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HPV na Prática Clínica

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Authored by Richard A Watson, MD, Program Director, Associate Professor, Department of Surgery, Division of Urology, University of Medicine and Dentistry of New Jersey
Coauthored by Robert J Irwin, Jr, MD, Chair, Harris L Willits Professor, Department of Surgery, Division of Urology, University Hospital, University of Medicine and Dentistry of New Jersey
Richard A Watson, MD, is a member of the following medical societies: Academy of Medicine of New Jersey, American Urological Association, Association of Military Surgeons of the US, and Society of University Urologists
Edited by Edward David Kim, MD, Associate Professor, Department of Urology, University of Tennessee School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Assistant Clinical Professor, Department of Urology, Medical College of Ohio

INTRODUCTION

Background: The term prostatodynia or chronic pelvic pain syndrome (CPPS) is used loosely to designate any unexplained complaints of chronic pelvic pain associated with the following 2 characteristics in a male patient:
1. Nonspecific voiding symptoms and/or pain located anywhere in or around the groin, genitalia, or perineum
2. The absence of pyuria and bacteriuria, with or without excess white cells or bacteria on Gram stain and culture of expressed prostatic secretions (EPS)
An academic distinction may be made between patients with excess WBCs in their prostatic secretions (chronic nonbacterial prostatitis) and those with normal prostatic secretions (prostatodynia), but these 2 conditions are inseparable in terms of symptomatology and lack of an effective, definitive treatment.

Frequency:

• In the US: Chronic prostatitis is the most common urological diagnosis in men older than 50 years and is the third most common diagnosis in men younger than 50 years. This diagnosis results in at least 2 million office visits per year. The average urologist sees about 10 prostatitis patients per month, of whom 30% are new patients. Specific urinary pathogens are detected infrequently on culture. The vast majority of these patients are categorized as patients with chronic nonbacterial prostatitis or prostatodynia, otherwise known as CPPS in the male.

Age: Chronic prostatitis most commonly affects men older than 50 years. It is only slightly less common in men younger than 50 years.

CLINICAL
History:

• Symptomatology parallels that experienced in chronic bacterial and nonbacterial prostatitis.
  
• The typical patient is a young-to-middle-aged man with variable complaints of chronic, irritative, and/or obstructive voiding symptoms accompanied by moderate-to-severe pain in the pelvis, lower back, perineum, and/or genitalia.
  
• Erectile dysfunction is the symptom that initially brings many men to seek medical attention; however, the patient often will wait until the end of the interview to mention the problem, or he may avoid mentioning it at all unless the physician specifically inquires.
  
• To facilitate history taking and to establish a more uniform standard, a National Institutes of Health (NIH) collaborative panel has proposed an NIH Chronic Prostatitis Symptom Index (NIH-CPSI). This index is comprised of a series of 9 questions that contain 21 items to assess patient history in a standardized and quantifiable format.

1. Pain or discomfort (4 questions)
2. Urinary symptoms (2 questions)
3. Impact of symptoms (2 questions)
4. Quality of life impairment (1 question)

• The NIH describes 4 categories of prostatitis, described below.

Table 1. Four Categories of Prostatitis Established by the NIH

Physical:

• No finding is pathognomonic.

o Examination of the genitalia reveals normal results.
o Digital rectal examination may reveal a tight anal sphincter.
o The prostate and adjacent tissues may be moderately to severely tender, and the gland itself may be slightly congested or boggy.

• The value of this examination is to rule out other diagnoses, such as prostate cancer, chronic urethritis/meatitis, and granulomatous prostatitis.

Causes:

• Bacteria: Ureaplasma urealyticum and Chlamydia trachomatis have been implicated as possible etiologic agents by some but refuted by others.
  
• Neuropathy

  o Findings on video-urodynamics of spastic hyperactivity in the absence of a definable underlying neuropathy suggest the presence of either an occult neural etiology or an acquired functional voiding disorder.
  o Myofascial pain syndrome has been postulated as a cause for CPPS/chronic prostatitis.

