Prostate Cancer and Prostatic Diseases (2002) 5, 172–179 ß 2002 Nature Publishing Group All rights reserved 1365–7852/02 $15.00 www.nature.com/pcan Review Management of prostatitis HS Gurunadha Rao Tunuguntla1 & CP Evans1* 1Department of Urology, University of California Davis School of Medicine and UC Davis Medical Center, Sacramento, California, USA 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 Diges- tive 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. Prostate Cancer and Prostatic Diseases (2002) 5, 172–179. doi:10.1038=sj.pcan.4500604 Keywords: prostatitis; expressed prostatic secretions; pelvic pain syndrome; midstream urine; microwave thermotherapy; prostatic massage; transurethral needle ablation Introduction 5 – 10% of patients with prostatitis (Table 1).4 Most patients do not have bacteria in the urinary tract but do Prostatitis is a disease entity that is diagnosed by suffer from urinary symptoms, perineal=suprapubic or symptoms, microscopy of expressed prostatic secretions low back pain and fatigue. Acute bacterial prostatitis is a (EPS) and culture of EPS and segmented urine samples. well recognized infectious disease of the lower urinary It is a common medical condition. The estimated preva- tract different from chronic prostatitis syndromes.5 lence of prostatitis in the US is approximately 5 – 9%.1,2 Different forms of chronic prostatitis syndrome are Between 1990 and 1994 prostatitis accounted for over 2 poorly demarcated and are believed to be caused by million hospital visits per year of which approximately both infectious=non-infectious inflammation of the one-half are to urologists and one-half to primary care prostate and non-inflammatory disease.6 physicians. Prostatitis contributes to approximately 8% of Acute bacterial prostatitis results from acute infection urology office visits and 1% of primary care physician of the prostate by recognized uropathogens (Table 1).7 office visits.1 An average American urologist sees 100 The organisms ascend along the urethra=urethral cathe- patients with prostatitis per year. The disorder severely ters or reach the urinary tract by sexual transmission and impairs the overall quality of life in the afflicted men.3 rarely bacteremia or septicemia. Acute bacterial prostatitis Currently, the etiology of prostatitis (more commonly is mainly due to aerobic Gram-negative rods, predomi- referred to as ‘prostatitis syndrome’) is mostly unknown nantly Escherichia coli and Pseudomonas spp. Obligate and the diagnostic criteria are weak. anaerobic bacteria rarely cause prostatitis. Fungi have Table 1 = Etiology Bacteriology of acute chronic prostatitis Etiologically recognized Organisms of doubtful Acute and chronic bacterial prostatitis syndromes are the pathogens significance best understood, but least common of the prostatitis syndromes. A causative pathogen is detected in only Escherichia coli Klebsiella spp. Staphylococci Proteus mirabilis Streptococci Pseudomonas aeruginosa *Correspondence: CP Evans, MD, FACS, Department of Urology, Enterococcus fecalis University of California, Davis School of Medicine, 4860 Y Street, Suite 3500, Sacramento, CA 95817, USA. Modified from:WeidnerWet al. Chronic prostatitis: A E-mail: [email protected] thorough search for etiologically involved microorganisms Received 7 March 2002; revised 24 April 2002; accepted 6 May 2002 in 1461 patients. Infection 1991; 19(Suppl 3): 119 – 125. Management of prostatitis HS Gurunadha Rao Tunuguntla and CP Evans 173 recently been implicated in prostatitis in immunosup- whether pain is the cause or the effect of other pathological pressed patients.8 If left untreated, the infection may processes. It is also difficult to attribute the pain to the result in septicemia or prostatic abscess. prostate, since nonspecific musculoskeletal abnormalities Chronic bacterial prostatitis is usually caused by can cause considerable discomfort in this region. Gram-negative bacteria such as Escherichia coli, Klebsiella and Proteus spp. and occasionally by Gram-positive bacteria such as Enterococcus fecalis, Staphylococcus and Streptococcus. Infections due to Gram-positive bacteria Classification rarely result in recurrent urinary tract infection (UTI) (Table 1). The clinical diagnosis of prostatitis depends on the history The exact etiology of chronic prostatitis=chronic pelvic and physical examination, although there is no patho- pain syndrome (CP=CPPS) is not completely understood gnomonic physical finding or