six treated, 12 placebo) who completed the 3 months of follow-up. At both baseline and 3 months, respectively, there was no statistically significant difference between the groups in the NIH-CPSI total score (P = 0.48 and 0.62; Mann-Whitney U-test), or in the HADS (anxiety, P = 0.85 and 0.67; depression P = 0.96 and 0.74), and there was no significant improvement or deterioration over time. Although not statistically significant, there was a trend to improvement in the depression score for the active group (P = 0.13). However, the clinical significance is doubtful, as both baseline and follow-up depression scores were within the normal range. No patient had clinically negative changes in depression. A 3-month follow-up analysis was not possible for the McGill Pain Questionnaire or GHQ-30 as not all patients completed the questionnaire.

CONCLUSIONS

Whilst the study showed no clinical benefit of using corticosteroids in the management of CPPS, the few patients recruited limited the validity of firm conclusions from the data. There was a trend towards an improvement of depression levels amongst subjects. The study highlights the difficulties of recruitment and illustrates the complex psychological profiles of patients with CPPS.

Relationship between Serum Prostate Specific Antigen and the Pattern of Inflammation in Both Benign and Malignant Prostatic Disease in Middle Eastern Men

To determine the effect of prostatitis on serum prostate specific antigen in the diagnosis of prostate cancer in Middle Eastern men, H&E-stained sections of all consecutive prostate specimens were reviewed for diagnosis (malignant or benign) and pattern of inflammation. Inflammation was categorized into acute, active chronic and chronic inactive and graded semi-quantitatively according to previously published criteria. Results were correlated with serum PSA obtained from patients' records. Of 513 prostate specimens reviewed; 435 (84.8%) were benign and 78 (15.2%) were malignant. Chronic inactive prostatitis was present in 259 (204 benign, 55 malignant) and active chronic prostatitis in 221 (204 benign, 17 malignant). Acute prostatitis alone was not observed and prostatitis was absent in 33 (27 benign, 6 malignant). There was no significant difference in the prevalence of inactive chronic prostatitis between benign and malignant specimens (p < 0.071), but active chronic prostatitis was more prevalent in benign specimens (p < 0.001). Increasing serum PSA was observed for increasing grades of both inactive and active chronic prostatitis in both benign and malignant disease. Prostate cancer showed higher serum PSA levels than benign, at different cut-off points (4 ng/ml = p < 0.0001; 8 ng/ml = p < 0.0001; 12 ng/ml = p < 0.0001). However, significant numbers of patients with benign prostate biopsies presented with PSA above 12 ng/ml (82/260 = 32%). We conclude that active chronic prostatitis is common in Middle Eastern men with benign prostatic disease and a significant number of these present with very high PSA levels, some over 300 ng/ml.

Consensus development of a histopathological classification system for chronic prostatic inflammation

OBJECTIVE

To develop a standardized histopathological classification system for chronic prostatitis (standardized description of prostatic inflammatory infiltrates) based on a literature review, extensive prospective evaluations in two recognized prostatitis research centres and widespread consensus of international urological centres identified as having major expertise or interest in chronic prostatitis.

METHODS

Relevant articles for review were identified by a Medline search undertaken by the Cochrane Review Group in Prostate Diseases and Urologic Malignancies, and cross-checking bibliographies of retrieved studies, reviews, book chapters and abstracts of the American Urological Association and International Prostatitis Collaborative Network Annual Meetings. Initial drafts were based on classification systems independently developed by the Prostatitis Research Centers at Queen's University in Canada and University of Washington in the USA. A collaborative draft was distributed to 20 urological/pathological clinical centres who participated in the North American Chronic Prostatitis Collaborative Research Network and First International Prostatitis Collaborative Network. A consensus classification system was then distributed to the participating panel for acceptance.

RESULTS

The literature review identified a reasonably consistent description of inflammatory infiltrate locations and patterns that were further incorporated into the draft based on the Queen's University and University of Washington proposals. Eighteen (90%) of the identified Prostatitis Centers participated in the revision of the draft and the final consensus process. The final consensus document classifies prostatic inflammation according to its extent and grade/severity in each tissue compartment (location). Conclusion The consensus of the expert panel was that this classification system can be used in the evaluation of prostatic inflammation in prostate biopsies, transurethral resected prostate chips or prostatectomy specimens. A standardized accepted framework to describe histopathological prostate inflammation will prove useful in evaluating prostate disease.

Short course oral prednisolone therapy in chronic abacterial prostatitis and prostatodynia: case reports of three responders and one non-responder

OBJECTIVE

To report on a small group of patients with chronic abacterial prostatitis/chronic pelvic pain syndrome treated with oral corticosteroids in order to suggest a hypothesis for a future randomised controlled trial.

DESIGN

A retrospective, observational report.

RESULTS

Three out of the four patients reported improvement in symptoms following steroid treatment.

CONCLUSIONS

These reports suggest that there is scope for conducting a randomised, placebo controlled study to investigate the role of oral corticosteroids in patients with chronic abacterial prostatitis/chronic pelvic pain syndrome who have failed on conventional therapy.

