Asymptomatic Inflammatory Prostatitis Research Articles

Classification and treatment of prostatitis: a review of literature

Prostatitis is one of the most common urinary tract diseases in men of all ages and is often challenging to manage. They can be classified based of the course of illness, presentation, and their etiology, and the investigation and treatment depend on how type of prostatitis. In this study we aim to look through the literature to find the various types of prostatitis and understand the respective methods of management. We did a systematic search for prostatitis using PubMed search engine (http://www.ncbi.nlm.nih.gov/) and Google Scholar search engine (https://scholar. google.com). The terms used in the search were: prostatitis, urinary tract diseases in men, classification of prostatitis, management of prostatitis. Prostatitis is a common disease and is considered to be the third most common urological disease in men. It has been categorized into four groups: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis. Treatment can be challenging, but mainly consists of use of fluoroquinolones.

The effect of prostatic inflammation on clinical outcomes in patients with benign prostate hyperplasia.

BackgroundTo investigate the effect of asymptomatic inflammatory prostatitis on clinical outcomes of patients undergoing trans urethral resection of prostate due to benign prostatic hyperplasia.Materials and methodsA total of 514 patients were enrolled in the study. Clinical parameters and pathological results were compared before and one year after surgery.ResultsOf the patients 310 were diagnosed with purely benign prostatic hyperplasia and the others were diagnosed with both prostatic inflamation (cathegory IV) and benign prostatic hyperplasia. No statistical significance was observed between two groups among the parameters including age, prostate volume and post voiding residue (P > 0.05). Patients with prostate inflammation presented higher preoperative International Prostate Symptom Score and lower Qmax values when compared to those without inflammation before trans urethral resection of prostate.ConclusionAsymptomatic prostate inflammation can lead to worsen lower urinary tract symptoms and urinary flow rate in patients with benign prostatic hyperplasia. Furthermore, the improvement of the complaints after surgery was worse in patients with asymptomatic prostate inflammation. Further well designed prospective-randomised studies are needed to support our findings.

Oxidative stress parameters in patients with prostate cancer, benign prostatic hyperplasia and asymptomatic inflammatory prostatitis: A prospective controlled study.

The imbalance between oxidant and reductant mechanisms creates a nidus for the etiopathogenesis of several diseases. In this study, we aimed to compare the oxidative stress (OS) parameters in patients who were diagnosed with prostate cancer (pCa), benign prostatic hyperplasia (BPH) or asymptomatic inflammatory prostatitis (AIP), according to the histopathologic examination of transrectal ultrasonographic prostate biopsy and transurethral prostate resection specimens. In this study, we aimed to compare oxidative stress between histologically proven prostate cancer, hyperplasia and prostatitis. According to histopathologic examinations, 97 patients were divided into 3 study groups: group 1: pCa (n = 30), group 2: BPH (n = 41), and group 3: AIP (n = 26). Finally, 30 patients were enrolled in a control group. MDA levels, CuZn-SOD, Se-GPx, CAT activities, and trace element levels were evaluated. A statistically significant difference between prostate cancer and other groups were documented in terms of MDA activity. Contrary to AIP, a statistically significant difference has also been encountered between BPH and the control group. Decreased CuZn-SOD enzyme levels were found in PCa and BPH patients without statistical significance. Increased CAT activity was also documented in PCa, BPH and AIP patients. No significant difference in GPX activity was documented between the groups, except BPH and control group. Trace element levels were low in the patients with prostate cancer and BPH when compared with the control group. Despite the data regarding OS in PCa patients, there is a paucity of data regarding BPH and especially AIP patients. Our study revealed obvious oxidative stress in BPH and PCa patients as opposed to AIP. Assessing the oxidative stress in these patients may assist in the future prevention, diagnosis and also treatment. However, the question whether the presence of OS-related parameters and drugs could be used for the diagnosis or management of prostatic diseases, needs to be addressed in future larger and better studies with a more rational basis.