Even in the face of clinical inflammation, a reflex triggering of spasm in the musculature of the pelvic floor can be the secondary, but clinically significant, source of much of the symptomatology (Zermann, 1999).

DIFFERENTIALS

Acute Bacterial Prostatitis and Prostatic Abscess
Appendicitis
Bladder Cancer
Bladder Stones
Carcinoma-in-Situ of the Urinary Bladder
Chronic Pelvic Pain
Condyloma Acuminatum
Cystitis, Nonbacterial
Enterobacter Infections
Enterococcal Infections
Fistula-in-Ano
Gonococcal Infections
Hematospermia
Infertility
Infertility, Male
Interstitial Cystitis
Nonbacterial Prostatitis
Perianal Abscess
Prostate-Specific Antigen
Prostatic Intraepithelial Neoplasia (PIN)
Prostatitis, Bacterial
Prostatitis, Tuberculous
Proteus Infections
Pyelonephritis, Chronic
Radiation Cystitis
Schistosomiasis
Tuberculosis
Tuberculosis of the Genitourinary System
Urethral Cancer
Urethral Diverticula
Urethral Diverticulum
Urethral Strictures
Urethral Syndrome
Urethral Trauma
Urethral Warts
Urethritis
Urinary Tract Infection, Males
Urinary Tract Obstruction

Other Problems to be Considered:
Other conditions in the differential include the following:
Tuberculous prostatitis
Sexually transmitted diseases
Congenital or acquired abnormalities of the urethra
Prostatic cyst
Prostatic abscess
Seminal vesiculitis
Myofacial pain syndrome

These many differential diagnoses-and this list is by no means exhaustive-reveal the conundrum of diagnosing prostatodynia. Because the diagnosis is one of exclusion, in theory, this diagnosis cannot be made until all of these alternatives have been excluded definitively. However, neither time, patience (the physician's and the patient's), nor the limited medical resources and/or the patient's finite finances allow for a categorical demonstration of the absence of each of these symptomatically related entities.

An archetypical example would be making a distinction between prostatodynia and interstitial cystitis in the male. A detailed review of the diagnosis of interstitial cystitis is presented thoroughly in Intersitial Cystitis. Suffice it to say here that the distinction between prostatodynia and interstitial cystitis is particularly challenging, in that both of these conditions are diagnoses of exclusion-2 separate "waste-can" diagnoses. Just as no definitive diagnostic test exists to document the diagnosis of prostatodynia, so too no test proves unequivocally the presence (or absence) of interstitial cystitis. If cystoscopy is planned as part of the workup, performing this study under anesthesia and including biopsy and hydrodistention, searching for telltale signs, is prudent and cost effective. However, the pathognomonic Hunner ulcer is as rare as it is classic. And the presence of glomerulations-not always an all-or-none
observation-has been described in asymptomatic women. At the most recent (2001) convention of the American Urological Association, no fewer than 3 reports disparaged the utility of the once heavily promoted potassium sensitivity test.

The point at which the physician empirically recommends (for a given patient with prostatodynia) a trial of therapies specific for interstitial cystitis is the physician's judgment call. Therapies such as Elmiron (pentosan sulfate) and intravesical instillations of dimethyl sulfoxide (DMSO), for example, have yielded success in selected patients with prostatodynia. Details regarding the array and application of various interstitial cystitis therapies are beyond the scope of this chapter (see Intersitial Cystitis). Nonetheless, the frustrated diagnostician should keep this option for diagnosis in mind when further evaluating a patient with refractory prostatodynia.

