Alpha-blockers for the treatment of prostatitis-like syndromes

Prostatitis is a common medical diagnosis. The etiology of this symptomatic syndrome can be an acute or chronic bacterial infection, a noninfectious initiator (the most common cause), or iatrogenic heat or radiation; the syndrome may coexist with benign prostatic hyperplasia. Alpha-blockers have a role in the treatment of the prostatitis syndromes. In Category I, acute bacterial prostatitis, alpha-blockers have been shown to possibly ameliorate obstructive and irritative voiding symptoms. In Category II, chronic bacterial prostatitis, alpha-blockers seem to reduce the risk of clinical and bacteriological recurrence. In Category III, chronic pelvic pain syndrome, alpha-blockers improve symptoms and quality of life. Alpha-blockers also seem to ameliorate the symptoms and reduce the risk of acute urinary retention in patients who suffer from either heat- or radiation-induced prostatic inflammation. Alpha-blockers improve lower urinary tract symptoms, including pain, in patients who are diagnosed with both prostatitis and benign prostatic hyperplasia. Evidence has proven there is definitely a role for alpha-blockers in the management of the prostatitis syndromes.     

Distinction des prostatites aiguës récidivantes et chroniques

The E.A.U. (European Association of Urology) published its Guidelines on Urinary and Male Genital Tract Infections in 2001. In the chapter devoted to prostatitis, epididymitis and orchitis, the E.A.U suggests a classification distinguishing prostatitis (usual clinical picture and demonstrated infection) from chronic pelvic pain syndrome (same clinical picture without demonstrable infection). Prostatitis is divided into three categories: acute bacterial prostatitis (type I), chronic bacterial prostatitis (type II) and asymptomatic inflammatory prostatitis (histological prostatitis, type IV). Type I and II prostatitis are considered here. The E.A.U. guidelines do not mention recurrent prostatitis. The authors discuss whether or not recurrent prostatitis should be distinguished from chronic prostatitis by raising three questions: does the literature provide precise data in favour of this distinction? Does this theoretical distinction have any practical consequences? Is this distinction feasible, especially in general practice? The Stanford sesearch team (Stamey and Shortliffe) has provided documented bacteriological data demonstrating recurrence of prostatitis with different bacteria in some cases and persistence of the same pathogen in other cases. The main consequence of these two situations concern treatment (which antibiotics? for how long?) On the basis of personal unpublished data, the authors discuss the feasibility of this distinction in general practice. They show that, in the case of several recurrences of prostatitis per year, it may be difficult to distinguish recurrent prostatitis from chronic prostatitis. They also show that the duration of symptoms is not a sufficiently discriminant factor and that bacteriological findings should be considered. In conclusion, recurrent prostatitis is a particular disease which should be distinguished from chronic prostatitis. The main consequence of this distinction concerns several unresolved questions about the therapy of recurrent prostatitis. In general practice, the distinction may be difficult when only routine bacteriological tests are available. The use of Meares and Stamey’s four glass technique is unusual in this setting, making it difficult to confirm prostatic disinfection.     

High frequency of chronic bacterial and non-inflammatory prostatitis in infertile patients with prostatitis syndrome plus irritable bowel syndrome

Background

Although prostatitis syndrome (PS) and irritable bowel syndrome (IBS) are common disorders, information on the prevalence of IBS in infertile patients with PS is relatively scanty. Therefore, this study was undertaken to estimate the frequency of PS and IBS and to evaluate the prevalence of the various diagnostic categories of prostatitis.

Methodology/Principal Findings

This study enrolled 152 patients with PS, diagnosed by the NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) in an andrological setting, and 204 patients with IBS, diagnosed according to the Rome III diagnostic criteria in a gastroenterological setting. The patients with PS were asked to fulfill the Rome III questionnaire for IBS, whereas patients with IBS were asked to complete the NIH-CPSI. The simultaneous presence of PS and IBS was observed in 30.2% and 31.8% of the patients screened by andrologists and gastroenterologists, respectively. Altogether, 111 patients had PS plus IBS (31.2%). They had a total NIH-CPSI and pain subscale scores significantly higher than patients with PS alone. Gastrointestinal symptoms in patients with PS plus IBS were similar to those reported by patients with IBS alone and significantly greater in patients with PS alone. Patients with PS plus IBS had a significantly higher frequency of chronic bacterial prostatitis (category II) and lower of non-inflammatory prostatitis (category IIIB), compared to patients with PS alone. The frequency of inflammatory prostatitis (category IIIA) resulted similar.