laboratory test. The condi- at present. Organs other than the prostate may be respon- tion results in considerable morbidity and patients may sible for CP=CPPS symptoms. Multiple disorders that experience symptoms for many years. Prostatitis is tradi- have been proposed to be causally associated include tionally classified into four groups: acute bacterial, bladder neck obstruction, urethral stricture, detrusor chronic bacterial, chronic nonbacterial and prostatodynia sphincter dyssynergia and dysfunctional voiding.5,9 (Table 2). The National Institutes of Health (NIH) estab- CPSS may be multifactorial and part of a more lished an International Prostatitis Collaborative Network to generalized pain disorder. Microbiologic, immunologic, improve diagnosis and treatment of prostatitis. This col- neurologic, chemical, psychologic and anatomic factors laborative network has so far convened four consensus are believed to be involved in its etiopathogenesis.10 conferences (in 1995, 1998, 1999 and 2000) to define and High-pressure voiding, ‘intra-prostatic reflux’ of urine,11 classify the syndrome based on contemporary literature autoimmune process,12,13 reflux of urine and metabolites and clinical practice and thereby optimize the diagnosis (urate) into the prostatic ducts=acini14 and infection due and therapy. to coagulase negative staphylococci, chlamydia, urea- The NIH consensus classification of prostatitis syn- plasma, anaerobes, or certain non-culturable organisms dromes22 includes the following four categories: such as ‘Biofilm’ bacteria=viruses=cell-wall deficient 15 – 17 (i) Acute bacterial prostatitis. bacteria have been suggested to result in chronic (ii) Chronic bacterial prostatitis. = non-bacterial prostatitis CPPS. The disorder has been (iii) Chronic prostatitis=chronic pelvic pain syndrome found to be associated with increased blood flow to the (CP=CPPS) prostatic capsule and diffuse flow throughout the 18 (a) Inflammatory prostatic parenchyma. (b) Noninflammatory. Inflammation of the prostate as indicated by leukocytes (iv) Asymptomatic inflammatory prostatitis. in the EPS may be present in 50% of patients with CP=CPPS on random prostate biopsies.19 Interleukins The new consensus classification recognizes pain as the (IL-1) and tumor necrosis factor (TNF-a) have been found primary component of the syndrome. The exclusion cri- in EPS from patients with CPPS.20 Nadler and associates teria include presence of active urethritis, urogenital found that IL-1b and TNF-a levels in EPS are higher in cancer, urethral stricture, or neurovesical dysfunction. men with category CPPS IIIA (inflammatory CPPS, with Patients with category III CPPS have discomfort or pain significant white cells in VB3=EPS=semen) than in those in the pelvic region for at least 3 months with variable with IIIB.20 voiding and sexual symptoms in the absence of demon- Chronic prostatitis has been reported with increased strable infection. Patients with the inflammatory subtype frequency in those with hypochondriasis, depression, of CP=CPPS have leukocytes in their EPS=post-prostate hysteria, somatization and depression.21 About 43% of the massage urine or semen. In contrast, those with the non- patients with chronic prostatitis have elevated Minnesota inflammatory subtype have no evidence of inflammation. Multiphasic Personality Inventory (MMPI) scores. Asymptomatic inflammatory prostatitis (evidence of Similar to other chronic pain syndromes, patients with inflammation in prostate biopsy=semen=EPS=voided chronic nonbacterial prostatitis experience pain as the bladder urine [VB3]; no symptoms) is diagnosed in primary complaint, have a low relationship between those with no history of genitourinary tract pain and is symptoms and findings, and have a history of multiple often diagnosed during evaluation for other genitourin- unsuccessful treatments. It is often difficult to determine ary pathology such as during prostatic biopsy to rule out Table 2 Traditional classification of prostatitis Acute bacterial prostatitis Acute bacterial infection of prostate; positive urine cultures; þ =7 positive blood cultures; obstructive voiding symptoms (or urinary retention); generalized symptoms of sepsis Chronic bacterial prostatitis Recurrent urinary tract infections; chronic infection of the prostate Chronic nonbacterial prostatitis Chronic discomfort or pain localized to the pelvis (genitourinary discomfort or pain); no associated bacterial infection; inflammation (WBC) noted