Clinical Evidence Concise

A Publication of BMJ Publishing Group

Chronic Prostatitis

THOMAS JANG, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois

ANTHONY SCHAEFFER, professor and chair, Department of Urology, Northwestern University Medical School, Chicago, Illinois

What are the effects of treatments for chronic bacterial prostatitis?

likely to be beneficial

Alpha Blockers. We found no randomized controlled trials (RCTs) comparing alpha blockers versus placebo or no treatment. We found limited evidence from one RCT suggesting that adding alpha blockers to antimicrobials improved symptoms and reduced recurrence compared with antimicrobials alone.

unknown

Oral Antimicrobial Drugs. We found no RCTs comparing oral antimicrobial drugs versus placebo or no treatment. Two RCTs found no significant difference between ciprofloxacin and other quinolones (levofloxacin or lomefloxacin) in rates of clinical success or bacteriological cure at six months. Retrospective observational studies report cure rates of up to 88 percent depending on the medication used and the duration of treatment.

Local Injection of Antimicrobials. We found no RCTs comparing local injection of antimicrobials with placebo or no treatment. One small RCT found that anal submucosal injection of amikacin improved symptom scores and bacterial eradication rates at three months compared with intramuscular amikacin.

Transurethral Resection. We found no RCTs on the effects of transurethral resection.

Radical Prostatectomy. We found no RCTs on the effects of radical prostatectomy.

What are the effects of treatments for chronic abacterial prostatitis?

likely to be beneficial

Alpha Blockers. Two small RCTs identified by a systematic review and three small subsequent RCTs found limited evidence that alpha blockers improved quality of life and symptoms compared with placebo. The RCTs may have been too small to detect other clinically important differences.

unknown effectiveness

5-Alpha Reductase Inhibitors. One RCT identified by a systematic review provided insufficient evidence to determine the effects of 5-alpha reductase inhibitors compared with placebo in men with chronic abacterial prostatitis.

Anti-Inflammatory Medications. One RCT identified by a systematic review provided insufficient evidence to determine the effects of anti-inflammatory medications compared with placebo or no treatment in men with chronic abacterial prostatitis.

Transurethral Microwave Thermo-
therapy. One systematic review found limited evidence from one small RCT suggest-
ing that transurethral microwave thermotherapy improved quality of life at three months and improved symptoms over 21 months compared with placebo. However, we were unable to draw reliable conclusions from this one small study.

Allopurinol. One RCT identified by a systematic review provided insufficient evidence to determine the effects of allopurinol compared with placebo in men with chronic abacterial prostatitis.

Prostatic Massage. We found no RCTs on the effects of prostatic massage.

Sitz Baths. We found no RCTs on the effects of sitz baths.

Biofeedback. We found no RCTs on the effects of biofeedback.

Definition

Chronic bacterial prostatitis is characterized by a positive culture of expressed prostatic secretions. It may cause symptoms such as suprapubic, low back, or perineal pain; mild urgency, frequency, and dysuria with urination; and may be associated with recurrent urinary tract infections. However, it also may be asymptomatic. Chronic abacterial prostatitis, or chronic pelvic pain syndrome, is characterized by pelvic or perineal pain in the absence of pathogenic bacteria in expressed prostatic secretions. It often is associated with irritative and obstructive voiding symptoms including urgency, frequency, hesitancy, and poor interrupted flow with urination. Symptoms also can include pain in the suprapubic region, low back, penis, testes, or scrotum. Chronic abacterial prostatitis may be inflammatory (white cells present in prostatic secretions) or noninflammatory (white cells absent in prostatic secretions).1

Incidence

One community-based study in the United States (including 58,955 visits by men 18 years or older to office-based physicians) estimated that 9 percent of men are diagnosed with chronic prostatitis at any one time.2 Another study found that, of men with genitourinary symptoms, 8 percent presenting to urologists and 1 percent presenting to primary care physicians are diagnosed with chronic prostatitis.3 Most cases of chronic prostatitis are abacterial. Acute bacterial prostatitis, although easy to diagnose, is rare.