Conclusions/Significance

Prostatitis syndromes and IBS are frequently associated in patients with PS- or IBS-related symptoms. These patients have an increased prevalence of chronic bacterial and non-inflammatory prostatitis.     

Prostatite chronique, syndrome douloureux pelvien chronique et dysfonctions sexuelles

In 1995, the NIH (National Institutes of Health, USA) proposed a new classification of chronic prostatitis (CP), no longer considered in the strict framework of the prostate, but based on the concept of pelvic pain. This classification introduced the term chronic pelvic pain syndrome (CPPS). The definition of this syndrome indicates that pain is sometimes associated with sexual disorders. Many surveys have demonstrated the considerable prevalence of CP/CPPS and have confirmed the impact of these diseases on quality of life, but only limited epidemiological data concerning the links between CP/CPPS and sexuality are available at the present time. The pathophysiology of sexual dysfunction associated with CP/CPPS (alteration of desire, erectile dysfunction and premature ejaculation) also remains poorly elucidated. A psychological factor is very probably involved, but many uncertainties persist concerning the other mechanisms possibly involved.     

Les prostatites chroniques: Microbiologie; Thérapeutique

Chronic prostatitis/Chronic pelvic pain syndrome (CP/CPPS) represents an important health problem resulting in considerable morbidity and of health care expenditure. CP/CPPS is a multifactorial problem affecting men of all ages and all demographic characteristics. Over recent years, progress has been made in the epidemiology and diagnosis of CP/CPPS. A new universally accepted classification system has become the gold standard in the contemporary literature. Men with CP/CPPS have significantly higher leukocyte counts in all segmented urine samples and expressed prostatic secretion (EPS) but not in semen. In segmented cultures, the urethral culture (first 10 ml of urine), EPS and first 10 ml of urine avoided immediately after prostatic massage are the “optimal” samples to detect the microbial agent. According to the four-glass test with polymerase chain reaction testing (PCR), Chlamydia and/or Ureaplasma infection can be suspected in several cases, but their role in the pathogenesis of prostatitis remains speculative. However, testing for these infections is highly recommended in non-documented infections. Quantification, speed and specificity make real-time PCR a promising approach for the quantitative detection and identification of prostatic bacteria from CP/CPPS patients. Several antibiotics have a good correlation between pharmacokinetic/pharmacodynamic parameters and efficacy for antibiotics in the treatment of chronic prostatitis. Fluoroquinolones, cotrimoxazole and ceftriaxone have a bactericidal concentration to the main pathogens in the prostatic fluid of patients with subacute and chronic prostatitis and in prostatic tissue.     

性病后慢性前列腺炎病原微生物分析

本文对性病后慢性前列腺炎病原微生物进行了研究。９０例患者前列腺液支原体检出率为２４．４４％（２２／９０）,其中解脲支原体为２２．００％（１８／９０）,人型支原体为４．４４％（４／９０）。另一组２３２例患者进行前列腺液细菌培养鉴定,总检出率为４２．７％（９９／２３２）,以金黄色葡萄球菌为主２４．５％（５７／２３２）,其它菌依次为表皮葡萄球菌７．３％（１７／２３２）,肠球菌４．３％（１０／２３２）,非发酵菌２．６％（６／２３２）,肠杆菌科细菌２．２％（５／２３２）和Ａ群链球菌１．７％（４／２３２）。作者认为,性病后慢性前列腺炎可能为急性尿道炎期,由于治疗不彻底或忽略非特异性性病病原菌的治疗而使条件致病菌上行感染所致。     

Le syndrome douloureux chronique pelvien chez l’homme. Quelle physiopathologie? Quel traitement?

Chronic pelvic pain, in young men or elderly men, has always been a challenge to the medical profession, raising problems of assessment and management. Chronic pelvic pain has a high prevalence, which is underestimated as indicated by the following figures: 4% to 8% of patients consulting chronic pain centres, 15% of patients consulting a urologist for symptoms of chronic prostatitis with alteration of quality of life, 70,000 cases of chronic cystitis per year in the USA. The circumstances of onset are multiple: postoperative, after minor or major trauma or postinfectious, sometimes without any particular aetiology and often in a multifactorial context. The pathophysiology is therefore vague and poorly elucidated, as only about 5% of cases of chronic prostatitis have a bacterial cause. However, any form of stimulation activates pain pathways with neurogenic inflammation followed by central sensitization and modification of neuronal plasticity, and finally chronic refractory pain with organic dysfunction. This mechanism is currently proposed in numerous publications concerning postoperative chronic pelvic pain and refractory cystitis and chronic prostatitis. The pathophysiology of these types of pain is probably therefore neurogenic. In the absence of stimulation, a pudendal nerve tunnel syndrome can be suggested. The treatment of chronic pelvic pain in men can be considered in the following way: aetiological treatment whenever possible, neurogenic medical treatment (tricyclic antidepressants for continuous pain, anticonvulsants for intermittent pain, NMDA receptor antagonists in the case of failure), treatment of organic dysfunction, pudendal nerve analgesic block in the case of suspected tunnel syndrome and global treatment of patient with impaired quality of life. In conclusion, a better pathophysiological approach to these forms of chronic pelvic pain can improve these difficult patients.     