Similarly, other diagnoses also must be excluded. Most importantly, any risk of underlying cancer must be dealt with urgently. Transitional cell cancer and carcinoma-in-situ of the bladder are deadly masqueraders. Cancer of the prostate also can present with symptoms suggestive of prostatodynia. Neoplasms of the rectum and GI tract, as well as rare tumors of other pelvic organs, have made their presence first known via irritative prostatic symptoms. Benign prostatic hyperplasia (BPH) and obstructive uropathy also have presented in this manner (see Prostate Hyperplasia, Benign). All of these possible diagnoses must be considered when diagnosing prostatodynia.

Ignoring these possibilities in all prostatodynia patients eventually would prove to be a fatal mistake. However, to subject every patient to a physically and financially exhaustive gauntlet of tests and procedures also clearly would be inappropriate. Tailoring the diagnostic workup to meet the needs of a specific patient is a skill that defies textbook codification. The 'art' of medicine comes into play in deciding, together with the patient, which possibilities to pursue and how vigorously to pursue each of them.

WORKUP
Lab Studies:

• Urinalysis and culture

  o No litmus test for CPPS exists.
  o The presence of pyuria and/or bacteriuria supports a diagnosis of bacterial prostatitis.
  o The presence in the EPS of an inordinate number of white cells and/or bacteria on Gram stain and/or a heavy, nearly pure growth of a known bacterial pathogen on culture indicates a diagnosis of bacterial prostatitis. However, contamination from the urethra, from an external site, or from a source of infection in the upper urinary tract can lead to a false-positive result, while errors in collection or processing can lead to a false-negative result.
  o Stamey recommended the 3-glass urinalysis method, and, while this approach is widely taught, it is much less widely practiced by clinical urologists today. (See Prostatitis, Bacterial for a detailed description of this examination.)

• Prostatic specific antigen

  o Prostate-specific antigen (PSA) often is elevated in acute bacterial prostatitis, and it may be modestly elevated in chronic prostatitis as well.
  o PSA testing in men with CPPS symptoms may be helpful in distinguishing between those with chronic bacterial prostatitis (elevated PSA) and those with prostatodynia (PSA within the reference range); however, this theory has yet to be tested in a well-controlled clinical trial.
  o Testing this theory presents problems because it involves counseling large numbers of men younger than 40 years with an elevated PSA secondary to benign inflammation to reassure them that their test results are not a positive cancer test.
  Imaging Studies:

• Because no definitive diagnostic finding exists, all radiological studies (kidneys, ureters, and bladder [KUB]; intravenous pyelogram [IVP]; videocystourethrogram [VCU]; CT scan; MRI; ultrasound of the scrotum; and transrectal ultrasound of the prostate) are aimed at excluding the presence of other, more definable and treatable causes of the patient's symptoms.
  
• None of these studies warrants universal application.
  
• A cost-effective diagnostic algorithm should be individualized for each CPPS patient, incorporating only those laboratory tests and radiographic procedures that are appropriate to that specific patient's problem.

Procedures:

• Prostatic massage (diagnostic) and 3-glass urinalysis

  o Massage of the prostate produces EPS.
  o The finding of high colony counts of bacterial pathogens and/or the finding of a significant excess of WBCs suggests the presence of a treatable infectious agent, particularly if these findings can be reproduced on a second massage.
  o Because eliminating the presence of urethral contaminants from these specimens is impractical, the clinical reliability of these findings is subject to challenge.
  o Most men find this process distinctly unpleasant, and many tolerate the procedure with great difficulty, if at all.
  o In many cases, no prostatic secretion flows from the meatus after massage. In these cases, Stamey recommends obtaining the first 10 cc of voided urine immediately following massage, a voiding bladder urine #3 (VB3) specimen, and submitting that specimen for Gram stain and culture as a substitute for the EPS.

• Video-urodynamics

  o Video-urodynamic evaluation often reveals a spastic dysfunction of the bladder neck and prostatic urethra.
  o Incomplete relaxation of the bladder neck and abnormal narrowing of the prostatic urethra occur on voiding views.
  o These findings alone might not clearly justify the expense and discomfort of undergoing the procedure.
  o The main role of urodynamic studies is to rule out another underlying, unsuspected, but well-defined neuropathy amenable to treatment.