Microbiology of the prostate

Prostatitis is a common genitourinary disease in men. The National Institutes of Health has defined four types of prostatitis. The bacteriology of acute and chronic bacterial prostatitis is well understood. Causative organisms can be isolated by four-glass urine cultures. Chronic pelvic pain syndrome (CPPS; chronic abacterial prostatitis) is an enigma; whether there is a microbiologic cause for this condition is unknown. Researchers have postulated that CPPS may be an infectious disease of the prostate. This article reviews current literature regarding the microbiology of the prostate in CPPS.

Prostate histopathology and the chronic prostatitis/chronic pelvic pain syndrome: a prospective biopsy study

PURPOSE

The chronic prostatitis/chronic pelvic pain syndrome is a common clinical syndrome characterized by lower genitourinary tract symptoms, particularly pain in the perineum or genitalia, voiding symptoms, such as dysuria or frequency, and sexual dysfunction in the absence of uropathogens in the urine or prostatic secretions. The term prostatitis is based on the presumption that prostatic inflammation is important in the pathophysiology of this syndrome. To our knowledge there has been no systematic characterization of the degree and nature of inflammation in the prostate in symptomatic cases.

MATERIALS AND METHODS

Prostate histopathology in 368 biopsies from 97 patients with the chronic prostatitis/chronic pelvic pain syndrome was characterized..

RESULTS

Prostatic inflammation was detected in only 33% of patients, including 29% with mild (less than 10 leukocytes per 1 mm. field) and 4% with moderate (between 10 and 200) or severe (more than 200) infiltrate. Of the 3 patients with moderate inflammation 1 had glandular, 1 periglandular and 3 multifocal or diffuse distribution of leukocytes in the interstitium. Some patients had more than 1 pattern of inflammation.

CONCLUSIONS

The finding of moderate or severe inflammation in only 5% of 97 patients argues for the need to reevaluate current concepts of the pathophysiology of the chronic prostatitis/chronic pelvic pain syndrome.

Non-obese diabetic (NOD) mice are genetically susceptible to experimental autoimmune prostatitis (EAP)

Rodents develop inflammatory, non-infectious, prostatitis upon autoimmuniz-ation with male accessory gland (MAG) extracts in complete Freund's adjuvant (CFA). Although there appears to be differences among strains, with respect to susceptibility to induction, specific details are not known about the genetic bases of such differences. Because NOD mice have inherited a genetic predisposition to autoimmune lesions affecting, apart from the islets of Langerhans, a large array of secretory glands such as salivary glands, thyroid, parathyroids and adrenal cortex, we selected this strain to assess the influence of inherited genes upon experimentally-induced autoimmune prostatitis (EAP). Indeed, MAG extracts injected into young NOD males in association with CFA cause a severe inflammatory reaction in the prostate, accompanied by a humoral and T cell-mediated response. NOD mice develop a more aggressive form of EAP than Wistar rats, the strain of reference used to establish the model. In NOD mice, disease begins earlier, affects 100% of the animals, does not require boosting and leads to florid infiltrates circumscribed to lateral and dorsal prostatic lobes. Immune mice develop a T cell-mediated response to MAG assessed by in vitro proliferation and accompanied by the release of IFN-gamma, whereas IL-4 is not detectable in the same culture super-natants. To assess the influence of the NOD background genes upon EAP susceptibility, we tested C57BL/6.H2(g7) mice in parallel. NOD mice are considerably more susceptible to EAP induction than congenic C57BL/6.H2(g7) mice. Both strains demonstrate a detectable humoral and cell-mediated response against MAG, but the histopathological manifestations are considerably more dramatic in NOD than in the C57BL/6.H2(g7) strain. Our results thus support the notion that NOD mice have background genes which favour severe autoimmune manifestations, irrespective of the target tissue.

Transrectal ultrasound in male urethritis

OBJECTIVE

To assess the prevalence of prostatic abnormalities in men with gonococcal and non-gonococcal urethritis using trans-rectal ultrasonic markers.

DESIGN

A case control study of patients attending a department of genitourinary medicine with symptoms of urethritis.

SETTING

Department of Genitourinary Medicine and Department of Radiology in Manchester Royal Infirmary.

RESULTS

A total of 42 patients were recruited to the study: 26 with urethritis and 16 controls. Of the 26 study patients, six were gonococcal, four chlamydial, two mixed gonococcal and chlamydia and nine non specific (no organisms detected). Of the 26 study patients, 16 had abnormal scans (61.5%), eight from the chlamydia group and eight from the non specific group. No abnormalities were found in the gonococcal and mixed group. Of the 16 control patients, five had abnormal scans (31.25%), three of these have had a past history of chlamydial urethritis.

CONCLUSION

The prevalence of prostatic abnormalities in patients with non-gonococcal urethritis was significantly higher when compared with controls. The cause of these abnormalities is unclear, but is compatible with inflammatory changes within the gland.