Absence of nuclear receptors LXRs impairs immune response to androgen deprivation and leads to prostate neoplasia

Chronic inflammation is now a well-known precursor for cancer development. Infectious prostatitis are the most common causes of prostate inflammation, but emerging evidence points the role of metabolic disorders as a potential source of cancer-related inflammation. Although the widely used treatment for prostate cancer based on androgen deprivation therapy (ADT) effectively decreases tumor size, it also causes profound alterations in immune tumor microenvironment within the prostate. Here, we demonstrate that prostates of a mouse model invalidated for nuclear receptors liver X receptors (LXRs), crucial lipid metabolism and inflammation integrators, respond in an unexpected way to androgen deprivation. Indeed, we observed profound alterations in immune cells composition, which was associated with chronic inflammation of the prostate. This was explained by the recruitment of phagocytosis-deficient macrophages leading to aberrant hyporesponse to castration. This phenotypic alteration was sufficient to allow prostatic neoplasia. Altogether, these data suggest that ADT and inflammation resulting from metabolic alterations interact to promote aberrant proliferation of epithelial prostate cells and development of neoplasia. This raises the question of the benefit of ADT for patients with metabolic disorders.

Mice lacking the liver X nuclear receptors (LXRs), crucial integrators of lipid metabolism, were used to study the response of the prostate to androgen deprivation. This reveals that lack of androgens leads to chronic inflammation due to impaired clearance of castration-induced apoptotic cells, allowing production of pro-inflammatory cytokines and promoting prostate neoplasia.     

Identification of potential causative infectious agents of chronic prostatitis

Analysis of the data on etiology and pathogenesis of inflammatory processes in prostate including acute and chronic prostatitis as well as chronic pelvic pain syndrome is presented. It has been noted that about 50% of men of fertile age had clinical signs of chronic prostatitis at least once in life and that more than 60% of admissions to urologists in outpatient practices are related with clinical signs of chronic prostatitis. An appreciable decrease in quality of life similar to that due to myocardial infarction or Crohn's disease is observed in patients with chronic prostatitis. Prostatitis often has a chronic cyclic course with exacerbation and remission phases. Not rarely the disease has primary chronic course--without an apparent beginning as acute prostatitis. This leads to late diagnostics and difficulties with identification of etiologic factor, which commonly is a conditionally pathogenic microorganisms and mixed infections. Such difficulties can be a reason for inadequate treatment and complications of chronic prostatitis such as abscess, paraprostatitis, impotence, and infertility.     

广东湛江地区前列腺炎患者病原体检测及临床治疗

目的:对广东湛江地区前列腺炎患者前列腺液病原菌分布及药敏情况进行分析,为临床合理用药和制定最佳治疗方案提供依据。方法:湛江市两间最大三甲医院2009年1月至2013年4月间共308例前列腺炎患者的前列腺液进行细菌学和药敏试验。运用全自动微生物分析仪鉴定细菌,采用K-B法测定药物敏感性。结果:308例前列腺液标本中,共17例(17/308,5.52%)分离出致病菌。这些致病菌以革兰氏阳性菌为主,共13株(13/17,76.47%),其中溶血葡萄球菌检测出6株(6/13,46.15%),全部是耐甲氧西林凝固酶阴性葡萄球菌。革兰氏阴性菌4例(4/17,23.53%),包括大肠埃希菌2株(其中一株产超广谱β-内酰胺酶(ESBLs)),粘膜炎莫拉氏菌1株,肺炎克雷伯菌亚种1株。结论:绝大多数前列腺炎患者属于慢性前列腺炎/慢性骨盆疼痛综合症,无需常规使用抗生素治疗。慢性细菌性前列腺炎致病菌感染以革兰氏阳性菌为主。对前列腺炎患者进行病原学检测及药敏试验是临床合理用药、制定最佳治疗方案的基础。     