• Flow rate

  o A formal flow rate study often may document intermittency of flow and weakening of the urinary stream with a diminished peak urinary flow rate.
  o The urethral pressure profile typically shows a high maximum urethral closing pressure.

• Cystoscopy

  o Though the study results may be entirely normal, cystoscopy at most will reveal only nonspecific findings of minimal-to-mild inflammation and congestion in the area of the trigone and prostatic urethra.
  o The main purpose of this intervention is, as with uroradiography, to rule out the presence of other causes of the patient's symptoms.

• Flexible cystoscopy can be performed on an outpatient basis after urethral injection of Xylocaine jelly; however, in performing cystoscopy under general or regional anesthesia to evaluate these patients, 3 considerations exist.

1. These patients tend to be, as a rule, somewhat high-strung and hypersensitive, with a low pain tolerance. When the patient is unable to cooperate fully, endoscopic inspection is compromised.
2. General or regional anesthesia allows for more comfortable performance of cold-mucosal cup biopsies to rule out carcinoma-in-situ (CIS) and for hydrodistention of the bladder to rule out interstitial cystitis.
3. Minor pathology, such as an annular stricture of the urethra or a prostatic polyp, can be treated at the same time.

• Anal sphincter electromyography (EMG) and/or sphincter function profiles (microtip catheter) record reflex reactivity during cystometrography (CMG) and indicate the presence of hypertonicity and failure of the pelvic floor musculature to relax-signs of an underlying myofacial pain syndrome. Overall pelvic floor activity during CMG also can be monitored by an intra-anal surface electrode. While such experimental evaluations are not yet part of the standard urological armamentarium, they are available at select centers (Zermann, 1999).
  

TREATMENT
Medical Care: Managing a patient with CPPS challenges even the most compassionate physician. The patient often is understandably tense, wary, and defensive. Most patients already have encountered frustration and rejection under the care of several unsympathetic physicians. These patients often approach new physicians with an off-putting combination of unrealistic hopes for a cure and suspicion related to past diagnosis and treatment failure. The patient and physician must agree mutually upon a workable relationship at the outset of treatment. Below are 11 points the urologist and patient may wish to address, perhaps approaching treatment as a contractual agreement.

1. CPPS is a well-established condition notorious for the pain and disability it causes.
2. CPPS is a condition, not a disease or syndrome. It is similar to other chronic conditions, such as arthritis, that while treatable, are not curable. No known cure exists for CPPS, but treatments that are based on the cooperation of patient and physician make this condition more bearable. Over time, this condition possibly will improve or stabilize on its own.
3. Because CPPS is a diagnosis of exclusion, the physician must review the patient's records and perform a thorough physical examination to eliminate the possibility that another more treatable disease is causing these symptoms. The physician should assure the patient that only those diagnostic tests that hold a reasonable chance of producing a significant result will be recommended. The patient should not rule out the possibility that these examinations may reveal an alternate diagnosis, but he also should not be burdened by excessive testing.
4. Many medications and other forms of treatment can help alleviate the symptoms of CPPS. However, being patient is important; try only 1 or 2 new treatments at a time, giving each enough time to take effect. The physician should not overwhelm the patient with an unreasonable number of treatments carried out simultaneously, which will only cause excessive inconvenience and expense. Simultaneous treatments actually might work against one another, and the chance exists that the side effects of these treatments might cause more, rather than less, problems for the patient.
5. The physician should reassure the patient that CPPS is a real physical condition; the problem is not imagined. However, this devastating problem causes many psychological stresses for the patient. The physician should suggest medications to help calm the patient, as well as consultation with a psychiatrist or psychologist. A mental health care professional who has a special interest in this area may prove beneficial.
6. The patient should be reassured that CPPS is a legitimate condition, and, more importantly, it is not cancer. This condition is not life threatening, it is not a venereal disease, and it is not contagious. The physician should explain that the patient did not acquire this condition from someone else nor will he pass it on to anyone.
7. The physician must remind the patient that he is not alone. Many men experience this problem. Local and national support groups recommended by the physician can provide additional information and encouragement.
8. Doctor and patient should agree upon a schedule of planned follow-up visits carried out on a regular basis as frequently as appropriate management of symptoms dictates. These scheduled appointments will minimize the need for emergency visits and telephone calls while providing comfort and creating trust between doctor and patient.
9. The urologist will carry out treatment through, and in close communication with, the patient's primary care physician who will remain the mainstay of care.
10. The patient should be reminded that he is free to seek the advice of other physicians and health care providers while he is under a urologist's care. However, the patient must keep the urologist informed of all other treatments and medications tried, including alternative medicines and home remedies.
11. The patient should be reminded that his problem is taken very seriously, and the physician will make every effort, with the patient's cooperation, to reduce to a minimum the problems that this condition causes. The patient-physician relationship should be a partnership formed to gain control of this condition and allow the patient to enjoy life more fully.