Inflammatory reaction found in prostate-specific material - method standardization and proposed optimal cut-off points.

only subjects with prostatic fluid volume >0.04mL were included. We propose standardized method for analysis of inflammatory reaction in prostate-specific materials. Based on these newly defined normal values, we verified high prevalence of inflammatory forms of disease in both study groups, but also high prevalence of asymptomatic inflammatory prostatitis among control group of Estonian men. Combining results of analysis of the different inflammatory markers from available prostate-specific materials allows us to differentiate better between inflammatory and non-inflammatory forms of prostate diseases and hence to choose more precise treatment strategies.

Role of inflammation in benign prostatic hyperplasia development among Han Chinese: A population-based and single-institutional analysis.

To explore whether asymptomatic inflammatory prostatitis is associated with prostatic enlargement beyond that of benign prostatic hyperplasia patients without asymptomatic inflammatory prostatitis, and whether asymptomatic inflammatory prostatitis affects long-term outcomes of transurethral resection of the prostate. The present study involved 106 benign prostatic hyperplasia patients who underwent transurethral resection of the prostate. Clinical and pathological parameters were compared between those with benign prostatic hyperplasia associated with asymptomatic inflammatory prostatitis and those with benign prostatic hyperplasia alone. A total of 55 patients (52%) were found to have benign prostatic hyperplasia and asymptomatic inflammatory prostatitis, whereas 51 patients (48%) had benign prostatic hyperplasia alone. The prostate volume of the benign prostatic hyperplasia/asymptomatic inflammatory prostatitis group was significantly larger than the benign prostatic hyperplasia alone group: 68.1 cm3 (interquartile range 45.7-86.3) versus 44.1 cm3 (interquartile range 30.9-72.1), P = 0.036. In terms of histopathological analysis, benign prostatic hyperplasia/asymptomatic inflammatory prostatitis patients were more likely to show mild (53%), focal (67%) and stromal (40%) prostatic inflammation in our study. Furthermore, statistically significant differences of International Prostate Symptom Score were found 3 years after transurethral resection of the prostate, with benign prostatic hyperplasia/asymptomatic inflammatory prostatitis patients reporting higher (worse) scores than benign prostatic hyperplasia alone patients (P = 0.025). Chronic prostatic inflammatory process might progressively conduce to benign prostatic hyperplasia development, which can also result in prostate enlargement and worsen long-term postoperative International Prostate Symptom Scores. Multicenter studies with larger cohorts and longer follow-up periods are required to confirm these findings.

Diagnosis and treatment of bacterial prostatitis.

Prostate inflammation is a common syndrome, especially in men under 50. It usually presents with voiding symptoms and pain in the genitourinary area, and sometimes as sexual dysfunction. Based on clinical and laboratory characteristics, prostatitis is classified as acute bacterial prostatitis, chronic bacterial prostatitis, chronic inflammatory and non-inflammatory prostatitis or chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis. Bacterial prostatitis is most often caused by infection with uropathogens, mainly Gram-negative bacilli, but Gram-positive and atypical microorganisms have also been identified as causative organisms of chronic prostatitis. According to reports by several authors, Chlamydia trachomatis and Trichomonas vaginalis are some of the most common pathogens, making chronic prostatitis a sexually transmitted disease. Diagnosis and treatment of acute and chronic bacterial prostatitis in particular can be challenging.

Tumor necrosis factor-α expression in patients with obstructive benign prostatic hyperplasia is associated with a higher incidence of asymptomatic inflammatory prostatitis NIH category IV and prostatic calcification