单纯治疗慢性前列腺炎对其合并早泄的影响

目的:探讨单纯治疗慢性前列腺炎对其合并早泄的影响。方法:选择372例前列腺炎继发早泄的患者进行单纯针对前列腺炎的治疗,评价前列腺炎的治疗效果(包括前列腺炎症状评分(NIH-CPSI)、前列腺液常规等)及早泄的治疗效果(包括患者性生活满意度评分、配偶性生活满意度评分及阴道内射精潜伏期等)。结果:慢性前列腺炎经综合治疗后,患者的NIH-CPSI评分及前列腺液白细胞计数均显著降低(P0.05)。前列腺炎治愈或好转后,大多数患者的早泄情况得到明显改善,患者性生活满意度、配偶性生活满意度均较治疗前显著提高,阴道内射精潜伏期亦较治疗前明显延长,差异均具有统计学意义(P0.05)。结论:单纯治疗慢性前列腺炎继可使大部分患者并发的早泄明显改善,而对少数前列腺炎好转后早泄症状改善不明显者,可联合应用SSRIs等药物治疗。     

URETHRAL STENOSIS IN YOUNG GIRLS—A Cause of Recurrent Infection of the Urinary Tract

Recurrent urinary tract infection in young girls may result from unsuspected urethral stenosis.The diagnosis should be considered in the presence of symptoms suggesting obstruction of the lower urinary tract—symptoms such as infrequent voiding and straining on urination, particularly in intervals between bouts of acute febrile illness accompanied by pyuria or bacilluria. If radiopaque medium is retained in the bladder in unusual quantity following voiding at the close of excretory urography, it is suggestive but not pathognomonic of urethral stenosis. The diagnosis is established by instrumental calibration of the urethra under general anesthesia.Treatment consists in removing the cause by urethral dilatation and administering antibiotics and chemotherapeutic agents to overcome the infection.     

Urethral stenosis in young girls; a cause of recurrent infection of the urinary tract

Recurrent urinary tract infection in young girls may result from unsuspected urethral stenosis. The diagnosis should be considered in the presence of symptoms suggesting obstruction of the lower urinary tract-symptoms such as infrequent voiding and straining on urination, particularly in intervals between bouts of acute febrile illness accompanied by pyuria or bacilluria. If radiopaque medium is retained in the bladder in unusual quantity following voiding at the close of excretory urography, it is suggestive but not pathognomonic of urethral stenosis. The diagnosis is established by instrumental calibration of the urethra under general anesthesia. Treatment consists in removing the cause by urethral dilatation and administering antibiotics and chemotherapeutic agents to overcome the infection.     

Sparfloxacin (Sparflo) in the treatment of urological infections]

Sparfloxacin efficacy evaluation for the treatment of urogenital tract infections is presented. The trial was performed on 43 patients with chronic complicated infections of urogenital tract (pyelonephritis, prostatitis). Sparfloxacin (once daily for 7-14 days) was highly effective in the infection management according to clinical and bacteriological results (83.7 per cent and 78.1 per cent subsequently).     

Toll-like receptor 4 in rat prostate: modulation by testosterone and acute bacterial infection in epithelial and stromal cells

The prostate gland is the most inflammation-prone organ in the male reproductive tract. However, little information is available regarding the immunobiology of this gland. Toll-like receptor 4 (TLR4) is considered to be a major sensor of danger signals and a key trigger of the innate immune responses. TLRs have also been implicated in the development of different inflammatory diseases in organs in which epithelial-stromal interactions are critical for homeostasis. The purpose of this work was to evaluate the presence and regulation of TLR4 in the rat prostate. Western blot and immunocytochemical studies revealed that constitutive expression of TLR4 in the rat ventral prostate was localized in the epithelial cells, mainly associated with the rough endoplasmic reticulum, as well as in smooth muscle cells in the stroma. In addition, increased concentrations of TLR4 were found in castrated rats, predominantly in hypertrophied smooth muscle cells. On the other hand, using a bacterial prostatitis model, we observed an increment in the TLR4 cytoplasmic content and migration of this receptor to the apical plasmatic membranes of epithelial cells at 24 h and 48 h post-infection. These findings suggest that the prostate gland is able to recognize pathogens and to initiate immune responses. In addition, TLR4 appears to be implicated in the vital stromal-epithelial interactions that maintain prostate homeostasis during prostatitis, as well as following androgen deprivation.     