• Prostatic massage (therapeutic)

o The role of prostate massage in providing symptomatic relief is controversial.
o With little evidence-based medicine to commend it, regularly repeated prostatic massages have been recommended in the past, particularly for patients with a large, congested gland.
o Some patients do find that it provides them temporary relief worth the awkwardness and discomfort of the maneuver itself.
o In 1969, Winter recommended prostatic massage 1-3 times weekly for 3-4 weeks for chronic infection of the prostate.
o Although this maneuver has largely fallen out of favor with many contemporary urologists, some still do revert to it, albeit on a less exuberant schedule, to provide supplementary symptomatic relief for select patients.

• Therapeutic ejaculation

  o The role of frequent ejaculation in either producing or reducing CPPS symptoms remains controversial.
  o Patients with enlarged, symptomatically congested glands often are advised that regular sexual intercourse may alleviate their symptoms.
  o While little objective evidence substantiates this claim, most patients do find this recommendation more attractive than serial prostate massages by their local urologist.
  o Whether frequent sexual intercourse relieves or actually exacerbates the condition seems to vary idiosyncratically from patient to patient.
  o Many patients enjoy informing their wives that the doctor prescribed frequent sex as therapy, and opportunities for amusement are few when dealing with this issue.
  o This author's anecdotal observation is that patients tend to be most adversely affected by sudden, dramatic changes in the frequency of intercourse, either increase or decrease. For example, a patient who remains sexually chaste while on prolonged business trips is apt to experience a flare-up both when he leaves home and again when he returns.
  o Whether masturbation produces an effect comparable to that of intercourse remains as unproved as it is widely advised. Ironically, similar prostatic maladies were attributed in 19th-century medicine to an excess of masturbation; what was condemned as a cause in the 1800s, has been promoted in the 20th century as a cure. Physicians should approach recommending masturbation in a sensitive manner, with the awareness that the act is objectionable to some patients' moral and religious standards.

Surgical Care: For instances of severely disabling CPPS, transurethral resection of the prostate (TUR-P) and even radical prostatectomy have been undertaken. A widely held opinion among urologists is that transurethral resection should be reserved for those who have experienced extreme, persistent symptoms over a protracted period of time, with no relief from nonoperative interventions. When TUR-P is undertaken, completing a thorough resection of all tissues, down to the capsule, is important. The concern is that residual tissue, partially coagulated, with obstruction of the ductal drainage from prostatic acini might create even worse symptoms (Smart, 1975).
Radical prostatectomy is an extreme measure, which should be entertained only in the most desperate of cases, if at all (Davis, 1990).