Objective. The aim of this study was to investigate the association of the expression of tumor necrosis factor-α (TNF-α) with asymptomatic inflammatory prostatitis National Institutes of Health (NIH) category IV and prostatic calculi, in patients with obstructive benign prostatic hyperplasia (BPH) treated by transurethral electroresection of the prostate (TURP). Materials and methods. Ninety-six patients with obstructive BPH and TURP were evaluated in a prospective study. Based on a preoperative transrectal ultrasound examination of the prostate gland, patients were divided into two groups, one with prostatic calculi (n = 31) and one without (n = 65). Prostatitis NIH category IV was classified according to Irani’s histological grading system (Irani et al. J Urol 1997;157:1301–3). Associations between the incidence of prostatic calculi, histological prostatitis, TNF-α expression, prostate-specific antigen, uric acid, cholesterol, triglycerides, C-reactive protein, International Prostate Symptom Score (IPSS), the International Index for Erectile Function (IIEF-5) and the NIH-Chronic Prostatitis Symptom Index Score (NIH-CPSI) were analyzed. Results. Prostatitis was confirmed by histological investigation in 71.9% of patients: 83.9% of those with prostatic calculi versus 66.1% of those without (p < 0.04). TNF-α expression was significantly higher in patients with prostatic calculi. Association calculations yielded significant values for the severity (histological grading) of inflammation (p < 0.029), TNF-α expression (p < 0.007), uric acid (p < 0.005), cholesterol (p < 0.028) and the NIH-CPS subdomain of urinary symptoms (p < 0.044) in patients with prostatic calculi. Conclusions. In patients with obstructive BPH, prostatic calculi were found on ultrasound in one-third of the cases, and histological NIH category IV prostatitis in two-thirds of cases. The incidence of both prostatitis NIH category IV and TNF-α expression was significantly higher in patients with prostatic calculi than in those without.

Immunohistochemical expression of interleukin-2 receptor and interleukin-6 in patients with prostate cancer and benign prostatic hyperplasia: Association with asymptomatic inflammatory prostatitis NIH category IV

Objective. This study prospectively investigated the immunohistochemical expression of interleukin-2 receptor (IL-2R) and interleukin-6 (IL-6) in patients with prostate cancer and benign prostatic hyperplasia (BPH), and a possible association of these conditions with asymptomatic inflammatory prostatitis National Institutes of Health (NIH) category IV. Materials and methods. The study included 139 consecutive patients who underwent transurethral resection of the prostate and transvesical enucleation of the prostate (n = 82) or radical prostatectomy (n = 57). To characterize inflammatory changes the criteria proposed by Irani et al. [J Urol 1997;157:1301–3] were used. IL-2R and IL-6 expression was studied by a standard immunohistochemical method. Results were correlated with tumour, node, metastasis stage, Gleason scores, total prostate-specific antigen, International Prostate Symptom Score and body mass index. Results. IL-2R and IL-6 expression was significantly higher in neoplastic prostate cancer tissue than in normal tissue of prostate cancer patients (p < 0.001 and p < 0.04, respectively). Prostate cancer patients with prostatitis showed significantly higher IL-2R expression than those without inflammation (p < 0.03). In patients with BPH, expression of IL-2R as well as IL-6 was higher in patients with prostatitis than in those without (p < 0.01 and p < 0.02, respectively). Conclusions. IL-2R and IL-6 expression was significantly higher in prostate cancer tissue than in normal tissue. Patients with asymptomatic inflammatory prostatitis NIH category IV showed significantly greater activity.

Intraepithelial lymphocytes in category IV prostatitis

Category IV chronic prostatitis (CP) is an asymptomatic inflammatory prostatitis. Different injury agents can caused damage of the prostate epithelial cells and initiate an immune response. The main type of the cells involved in the immunity of the prostate is lymphocytes, particulary intraepithelial lymphocytes (IEL). <h3>Aim</h3> A quantitative analysis of the IEL population in prostate regarding a presence of CP. <h3>Methods</h3> Fifty-nine non-consecutive autopsy prostate glands were retrospectively evaluated for presence of CP. The density of IELs was scored using CD3 immunohistochemistry. Cell count was performed in two steps: within inflammatory zones and in areas around inflammation. <h3>Results</h3> Patients' ages ranged from 19 to 87 years (mean 50.9). The vast majority of the IEL were T-cells. There was significant difference (<i>p</i><0,001) in the mean IELs number between non-CP group (0.61±0.34; n=19) and group with CP (3.43±2.38) around; 8.53±3.25 with inflammation (n=40). In patients with mild (n=13) and moderate (n=16) grade of CP the mean IELs count was significantly higher around inflammatory areas (9.51±2.72 and 13.67±3.72) than within them (2.15±1.02 and 2.89±1.89); <i>p</i>=0.0009 and <i>p</i>=0.0064, respectively. <h3>Conclusion</h3> IELs have a fundamental role in the development of CP, suggesting an autoimmune character of the process.

