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The Chronic Prostatitis Information site: Superb compilation of information and files for download
The Prostatitis Foundation: Non-profit organization devoted to this disorder. A comprehensive resource for patient information on chronic prostatitis
Reading List: A list of books about prostate problems in men. Only "Textbook of Prostatitis" by Curtis Nickel deals with the subject exclusively.
Approach to Prostatitis by Dr. Shoskes
There are 3 clinical prostatitis syndromes, which we
differentiate based upon symptoms and cultures:
1) Acute Prostatitis (NIH category I):
Characterized by an acute febrile illness often associated with
chills, sweats, suprapubic pain, urinary frequency, poor stream and
often acute urinary retention. The prostate is swollen, extremely
tender and should not be massaged. Bacteria are readily grown from the
urine. Patients may require admission to hospital for intravenous
hydration and antibiotics. A suprapubic catheter may be required to
alleviate urinary retention. All antibiotics penetrate into the
prostate equally well during the acute attack. Eradication of the
bacteria leads to complete resolution of symptoms. Failure to improve
within 48 hrs may indicate the presence of an abscess.
2) Chronic Bacterial Prostatitis (NIH category II):
This clinical syndrome is characterized by recurrent urinary tract
infections by typical uropathogens (eg. E. coli). Culture of prostatic
fluid in between these episodes of infection typically find the same
pathogens. Symptoms include pain, urinary frequency, weak stream and
erectile dysfunction (impotence). Fertility may also be impaired.
Eradication of the causative bacteria with prolonged courses of
antibiotics usually leads to complete resolution of symptoms, however
the recurrence rate is high. Antibiotics must be chosen with high
lipid solubility and a high pKa (eg sulphas, quinolones,
erythromycins, tetracyclins). Infected prostatic stones, obstructed
seminal vesicles or dysfunctional voiding with high urinary residuals
may all contribute to the recurrent infections. Probably fewer than 5%
of men with chronic prostatitis have this clinical syndrome. Many of
these men had a previous bout of acute prostatitis.
3) Chronic Pelvic Pain Syndrome (NIH category III):
By far the most common clinical syndrome, it is primarily
characterized by pain which may be penile, scrotal, perineal, rectal,
suprapubic or in the lower back. There may also be a weak urinary
stream, frequency, nocturia, urinary urgency and erectile dysfunction.
Ejaculation may relieve symptoms or may significantly worsen them. A
history of acute prostatitis is rare. Cultures of prostatic fluid may
find bacteria, but not those that are usually considered to be
uropathogens. Microscopic examination of the prostatic fluid may
reveal significant inflammation (NIH category IIIa) or not (NIH
category IIIb). Some men may improve with antibiotic therapy although
most do not. There is NO agreement in the literature over the cause
and best treatment for this disorder. A review of the literature shows
in fact that many investigators hold strong and mutually contradictory
opinions.
Possible Causes of Chronic Pelvic Pain Syndrome (CPPS)
a) Infection
It has long been suspected that despite negative cultures, CPPS is
caused by micro-organisms that are either not considered to be
uropathogens (eg Gram positive bacteria) or are difficult to culture
(eg Chlamydia, Mycoplasma, Ureoplasma, Anaerobes, fungi). That these
organisms can be found in the prostate of men with CPPS is
unquestioned - what is controversial is whether they always, sometimes
or never represent the cause of the symptoms and what the incidence is
of these micro-organisms in healthy men without CPPS.
In our experience, treating men with positive Gram positive cultures
can successfully eradicate these bacteria, but produces durable
improvement in the symptoms of CPPS in at most 40% of the men so
treated. We do have credible basic science evidence that some Gram
positive infections are associated with increased markers of cell
injury and inflammation in the prostatic fluid which are hallmarks of
pathogens. We have had less success treating empirically with agents
against anaerobes or fungi, but have seen some responses.
b) Inflammation
Men with CPPS often have fluctuating levels of white cells in their
prostatic fluid. While inflammation can be a response to infection, it
can also be in response to other types of injury such as trauma or
represent an autoimmune reaction. Some believe that CPPS is a true
autoimmune disorder. Others believe that reflux of urine into the
prostate produces a chemical injury that elicits the inflammation.
While these mechanisms are possible, we have felt that this might
represent an inability of the inflammatory response to shut itself off
after an infection has been cleared. This is the rationale for our
treatment with a bioflavonoid herbal supplement that we have
shown decreases inflammation and oxidant stress in the prostate while
increasing local concentrations of beta-endorphins (the body's natural
pain killers). Immunosuppression might have the potential to treat the
disorder if it is a true autoimmune disease, but the risks and side
effects are unacceptably high. Some have used allopurinol to prevent
uric acid in the urine from accumulating in the prostate, but we have
not found this approach to be successful in our patients. Some have
tried Proscar, a drug used in benign prostatic hypertrophy to shrink
the prostate and found that the pain from CPPS may decrease, even if
the prostate is small.
Interstitial cystitis is a pain syndrome involving the bladder and
perineum, diagnosed most often in women. Some investigators believe
that CPPS and interstitial cystitis may be manifestations of the same
disease process. Diagnosis requires a cystoscopy under general
anesthetic, although the findings of this and other tests are still
controversial. Techniques used in interstitial cystitis which may have
some benefit in CPPS include DMSO bladder instillations, oral Elmiron
and bioflavonoids. The latter 2 therapies are currently under study.
3) Neuromuscular
Men with CPPS have been shown to have spasm of the pelvic floor
muscles (voluntary) and the smooth muscles around the base of the
prostate and bladder (involuntary). In some patients this may be a
reaction to the infection and/or inflammation occurring in the
prostate, in others it may be the primary problem itself. Physical
exam may show that most of the tenderness is in the pelvic side wall
rather than the prostate itself. Approaches to relieve muscle spasm
include the use of alpha blockers (eg Flomax, Uroxatral), pelvic physiotherapy,
muscle relaxants and other chronic pain agents (eg Neurontin, Elavil,
Flexeril).