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Prostatitis Crónica: Una Revisión Crítica De Su Actual Definición Nosológica, Clasificación Y Potencial Carcinogénesis

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Prostatitis Crónica: Una Revisión Crítica De Su Actual Definición Nosológica, Clasificación Y Potencial Carcinogénesis Artículo Especial Arch. Esp. Urol., 60, 6 (617-623), 2007 PROSTATITIS CRÓNICA: UNA REVISIÓN CRÍTICA DE SU ACTUAL DEFINICIÓN NOSOLÓGICA, CLASIFICACIÓN Y POTENCIAL CARCINOGÉNESIS. Remigio Vela Navarrete, Carmen González Enguita, Juan Vicente García Cardoso, G. Manzarbeitia y F. Soriano García. Cátedra de Urología de la Universidad Autónoma de Madrid. Servicio de Urología de la Fundación Jiménez Díaz. Departamentos de Anatomía Patológica y Microbiología de la Fundación Jiménez Díaz. Madrid. España. Resumen.- Revisión crítica actualizada de la prostati- Palabras clave: Prostatitis crónica. Inflamación tis crónica, como entidad nosológica, anatomoclínica, prostática. Dolor pélvico. supuestamente de origen microbiológico o inflamatorio. Argumentación científica, a la luz de los nuevos pro- gresos, sobre el papel de la inflamación amicrobiana, Summary.- Updated critical review of chronic prosta- tanto a nivel de la próstata craneal como de la caudal, titis as a nosologic, anatomic-clinical entity of supposed para reconsiderar la conveniencia de mantener la cla- microbiological or inflammatory origin. Scientific reaso- sificación actual de las prostatitis crónicas, y especial- ning about the role of amicrobial inflammation in both mente el apartado referido a la “prostatitis histológica”. caudal and cranial prostate, after new progresses, to Análisis de evidencias relacionando la prostatitis “con el reconsider the convenience of maintaining the current dolor pélvico”, síndrome dominante en muchos pacien- classification of chronic prostatitis, mainly in the section tes y fundamento de la actual propuesta terminológica; referred to “histological prostatitis”. Analysis of scientific prostatitis-dolor pélvico. Papel de la inflamación en la evidences relating prostatitis and “pelvic pain”, the do- génesis de la HBP y cáncer de próstata. Justificación y minant syndrome in many patients and basement of the conveniencia de un nuevo consenso terminológico so- current terminological proposal: prostatitis-pelvic pain. bre las prostatitis, en general. The role of inflammation in the genesis of BPH and pros- tate cancer. Justification and convenience of a new term in logic consensus on prostatitis. Keywords: Chronic prostatitis. Prostatic inflammation. Pelvic pain. INTRODUCCIÓN Cuando nos enfrentamos al inconfundible cuadro clínico de la prostatitis aguda, con el riguroso R. Vela Navarrete cumplimiento de los postulados exigidos por la me- Servicio de Urología dicina anatomoclínica en los procesos de etiología bacteriana, con evidentes signos y síntomas de foca- Fundación Jiménez Díaz lidad, junto a síndrome febril llamativo, evidencias Avda. Reyes Católicos, 2 analíticas y microbiológicas de infección y respuesta 28040 Madrid. (España). satisfactoria al tratamiento con antimicrobianos, la [email protected] prostatitis crónica, por el contrario, se muestra, des- de que este término fue introducido en clínica, como Correspondencia Trabajo recibido: 2 de enero 2007. un proceso de límites nosológicos confusos, de etio- 618 R. Vela Navarrete, C. González Enguita, J.V. García Cardoso y cols. logía indeterminada, englobando bajo su definición prostatitis crónica, desde la más que razonable sos- enfermos con un perfil clínico muy variado en los que pecha de que no todas tenían un fundamento etioló- suele dominar el carácter incómodo y doloroso del gico bacteriano. De este modo, el objetivo inicial fue proceso, fundamentalmente referido al área perineal, comprobar en cuantos pacientes existían argumentos sobre signos y síntomas genuinamente infectivos. Y y evidencias de un proceso infectivo y en cuántos sucede todo ello a pesar de los enormes esfuerzos de ellos, en ausencia de infección demostrable, exis- realizados en los últimos años para desentrañar los tía un proceso inflamatorio, revelado por alteracio- misterios microbiológicos y patrones anatomoclínicos nes reconocibles en la secreción prostática, tras un ocultos detrás de un término de tan extraordinaria masaje intenso, que permitía la identificación, al mi- ambigüedad. croscopio, especialmente el microscopio de contraste de fases, de un mayor número de leucocitos que en En los comentarios que siguen pretendemos individuos normales. Las cuestiones que se debatían hacer una valoración crítica de los últimos progresos pueden resumirse en estas dos preguntas: ¿son todas conceptuales sobre éste padecimiento, que han mo- las prostatitis crónicas infecciosas o motivadas por un tivado una nueva clasificación de las prostatitis, con proceso inflamatorio de otra naturaleza?; ¿es el dolor innovaciones terapéuticas aún de dudosa eficacia, pélvico acompañante, y a veces el más