Prostatitis: what is the role of infection
Introduction
Bacterial prostatitis is a common diagnosis and a frequent indication for antimicrobial therapy. Estimates are that 9–11% of the adult male population has symptoms of prostatitis at any given time [1], [2]. Prostatitis is also a common indication for antimicrobial therapy, with estimates that anywhere from 2 [2] to 8 million [3] outpatient visits are made per year in the United States, with antimicrobial agents prescribed for most patients.
The problem is that well documented infections of the prostate are exceedingly uncommon. For example, in our clinic, only about 7% of patients with chronic prostatitis have chronic bacterial prostatitis [4]. Standard uropathogens, that is, those organisms that cause bacteriuria, are thus identified in very few cases. Patients with bacteriuria are exceedingly important because they may have acute or chronic bacterial prostatitis. For these patients there is a very clear role for antimicrobial therapy and reasonable protocols [5] that have been validated in clinical trials [6], [7], [8]. Unfortunately, there are very few data on the aetiology of the other clinical syndromes and therefore, treatment is largely empirical and unsuccessful for many patients [9].
Most patients with prostatitis have no history of bacteriuria and very little evidence for bacterial infection in their prostates. Such patients were classified based on the presence or absence of leukocytes, in the traditional classification, as non-bacterial prostatitis for patients with leukocytes in their prostatic fluid, or as prostatodynia for patients without leukocytes in their prostatic fluid [10]. In the new consensus classification, patients are classified as having chronic prostatitis/chronic pelvic pain syndrome [11]. There are two subgroups. Patients with white cells in their prostatic fluid, post-massage urine, or seminal fluid are classified in the inflammatory category, while patients with white cells in none of these specimens are classified in the non-inflammatory category. There are very few data supporting rational treatment decisions for patients with either chronic inflammatory or chronic non-inflammatory chronic prostatitis/chronic pelvic pain syndrome.
There is some substantial empirical support for a potential role of genitourinary tract infections in chronic prostatitis/chronic pelvic pain syndrome [12]. Many patients relate the onset to sexual activity, often to an episode of urethritis. Antimicrobials often provide transient or partial relief of symptoms and standard practice is to provide multiple courses of antimicrobials [13], [14]. For example, in our study of 75 consecutive men evaluated for symptoms of chronic prostatitis, the average patient had received ten weeks of antimicrobial therapy in the 3 months before evaluation [4].
There are also microbiological data supporting a potential role of cryptic microorganisms in chronic prostatitis/chronic pelvic pain syndrome [12]. Organisms suggested as important in the literature include: Chlamydia trachomatis [15], [16], [17], [18], Ureaplasma urealyticum, other genital mycoplasmas [19], [20], [21], and the protozoan pathogen, Trichomonas vaginalis [22], [23]. Other organisms suggested as important in the literature are Neisseria gonorrhoea, which was a common cause of prostatitis in the pre-antibiotic era, genital viruses, particularly herpes simplex type 1, herpes simplex type 2, cytomegalovirus, fungi, and various other anaerobic and Gram positive bacteria [12], [14].
This article outlines our recent experience using a variety of microbiological and molecular biological methods to investigate the potential role of genitourinary tract infection in the difficult group of patients with chronic prostatitis/chronic pelvic pain syndrome.
Section snippets
Methods
In our initial studies we had very limited success in identifying pathogens in non-invasive genital tract specimens such as urine, expressed prostatic secretions and urethral swabs [4], [24]. This experience led us to investigate prostate tissue, obtained via the perineal approach and cultured in an anaerobic research lab [25]. In this study, we evaluated 85 men who met the current definition of chronic prostatitis/chronic pelvic pain syndrome. These patients had urethral swabs, lower tract
Results
This 5-year study evaluated 135 men by standard clinical evaluation, including history and physical, symptom scores, uroflowimetry, and an ultrasound residual urine determination. Microbiological studies included: studies for fastidious organisms (gonorrhoea, C. trachomatis, T. vaginalis, and genital mycoplasmas), lower urinary tract localization cultures, as well as chamber counts of expressed prostatic secretion leukocytes. These studies included a protocol with more than one thousand
Discussion
Our findings suggest that many patients with chronic prostatitis/chronic pelvic pain syndrome have a wide variety of bacterial DNA-encoding sequences despite extensive negative microbiological investigations. Our findings also suggest that some patients with chronic prostatitis/chronic pelvic pain syndrome may have C. trachomatis, T. vaginalis and M. genitalium in their prostates despite having no evidence of urethritis and negative urethral cultures or antigen tests for these pathogens.
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2009, Cancer LettersCitation Excerpt :This belief is strengthened by the isolation of gram negative enteric bacteria commonly associated with urinary tract infections from the affected prostate [92]. However, a wide spectrum of organisms have also been identified to be involved in prostatitis; from Enterobacteria like Escherichia coli, Enterococcus fecalis, and Proteus mirabilis to Chlamydia spp. and Ureaplasma spp. [94]. This has strengthened the belief of possible contiguous spread from other sources including the bladder, bowels, blood or the lymph to prostate [95].