Male Infertility Workup Needs Additional Testing of Expressed Prostatic Secretion and/or Post-Massage Urine

The male factor accounts for almost 50% of infertility cases. Inflammation may reduce semen quality via several pathways, including oxidative stress (OxS). As male infertility routinely is assessed using semen analysis only, the possible presence of non-leukocytospermic asymptomatic inflammatory prostatitis may be overlooked. We compared local and systemic OxS levels in male partners of infertile couples with different inflammation patterns in their genital tract and/or oligospermia.Subjects (n=143) were grouped according to inflammation in their semen, expressed prostatic secretion (EPS), and/or post-massage urine (post-M). Systemic (8-isoprostanes in urine) and local (diene conjugates and total antioxidant capacity in seminal plasma) OxS was measuredThe levels of OxS markers were significantly elevated in both severe inflammation groups – leukocytospermic men and subjects whose inflammation was limited only to EPS and/or post-M. Comparison between oligospermic and non-oligospermic men with genital tract inflammation, and oligozoospermic men with or without inflammation in the genital tract indicated that inflammation but not oligospermia status had significant impact on the measured OxS markers.Hence, a high leukocyte count in prostate-specific materials (EPS, post-M), even in absence of clear leukocytopsermia, is an important source of local and systemic OxS that may be associated with male infertility and affect general health. We suggest including the tests for detection of inflammation of the prostate into the workup of infertile men as was suggested in the WHO 1993 recommendation.

Prevalence of and Risk Factors for Asymptomatic Inflammatory (NIH-IV) Prostatitis in Chinese Men

BackgroundWhile many investigators have studied symptomatic prostatitis, little research has been done with regard to asymptomatic (NIH-IV) prostatitis.PurposeTo describe the prevalence of and risk factors for NIH-IV prostatitis among a large male population.MethodsThe study population was comprised of 1,868 men at the second phase recruitment of a population-based cohort in China. Asymptomatic and symptomatic men were defined by the National Institutes of Health Chronic Prostatitis (CP) Symptom Index. Meanwhile, EPS specimens and their leukocyte count were collected. Lifestyle and demographic characteristics were obtained through a questionnaire.ResultsPrevalence of NIH-IV prostatitis was 21.1% among 1,868 asymptomatic men aged 19–78 years and increased with age. After adjusteing for potential confounding variables (age, smoking habits, alcohol drinking habits, education, physical activity, hypertension, dyslipidemia, obesity and diabetes), age remained a significant factor for NIH-IV prostatitis (OR = 1.35; 95% CI = 1.06–1.71; P = 0.01) and the risk of NIH-IV prostatitis was significantly higher in smokers≧15 pack/years than non-smokers (OR = 1.33; 95% CI = 1.01–1.75; P = 0.03). In addition, compared with non-drinkers, the OR of NIH-IV prostatitis in drinkers ≧1 drinks/week was 1.35 (95% CI = 1.03, 1.77, p = 0.02) after adjusting for the other variables above. In addition, having less than a college education may be a risk factor for NIH-IV prostatitis, although a statistically significant difference did not exist in our data (OR = 1.22; 95% CI = 0.97–1.52; P = 0.08).ConclusionsOur findings suggest that NIH-IV prostatitis is prevalent in China. Age, smoking, drinking and lower education levels were associated with an increased risk of NIH-IV prostatitis. The prevalence of NIH-IV prostatitis should be taken into account when estimating the total prevalence of CP in future studies.

Asymptomatic Prostatitis: Clinical Significances and Management

Asymptomatic inflammatory prostatitis (National Institutes of Health, category IV) has been introduced as a separate clinical entity among other prostatitis syndromes. Asymptomatic inflammatory prostatitis is characterized by the presence of significant amount of leukocytes (white blood cells) in prostate-specific samples (post-prostatic massage urine, expressed prostatic secretion, semen, and prostate biopsy) but no subjective symptoms are found, and is therefore diagnosed solely in the laboratory. There have been many questions regarding the clinical role of asymptomatic inflammatory prostatitis and its impact on the management of prostate disease and sterility. This review presents the current definition of asymptomatic inflammatory prostatitis, summarizes the clinical evidence on the two important issues prostate specific antigen and pyospermia, and discusses the optimal approaches to reduce its confounding impact on prostate cancer screening and indiscriminate use of antibiotics.