Etiology

Organisms commonly associated with bacterial prostatitis include Escherichia coli, other gram-negative Enterobacteriaceae, occasionally Pseudomonas species, and rarely gram-positive enterococci. The cause of abacterial prostatitis is unclear, although it has been suggested that it may be caused by undocumented infections with Chlamydia trachomatis,4 Ureaplasma urealyticum,5 Mycoplasma hominis,6 and Trichomonas vaginalis.7 Other possible factors include inflammation,8 autoimmunity,9 hormonal imbalances,10 pelvic floor tension myalgia,11 intra-
prostatic urinary reflux,12 and psychological disturbances.13

Prognosis

The natural history of untreated chronic bacterial and abacterial prostatitis remains undefined. Chronic bacterial prostatitis may cause recurrent urinary tract infections in men.14 Furthermore, several researchers have reported an association between chronic bacterial prostatitis and infertility.15 The sequelae of chronic abacterial prostatitis are similar to those of chronic bacterial prostatitis, and fertility also may be decreased with abacterial prostatitis.16 One study found that chronic abacterial prostatitis had an impact on quality of life similar to that from angina, Crohn's disease, or a previous myocardial infarction.17

search date: July 2004

Adapted with permission from Jang T, Schaeffer A. Clin Evid Concise 2004;12:246-7.

REFERENCES

1. Nickel JC, Nyberg LM, Hennenfent M. Research guidelines for chronic prostatitis: consensus report from the first National Institutes of Health International Prostatitis Collaborative Network. Urology 1999;54:229-33.

2. Roberts RO, Lieber MM, Rhodes T, et al. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County study of urinary symptoms and health status among men. Urology 1998;51:578-84.

3. Collins MM, Stafford, RS, O'Leary MP, et al. How common is prostatitis? A national survey of physician visits. J Urol 1998;159:1224-8.

4. Poletti F, Medici MC, Alinovi A, et al. Isolation of Chlamydia trachomatis from the prostatic cells in patients affected by nonacute abacterial prostatitis. J Urol 1985;134:691-3.

5. Weidner W, Brunner H, Krause W. Quantitative culture of Ureaplasma urealyticum in patients with chronic prostatitis or prostatosis. J Urol 1980;124:622-5.

6. Brunner H, Weidner W, Schiefer HG. Studies on the role of Ureaplasma urealyticum and Mycoplasma hominis in prostatitis. J Infect Dis 1983;147:807-13.

7. Skerk V, Schonwald S, Granic J, et al. Chronic prostatitis caused by Trichomonas vaginalis-diagnosis and treatment. J Chemother 2002;14:537-8.

8. Jang TL, Schaeffer AJ. The role of cytokines in prostatitis [published correction appears in World J Urol 2003;70:223]. World J Urol 2003;21:95-9.

9. Alexander RB, Brady F, Ponniah S. Autoimmune prostatitis: evidence of T cell reactivity with normal prostatic proteins. Urology 1997;50:893-9.

10. Naslund MJ, Strandberg JD, Coffey DS. The role of androgens and estrogens in the pathogenesis of experimental nonbacterial prostatitis. J Urol 1988;140:1049-53.

11. Nadler RB. Bladder training biofeedback and pelvic floor myalgia. Urology 2002;60:42-3.

12. Kirby RS, Lowe D, Bultitude MI, et al. Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis. Br J Urol 1982;54:729-31.

13. de la Rosette JJ, Ruijgrok MC, Jeuken JM, et al. Personality variables involved in chronic prostatitis. Urology 1993;42:654-62.

14. Roberts RO, Lieber MM, Bostwick DG, et al. A review of clinical and pathological prostatitis syndromes. Urology 1997;49:809-21.

15. Giamarellou H, Tympanidis K, Bitos NA, et al. Infertility and chronic prostatitis. Andrologia 1984;16:417-22.

16. Leib Z, Bartoov B, Eltes F, et al. Reduced semen quality caused by chronic abacterial prostatitis: an enigma or reality? Fertil Steril 1994;61:1109-16.

17. Wenninger K, Heiman JR, Rothman I, et al. Sickness impact of chronic nonbacterial prostatitis and its correlates. J Urol 1996;155:965-8.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please send an e-mail to CEcommissioning@bmjgroup.com. This series is part of the AFP's CME. See "Clinical Quiz" on page 375.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been reviewed systematically by an AAFP-approved source. The evidence is available at http://www.clinicalevidence.com/ceweb/conditions/msh/1802/1802.jsp.

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