Use of terazosin in prostatodynia and validation of a symptom score questionnaire

OBJECTIVE

The purpose of this trial was to study the use of terazosin in nonbacterial prostatitis/prostatodynia, and to evaluate a new symptom score sheet for this disease.

METHODS

Twenty-five patients who presented with lower urinary tract symptoms suggestive of prostatitis were evaluated for evidence of bacterial infection by Meares-Stamey criteria and found to be negative. They were then treated with the alpha-blocking drug terazosin in doses from 1 to 10 mg. A symptom score index for prostatitis was developed, tested in these patients, and validated against patients with benign prostatic hyperplasia. Normal control patients, who presented for vasectomy, were studied as well.

RESULTS

Nineteen patients (76%) responded to one month's therapy, with 11 (58%) remaining asymptomatic three months later. The symptom score index, as measured by Cronbach's alpha measure of index reliability, was excellent at 0.78 and logistic regression analysis demonstrated each prostatitis question to have independent validity (P < 0.001) but not to the extent of the combined score.

CONCLUSIONS

Terazosin appears effective in treating patients with nonbacterial prostatitis/prostatodynia. This new symptom score is one way to evaluate and track patients with this disease. A randomized, placebo-controlled clinical trial has been initiated to study this.

Bacterial localization in antibiotic-refractory chronic bacterial prostatitis

Chronic bacterial prostatitis, that has become resistant to antibiotic therapy, remains a frustrating clinical entity for both clinicians and patients. Twenty men with a history of documented bacterial prostatitis, that had become resistant to appropriate antibiotic therapy, were studied in an attempt to determine where the bacteria had become localized, and possibly explain their survival in a relative bactericidal environment. The antibiotics were discontinued for 4 weeks, and cultures of the expressed prostatic secretions, tissue biopsies, histology, and ultrastructure were correlated. Twelve (60%) of the tissue biopsies cultured presumed pathogens. In six of the tissue-positive cases, the expressed prostatic secretion was negative. Specific electron micrographs demonstrate exopolysaccharide coated microcolonies of bacteria firmly attached to the ductal and acinar walls. This mode of growth helps explain some of our difficulties in the diagnosis and treatment of chronic bacterial prostatitis.

Prostatitis--clinical and bacterial studies

Forty men with clinical prostatitis were studied to determine the value of symptomatology and categorization and 30 (75%) were classified as having prostatitis on the basis of prostatic localization studies. Of these 3 (10%) had chronic bacterial prostatitis, 18 (60%) had chronic abacterial prostatitis, and 9 (30%) had prostatodynia. No patient had acute bacterial prostatitis. Although Enterobacteriaciae were isolated from the 3 men with chronic bacterial prostatitis, these bacteria along with Staphlococcus aureus, Streptococcus faecalis, and Chlamydia trachomatis were isolated from a further 6 patients. The mean pH of the expressed prostatic secretion was measured for each group and was found to be 7.6 for those with chronic bacterial prostatitis, 7.1 for chronic abacterial prostatitis, 6.5 for prostatodynia, and 6.9 for those with urethritis suggesting that this test may be of value in the diagnosis of chronic bacterial prostatitis.

Coagulase-negative staphylococcus in chronic prostatitis

Three male patients with a clinical history of prostatitis with coagulase-negative staphylococci localized to the expressed prostatic secretion and who did not respond to antibiotics were studied intensively 4 weeks after cessation of therapy with repeat culture of the prostatic fluid, as well as with culture, and histological and ultrastructural examination of multiple prostatic biopsies. Coagulase-negative staphylococci were cultured in the biopsied prostatic tissue, and gram-positive staphylococci were identified in sparse and focal microcolonies adherent to the prostatic ductal walls. Coagulase-negative staphylococci may be implicated in the pathogenesis of chronic bacterial prostatitis.

The diagnosis of prostatitis: a review

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Intraprostatic antibody deposition in chronic abacterial prostatitis

Sixty patients with chronic abacterial prostatitis and 21 men without prostatitis were studied. Transperineal prostatic biopsies taken under transrectal ultrasound control were examined for antibody, complement (C3) and fibrinogen deposition using a direct immunofluorescence (IF) technique; 34 patients (57%) had prostatic tissue that displayed IF staining compared with only 1 (5%) in the non-prostatitis group. IF staining for IgM was found in 85%, for C3 in 44%, for IgA in 35% and for fibrinogen in 24%, but the IgG subclass was not detected. Antibody deposition was mainly periglandular and glandular and in the wall of vessels. Five symptoms, particularly poor urinary flow, irritative voiding and urgency, were significantly correlated with IgM and C3 deposition and, to a lesser extent, fibrinogen deposition. The aetiology of chronic abacterial prostatitis remains obscure but several possible mechanisms are discussed. The link between symptomatology and immunology could rest with functional outflow obstruction causing intraprostatic reflux of urine, this in turn inciting an immunological response, the inducing antigens being organism remnants or products, urinary constituents or autoantibodies.