Oxidative Stress—Cause or consequence of male genital tract disorders?

Inflammatory prostatitis patients are characterized by oxidative stress (OxS) at local and systemic levels. Less is known about the occurrence of OxS in the case of other frequent male genital tract disorders. The study included 196 men: controls (n = 28), asymptomatic inflammatory (NIH category IV) prostatitis patients (n = 21), non-inflammatory (NIH category IIIb) chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients (n = 48), inflammatory (NIH category IIIa) CP/CPPS patients (n = 44), benign prostate hyperplasia (BPH) patients (n = 33), and patients with BPH and NIH IV category prostatitis (n = 22). In all subjects, 8-isoprostanes (8-EPI) in urine were determined by competitive enzyme-linked immunoassay. The levels of 8-EPI were substantially higher in all diseased groups-inflammatory CP/CPPS (P < 0.001), non-inflammatory CP/CPPS (P = 0.03), asymptomatic inflammatory prostatitis (AIP; P = 0.02), BPH (P = 0.007), and BPH + AIP (P = 0.014) in comparison with controls. Importantly, our study showed that OxS is also present in the case of NIH IIIb category prostatitis when the patients have just chronic pelvic pain but no inflammation in prostate-specific materials, as well as in the patients with just lower urinary tract symptoms without pain or overt inflammation. This study revealed that several male genital tract disorders-BPH and different forms of prostatitis (NIH categories IIIa, IIIb, and IV)-are tightly interconnected via OxS-mediated pathways. Acknowledging OxS as an important pathogenesis mechanism of these diseases helps to open up new horizons for their treatment.

Seminal Interleukin-6 and Serum Prostate-specific Antigen as Possible Predictive Biomarkers in Asymptomatic Inflammatory Prostatitis

To determine the possible predictive values of seminal interleukin-6 (IL-6) and serum prostate-specific antigen (PSA), as well as their combined values, in differentiating between subjects with or without asymptomatic inflammatory prostatitis. The study group consisted of 490 men (mean age 18.9 ± 1.8 years, range 16-25). Cytologic examination of all ejaculates (using Bryan-Leishman-stained slides) and clinical examination for possible pathologic findings in the genital region were performed. The subjects with any clinical symptoms of inflammation were excluded. The levels of PSA in the blood serum and IL-6 in the seminal plasma were also determined. The IL-6 and PSA levels for different leukocytospermia status were statistically compared, and receiver operating characteristic curves were designed to determine the sensitivity versus specificity and the positive and negative predictive values of IL-6 and PSA levels against different thresholds of leukocytospermia (0.2, 0.5, and >1.0 × 10(6) leukocytes/mL). The levels of both IL-6 in the seminal plasma and PSA in the blood serum were significantly greater in National Institutes of Health prostatitis IV than in the controls. The receiver operating characteristic curves for seminal IL-6 and serum PSA showed high negative prognostic values for all 3 leukocytospermic subgroups, and positive prognostic values were seen only with IL-6 in the lower leukocytospermic range. Both seminal IL-6 and serum PSA are excellent negative predictive markers for asymptomatic inflammatory prostatitis in young men, although positive predictive values of these biomarkers remain less indicative in this age group.