Diagnostic potential of trace metals concentration in expressed prostatic secretion and serum of patients with category IV prostatitis

BackgroundThe National Institutes of Health (NIH) category IV prostatitis is a painless prostate gland inflammation, just as its name implies, this type of prostatitis is related with inflammation of the prostate, but most men are not conscious of it. However, category IV prostatitis is fairly common in general populations and reported having indirect relationships with prostate cancer.MethodWe analyzed the concentration of zinc (Zn), copper (Cu), calcium (Ca) and magnesium (Mg) in expressed prostatic secretion (EPS) and serum of patients with category IV prostatitis and healthy controls, investigating the diagnostic potential of different metals in category IV prostatitis using a flame atomic absorption spectrometer (FAAS).ResultsMetal concentration combined clinical characteristics analysis suggested that average level of Zn, Ca, Mg were significantly lower in the EPS of patients with category IV prostatitis (P-value< 0.000), while Cu level raised obviously (P-value< 0.000). And in the serum, mean concentrations of Ca was also found to increase significantly in the patients with category IV prostatitis compared to healthy controls. Moreover, the correlation analysis indicated that age showed a positive correlation with EPS Zn, Ca, Mg concentration (P-value< 0.05), while albumin correlates with EPS Zn, Ca, Mg concentration reversely (P-value< 0.05) in patients with category IV prostatitis.ConclusionOur report revealed that determination of the metal elements zinc, copper, calcium and magnesium in the serum and EPS could be a new and promising strategy for the rapid diagnosis of category IV prostatitis.     

The soy effect in the disease models of nonbacterial prostatitis and obstructive voiding

The goal of this study was to improve the understanding of the potential significance of dietary soy for human health by investigating its effects in the animal models of nonbacterial prostatitis and urethral obstruction. Nonbacterial prostatitis was induced in adult Noble rats with the combined treatment of testosterone and 17beta-estradiol. The inflammatory foci categorized into three forms were counted and correlated with expression of an estrogen-responsive gene, progesterone receptor (PR), in the dorsolateral lobes of the rats on soy (+) and soy (-) diets. Development of obstructive voiding after neonatal estrogenization of Noble rats (NeoDES rats) was followed with urodynamic measurements in rats on soy (+) and soy (-) diets. The amounts of genistein and daidzein, two major soy-derived isoflavones, were measured in the urine of Noble rats by the high-performance liquid chromatography-photodiodearray method. Dietary soy decreased the total number of inflammatory foci while no demonstrable effects were seen on the cellular composition of the infiltrates. Soy did not increase the weights of the pituitary gland, testes, or sex accessory glands, but it did increase the number of PR-positive epithelial cells in the dorsolateral prostate. It also decreased the bladder pressures in NeoDES rats but did not increase the flow rates. The soy effects may be mediated by the strong estrogen influence involved in the animal models. Dietary soy had anti-inflammatory effects in the prostate but only marginal effects on the development of obstructive voiding in Noble rats. The anti-inflammatory effects of soy may contribute to the lower prevalence of prostatitis-like symptoms and the historically lower risk of benign prostatic hyperplasia in Japan; however, no evidence was found that regular consumption of soy influences the age-related development of lower urinary tract symptoms or decline of flow rate.     

A severely symptomatic case of anaerobic chronic bacterial prostatitis successfully resolved with moxifloxacin therapy

It has been demonstrated that patients showing symptoms of chronic bacterial prostatitis but culture-negative prostate-specific specimens can benefit from administration of antibacterial agents. This suggests that organisms that are not isolated in the routine practice may be responsible for prostate infection in an undefined fraction of subjects. Anaerobic bacteria have been proposed to play a pathogenic role in CBP, on the basis of studies describing clinical remission after eradication of pathogens like Peptostreptococcus spp or Bacterioides spp from prostatic secretions of symptomatic patients, or the significant association between prostatic infection by anaerobes and the presence of inflammation markers in prostatic secretions.In this paper, we report in detail a case of severely symptomatic chronic prostatitis in a patient with evidence of infection by Peptostreptococcus. We also report for the first time that treatment with the 3rd generation fluoroquinolone moxifloxacin was successful in eradicating the pathogen and in causing dramatic resolution of signs and symptoms of chronic bacterial prostatitis.The strict association between eradication of Peptostreptococcus and the rapid disappearance of clinical signs/symptoms points to a causative role of this anaerobe in the chronic bacterial prostatitis case described in this report.     

La place de l’examen direct des prélèvements bactériologiques dans le diagnostic des infections bactériennes

Routine examination of bacteriological sample presents two steps: direct examination and culture. Final aim of these examinations is to identify most of bacteria responsible of infection in order to justify an antibiotic treatment. Interest of direct examination in the identification of bacterial colony is well-established; however its importance in the appreciation of bacteriological samples is sometimes neglected by technician and intern of bacteriology. This presentation aim to remind us this importance in current bacteriological diagnosis by relating what responses it could bring in asked bacteriological analyses which are: cerebrospinal fluid, urine collection and cervicovaginal secretion.