relevante sín- incluyendo un análisis de sospechas y evidencias re- toma de estos procesos, de origen prostático?. lacionadas con el potencial efecto carcinogénico de la inflamación prostática o su relación con la hiper- A la primera pregunta intentaron contestar plasia prostática. Quizás deba presidir esta revisión Stamey y Meares (2) mediante el contaje diferencia- una observación clínica incontestable; rara vez los do de bacterias y leucocitos en muestras secuencia- pacientes diagnosticados de prostatitis crónica, no les, cada una de ellas representativa de una zona de bacteriana, tienen en su historia clínica un episodio la vía urinaria inferior, del siguiente modo: las mues- previo, rotundo, de prostatitis aguda. tras iniciales (M1 y M2) corresponden a unos centí- metros cúbicos de orina obtenidos en la fase inicial de la micción; la muestra siguiente (M3) representa Perfil clínico y clasificaciones de las prostá- la secreción obtenida después de un intenso masaje titis crónicas prostático; la siguiente muestra (M4) se obtiene de la micción que se realiza después del masaje. El re- Constituye una referencia obligada el tra- sultado de estos estudios diferenciados de muestras bajo de Stamey de finales de los 60, publicado en secuenciales, se basaba, más que en valores absolu- 1972 (1) para aclarar los motivos que han guiado tos de recuentos bacterianos o de leucocitos, en las a los urólogos para determinar la patogenia de la diferencias cuantitativas observadas en las diferentes TABLA I.CLASIFICACION DE LAS PROSTATITIS. DRACH 1978 NIH 1995 TERMINOLOGÍA CATEGORÍAS NUEVA TERMINOLOGÍA Prostatitis bacteriana aguda I I Prostatitis bacteriana aguda Prostatitis bacteriana crónica II II Prostatitis bacteriana crónica Prostatitis crónica abacteriana III III Síndrome P. crónica/Dolor pélvico crónico IIIa con inflamación IIIb sin inflamación Prostatodinia IV IV Prostatitis inflamatoria asintomática (prostatitis histológica 619 PROSTATITIS CRÓNICA: UNA REVISIÓN CRÍTICA DE SU ACTUAL DEFINICIÓN NOSOLÓGICA... muestras, asumiéndose que un número mayor de bac- veces irrelevantes y dudosamente motivados por una terias o leucocitos en las últimas nuestras orientaban patología específicamente prostática. En la nueva hacia un proceso infeccioso, simplemente inflamato- clasificación se introducen variaciones conceptuales rio, o ausencia de cualquier inflamación. que no necesariamente parecen pertinentes desde una perspectiva crítica. Se mantienen los términos de Basándose en estas investigaciones DRACH prostatitis aguda, crónica bacteriana o inflamatoria, (3) estableció en 1978 la clasificación de las pros- que tienen su correspondencia con la terminología tatitis (Tabla I) que oficialmente ha perdurado hasta previa, pero se da un protagonismo especial al dolor 1995, momento en que se ha sido sustituida por la pélvico, sea cual sea su origen y motivación (síndro- patrocinada por el NIH (más concretamente por las me prostatitis crónica-dolor pélvico) y se introduce sección del Nacional Institute of Health que se ocupa un cuarto término que corresponde a una definición de la diabetes y enfermedades digestivas y renales) histológica y no anatomoclínica, que ciertamente po- (4-6). En la clasificación de DRACH, la prostatitis cró- demos calificar de “prostatitis histológica”, que ha de nica se califica de bacteriana o no bacteriana y se ser considerado con las mayores reservas. añade el término de prostatodinia, término que cobi- ja un variado grupo de pacientes en los que dominan El protagonismo concedido al dolor pélvico, las incomodidades, molestias y dolores perineales que es el síntoma dominante en un grupo notable de (7), asociadas o no a trastornos miccionales, en los estos pacientes (7), ha instalado la terminología de que los hallazgos analíticos son la mayor parte de las la prostatitis crónica en un campo aún más confuso, de límites mucho más imprecisos que el de prostato- dinia (8). Por otro lado, la relevancia sintomática do- lorosa ha justificado, además de una exigencia más rigurosa en la historia clínica de estos enfermos, un TABLA II. PROSTATITIS nuevo baremo sintomático que también ha sido moti- POBLACIONES MICROBIANAS AISLADAS. vo de aprobación general e incluso convalidación al español (puertorriqueño) (9). Diversos estudios han AGUDA CRÓNICA demostrado que la localización más frecuente del do- lor en los pacientes con síndrome de prostatitis-dolor Patógenos frecuentes: Patógenos reconocidos: pélvico, se refiere a las siguientes áreas; próstata y área perineal (46%), escroto y testículos (39%), pene • frecuentes: E. Coli (6%), vejiga (6%), área lumbar baja (2%) (Zermann y Proteus mirabilis E. Coli (80%) cols. 1999) (10). Los síntomas urinarios que más fre- Klebsiella spp. Klebsiella spp. cuentemente acompañan al dolor son los siguientes: P. aeruginosa Proteus mirabilis aumento de la frecuencia miccional, dificultad para Enterococcus spp. Otras Enterobacteriaceae iniciar la micción,
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