Effectiveness of doxazosin on erectile dysfunction in patients with lower urinary tract symptoms

We evaluated the effectiveness of doxazosin on ED in patients with LUTS/BPH and ED by using symptom score scales. We also evaluated whether or not the presence of asymptomatic inflammatory prostatitis had an effect on the alteration in the symptom scores. A total of 36 male patients were included in the study. For all the cases, "International Prostate Symptom Score" (IPSS), "National Health Institute Chronic Prostatitis Symptom Index" (NIH-CPSI) and "International Index of Erectile Function" (IIEF-5) were investigated, and the scores were calculated in the first visit. Doxazosin was given for 30 days, and at the second visit IPSS, NIH-CPSI and IIEF-5 scores, Qmax and PMR were once more analysed. Afterwards, the alterations of the scores between visits were statistically compared. Mean age of the 36 cases included in the study was 59.03 ± 1.35. The alterations in parameters between 1st and 2nd visit were compared in the cases who used doxazosin and a statistically significant decrease in IPSS, NIH-CPSI scores and statistically significant increase in Qmax were observed. Besides, there was a statistically significant increase in IIEF-5 score. In addition, when the cases were divided into two groups patients with asymptomatic inflammatory prostatitis and without asymptomatic inflammatory prostatitis, there was not any difference in all scores. Doxazocin use in cases with LUTS/BPH and ED has an improving effect on ED as well as LUTS. Therefore, we believe that in the future, single agents or combined therapies might have a place in cases with LUTS/BPH and ED.

The effectiveness of sildenafil citrate in patients with erectile dysfunction and lower urinary system symptoms and the significance of asymptomatic inflammatory prostatitis

We evaluated the effectiveness of sildenafil citrate on lower urinary system symptoms (LUTS) by using symptom score scales. We also evaluated whether or not the presence of asymptomatic inflammatory prostatitis had an effect on the alteration in the symptom scores. A total of 36 male patients were included in the study. For all the cases, 'International Prostate Symptom Score' (IPSS), 'National Health Institute Chronic Prostatitis Symptom Index' (NIH-CPSI) and 'International Index of Erectile Function' (IIEF-5) were investigated and the scores were calculated in the first visit. Sildenafil citrate was given for 30 days and at the second visit IPSS, NIH-CPSI and IIEF-5 scores were once more analyzed. Afterwards, the alterations of the scores between visits were statistically compared. Mean age of the 36 cases included in the study was 59.03±1.35. When the alterations in parameters of first visit and second visit were evaluated, we found a statistically significant increase in IIEF-5 and a statistically significant decrease in IPSS, IPSS-QOL (Quality of Life). In addition, when the cases were divided into two groups with and without asymptomatic inflammatory prostatitis, in the cases with asymptomatic inflammatory prostatitis, sildenafil citrate caused improvement only in ED, but had no effect on LUTS. Sildenafil citrate use in cases with LUTS and ED has an improving effect on LUTS as well as ED. However, in cases with asymptomatic inflammatory prostatitis, sildenafil citrate did not lead to an improvement in LUTS.

Predictive value of post-massage urine leukocyte count for AIP

An article in The Journal of Urology addresses a frustrating feature of PSA-based prostate cancer screening, namely the fact that PSA is a fairly nonspecific marker for cancer. The authors provide a potential diagnostic test for the most common non-cancer diagnosis on prostate biopsy—asymptomatic inflammatory prostatitis (AIP)—and recommend its use as a means of avoiding unnecessary prostate biopsies.

N51 Prevalence of asymptomatic inflammatory prostatitis in ageing male with lower urinary tract symptoms

N51 Prevalence of asymptomatic inflammatory prostatitis in ageing male with lower urinary tract symptoms

Approach to urinary tract infections.

