Prostatitis

K. G. Naber
Urologic Clinic, Hospital St. Elisabeth, Straubing, Germany
It has been estimated that up to half of all men suffer
from symptoms of prostatitis at some time in their lives.
In the early 1900s, prostatitis resulted in 2 million
ofce visits per year in USA, rivalling the number of
visits for benign prostatic hypertrophy (BPH) at the
time. It is the most common urological diagnosis in
men younger than 50 years of age and the third most
common urological diagnosis in men older than
50 years of age w1x. It has been clearly demonstrated
that patients diagnosed with chronic prostatitis have
a qualitiy of life impact similar to patients suffering
from myocardial infarction, angina, or Crohns disease
w2x. Thus, prostatitis is a major health care issue, just
as important as the other two major prostatic diseases,
benign hyperplasia and carcinoma w3x. But our
knowledge of this subject is limited.
Acute bacterial prostatitis
The diagnosis of prostatitis suggests that this disease
is of an inammatory nature possibly caused by an
infective agent. This obviously holds true for patients
with acute bacterial prostatitis. These patients often
present with a u-like illness with systemic symptoms,
indicating a tissue-invasive infection, in addition to
urinary tract symptoms of bacteriuria, such as urinary
urgency, dysuria, frequency, etc. On physical exami-
nation, the prostate can be tense and extremely
tender. There are leukocytes in the prostatic uid and
midstream urine. Culture demonstrates most fre-
quently Escherichia coli, and less commonly, other
organisms such as species of Klebsiella, Pseudomonas,
Enterococcus, etc. Prostatic massage, however, should
not be performed in these patients because septicaemia
could be induced. The majority of these patients get
better when treated with appropriate antibiotics.
Occasionally patients develop complications such as
urinary retention, septicaemia, prostatic abscess, and
in rare cases metastatic infections such as pyogenic
vertebral osteomyelitis. How often the acute status of
infection is transformed into a chronic status, is
unclear.
Chronic prostatitis syndrome
In contrast, the diagnosis of chronic prostatitis
apparently represents a mixture of possibly different
entities, which cannot be clearly separated with our
present knowledge. Therefore, this complex is best
described as a syndrome consisting of various qualities
of chronic pelvic pains, voiding disturbances and
sexual dysfunctions, whereas the pelvic pains represent
the most prominent urogenital symptoms as compared
to patients with benign hyperplasia of the prostate
(BPH) and those with sexual dysfunctions w4x. Stress
and psychological problems, particularly depression,
are very commonly found in these patients. But it
is not clear yet whether psychological dysfunctions
a priori are causing this syndrome, or if this syndrome
itself causes the psychological dysfunctions.
Classication of prostatitis syndrome
In the past the classication according to Drach et al.
w5x was most frequently used. It is based on the results
of the bacteriological localization patterns obtained by
the four glass specimens w6x.
Because of lack of knowledge concerning epidemi-
ology, pathophysiology, diagnosis, and treatment of
prostatitis, the National Institutes of Health (NIH) of
the USA started an international initiative. As a rst
step, a new classication system w7x was suggested that
provides uniform denitions of the various types of
prostatitis. The NIHuNIDDK (National Institute of
Diabetes and Digestive and Kidney Diseases) pro-
posed this new classication system in 1995, which
was reafrmed in 1998 (Table 1).
What pathogens cause chronic prostatitis?
There is an ongoing debate on which bacteria can be
taken as pathogens. In the most conservative approach
Correspondence and offprint requests to: Kurt G. Naber, Urologische
Klinik, Klinikum St. Elisabeth, St. Elisabeth str. 23, D-94375,
Straubing, Germany.
Nephrol Dial Transplant (2001) 16 wSuppl 6x: 132134
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2001 European Renal AssociationEuropean Dialysis and Transplant Association
only those bacteria are considered pathogens, which
can be localized in the prostatic secretion and cause
documented recurrent urinary tract infections w7x. In
this view, pathogens other than E. coli, other members
of the Enterobacteriaceae family, such as Klebsiella,
Enterobacter, Proteus and Serratia, and Pseudomonas
aeruginosa can be considered as pathogens. Using
this denition enterococci and staphylococci would
be outside of the scope even though these pathogens
are often localized in the prostate and may also be
associated with chronic prostatitis syndrome.
A number of other organisms have been reported to
cause this syndrome: Trichomonas vaginalis, Chlamydia
trachomatis, genital mycoplasmas, difcult-to-culture
Coryneforms, and genital viruses, not to mention rare
cases with mycobacterial, gonococcal, parasitic or
fungal prostatitis. This subject has been carefully
reviewed elsewhere w8x. Evidence of the misclassica-
tion of at least some cases of non-bacterial prostatitis
is accumulating w3x. Immunologic evidence, such as
the existence of antibodies to uropathogenic bacterial
antigens, are detected in patients with negative cultures
w9,10x, suggesting a non-culturable bacterial presence.
This is further substantiated by evidence of both
bacterial DNA w11x and specically cultured cryptic
bacteria w8x detected in prostate biopsies and prostatic
uids of patients with sterile cultures. As many as 50%
of perineal biopsies in patients with prostatitis grow
bacteria w12x, presumably related to prostatic inam-
mation. Thus, the full impact of infection remains
unresolved in chronic inammatory prostatitis and
until now the mechanisms as well as alternative
treatment modalities are not well understood.
The role of antimicrobial therapy in
chronic prostatitis
Despite reports that -0% of prostatitis cases are
bacterial w13x a much higher proportion of men dia-
gnosed with prostatitis receive antimicrobials. Anti-
biotic therapy is recommended for acute bacterial
prostatitis (ABP) and chronic bacterial prostatitis
(CBP); it is debatable in patients with inammatory
chronic pelvic pain syndrome (CPPS) w14x.
Because of their favourable pharmacokinetic prop-
erties the uoroquinolones can be considered drugs of
choice. In the meantime, several clinical studies with
quinolones have been published w15x. The results are
difcult to compare, however, because not all workers
used the Meares and Stamey technique for diagnosis.
The duration of treatment, which should last for
a minimum of 24 weeks, and the follow-up period
greatly differed. Only a few studies had a follow-up
period of at least 4 weeks. Since in chronic prostatitis
relapse is the main problem, the follow-up period must
be sufciently long in order to state that the patient is
cured. The rst clinical results with uoroquinolones
are promising, at least in patients with chronic bacterial
prostatitis due to E. coli and other Enterobacteriaceae.
The therapeutic role of these drugs, however, needs to
be dened by controlled studies. In order to achieve
comparable results an internationally accepted proto-
col should be utilized. Such a protocol was propagated
at the 3rd International Symposium on Clinical
Evaluation of Drug Efcacy in UTI w16x.
Conclusion
In contrast to acute bacterial prostatitis, the chronic
prostatitis syndrome is caused by infection and needs
antimicrobial therapy in only a minority of patients. In
these cases, the uoroquionolones can be considered
drugs of choice. But controlled clinical studies with a
sufcient long-term follow-up period are still needed
to dene the denitive role of antimicrobial therapy.
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Table 1. NIHuNIDDK classication of prostatitis (1995)
Category I Acute bacterial prostatitis
Category II Chronic bacterial prostatitis
Category III Chronic pelvic pain syndrome (CPPS)
IIIA CPPS: inammatory
IIIB CPPS: non-inammatory
Category IV Asymptomatic inammatory prostatitis
133 Prostatitis
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134 K. G. Naber