Urinary tract infection (UTI) is the most common infection experienced by humans after respiratory and gastro-intestinal infections, and also the most common cause of both community-acquired and nosocomial infections for patients admitted to hospitals. For better management and prognosis, it is mandatory to know the possible site of infection, whether the infection is uncomplicated or complicated, re-infection or relapse, or treatment failure and its pathogenesis and risk factors. Asymptomatic bacteriuria is common in certain age groups and has different connotations. It needs to be treated and completely cured in pregnant women and preschool children. Reflux nephropathy in children could result in chronic kidney disease; otherwise, urinary tract infections do not play a major role in the pathogenesis of end-stage renal disease. Symptomatic urinary tract infections occur most commonly in women of child-bearing age. Cystitis predominates, but needs to be distinguished from acute urethral syndrome that affects both sexes and has a different management plan than UTIs. The prostatitis symptoms are much more common than bacterial prostatic infections. The treatment needs to be prolonged in bacterial prostatitis and as cure rates are not very high and relapses are common, the classification of prostatitis needs to be understood. The consensus conference convened by National Institute of Health added two more groups of patients, namely, chronic prostatitis/chronic pelvic pain syndrome and asymptomatic inflammatory prostatitis, in addition to acute and chronic bacterial prostatitis. Although white blood cells in urine signify inflammation, they do not always signify UTI. Quantitative cultures of urine provide definitive evidence of UTI. Imaging studies should be done 3-6 weeks after cure of acute infection to identify abnormalities predisposing to infection or renal damage or which may affect management. Treatment of cystitis in women should be a three-day course and if symptoms are prolonged, then a seven day course of antibiotics should be given. Selected group of patients benefits from low-dose prophylactic therapy. Upper urinary tract infection may need in-patient treatment. Treatment of acute prostatitis is 30-day therapy of appropriate antibiotics and for chronic bacterial prostatitis a low dose therapy for 6-12 months may be required. It should be noted that no attempt should be made to eradicate infection unless foreign bodies such as stones and catheters are removed and correctable urological abnormalities are taken care of. Treatment under such circumstances can result only in the emergence of resistant organisms and complicate therapy further.

Chronic Prostatitis

The National Institutes of Health (NIH) has redefined prostatitis into four distinct entities. Category I is acute bacterial prostatitis. It is an acute prostatic infection with a uropathogen, often with systemic symptoms of fever, chills and hypotension. The treatment hinges on antimicrobials and drainage of the bladder because the inflamed prostate may block urinary flow. Category II prostatitis is called chronic bacterial prostatitis. It is characterized by recurrent episodes of documented urinary tract infections with the same uropathogen and causes pelvic pain, urinary symptoms and ejaculatory pain. It is diagnosed by means of localization cultures that are 90% accurate in localizing the source of recurrent infections within the lower urinary tract. Asymptomatic inflammatory prostatitis comprises NIH category IV. This entity is, by definition, asymptomatic and is often diagnosed incidentally during the evaluation of infertility or prostate cancer. The clinical significance of category IV prostatitis is unknown and it is often left untreated. Category III prostatitis is called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). It is characterized by pelvic pain for more than 3 of the previous 6 months, urinary symptoms and painful ejaculation, without documented urinary tract infections from uropathogens. The syndrome can be devastating, affecting 10-15% of the male population, and results in nearly 2 million outpatient visits each year. The aetiology of CP/CPPS is poorly understood, but may be the result of an infectious or inflammatory initiator that results in neurological injury and eventually results in pelvic floor dysfunction in the form of increased pelvic muscle tone. The diagnosis relies on separating this entity from chronic bacterial prostatitis. If there is no history of documented urinary tract infections with a urinary tract pathogen, then cultures should be taken when patients are symptomatic. Prostatic localization cultures, called the Meares-Stamey 4 glass test, would identify the prostate as the source for a urinary tract infection in chronic bacterial prostatitis. If there is no infection, then the patient is likely to have CP/CPPS. For healthcare providers, the focus of therapy is symptomatic relief. The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. Second-line pharmacotherapy involves anti-inflammatory agents for pain symptoms and alpha-adrenergic receptor antagonists (alpha-blockers) for urinary symptoms. Potentially more effective is pelvic floor training/biofeedback, but randomized controlled trials are needed to confirm this. Third-line agents include 5alpha-reductase inhibitors, glycosaminoglycans, quercetin, cernilton (CN-009) and saw palmetto. For treatment refractory patients, surgical interventions can be offered. Transurethral microwave therapy to ablate prostatic tissue has shown some promise. The treatment algorithm provided in this review involves a 4- to 6-week course of antibacterials, which may be repeated if the initial course provides relief. Pain and urinary symptoms can be ameliorated with anti-inflammatories and alpha-blockers. If the relief is not significant, then patients should be referred for biofeedback. Minimally invasive surgical options should be reserved for treatment-refractory patients.