Consultations:

• Pain management consultation

  o Anesthesiologists and other experts in pain management sometimes can assist importantly in providing significant symptomatic relief.
  o No analgesics specifically are appropriate to the treatment of prostatitis. Standard mild analgesics, such as Tylenol, aspirin, and ibuprofen, are well within the purview of the urologist's (and indeed the primary care physician's) domain of management. Be mindful that your patient's analgesic needs are likely to fluctuate. Often, encouraging your patient to maintain a chronic, low-level intake of a minor analgesic, such as acetylsalicylic acid (ASA) or Tylenol tid, will diminish his need for more potent analgesics.
  o Both patient and physician fear of analgesic abuse or addiction often have led to under-medication, causing unnecessary pain and suffering.
  o Be quick to invite consultation from an established pain management center. Clinicians at Washington University have documented the beneficial impact that a coordinated, multidisciplinary approach between the urologist and the pain management team can have on improving the quality of life for many of these patients. These patients are dismissed often too easily, and their complaints are trivialized. Symptomatic patients can be encumbered by pain as devastating as that experienced by cancer patients, neurological patients, and others with debilitating conditions who merit a vigorous approach to the effective management of their pain.

• Psychiatric consultation

  o It frequently, if only anecdotally, is observed that patients with CPPS tend to be tense, high-strung, hypochondriacal, and even neurotic.
  o Experiencing the daily torment of uncontrolled pelvic pain, urinary dysfunction, and social embarrassment often causes psychological sequelae.
  o Many patients encounter frustrated, dismissive, and unhelpful physicians in the course of treatment, which is discouraging.
  o If the physician presents a sympathetic, constructive attitude, it can do much to alleviate the strain on the patient (see Medical Care).
  o Moreover, a mild relaxant, such as Valium, that is prescribed judiciously may help the patient to adjust to his condition and, at the same time, relax the spasm of the pelvic floor muscles, providing objective relief as well.
  o Psychiatric medications should be prescribed with caution and rarely without consultation with a psychiatrist.
  o A psychiatrist who is particularly interested in helping these patients can be a valuable member of the treatment team that includes the primary care physician, the urologist, and the pain management experts.
  o Avoiding a misunderstanding when recommending psychiatric counseling is important because the patient may perceive that his physician suspects that he is insane, hysterical, or delusional.
  o Reassure the patient that his condition is real and that his suffering is not imaginary.
  o Psychological support is appropriate in helping the patient cope more effectively with his serious, real-life problem.

• Andrology consultation (management of erectile dysfunction)

  o While erectile dysfunction and its remedies are discussed in detail in another chapter (see Erectile Dysfunction), the physician must remember that managing this potentially devastating effect of CPPS can have a highly positive impact on the patient's attitude and enjoyment of life.
  o Many remedies and treatments are available, including sildenafil, vacuum devices, injection and intraurethral therapies, and penile implants; a physician would be profoundly remiss not to broach the topic and its treatment possibilities.
  o Involving the patient's wife in the discussion early in treatment can be very worthwhile.

• Physical medicine and physiatry consultation

  o Lately, authorities have appreciated that, in many cases, the symptoms formerly attributed to "prostatodynia" actually may reflect pelvic floor spasm and chronic pelvic pain that is not prostatic in origin. In light of this, physiotherapists may provide an important role in helping to distinguish diagnostically and to ameliorate therapeutically those symptomatologies that are neuromuscularly based. For example, patients with palpable myofascial tenderness in the rectal area often experience a chronic inability to relax their pelvic floor musculature. This dysfunction of the pelvic floor muscles-levator syndrome-is objectively documentable. Moreover, significant symptomatic relief has been achieved through modulation-based therapies such as biofeedback, alpha-blockers, and sacral nerve stimulation.
  o Clinical researchers at Columbia University have found that an important subset of patients who had been treated unsuccessfully for symptoms of chronic abacterial prostatitis for 1.5 to more than 10 years and who were unresponsive to long-term antibiotics and alpha-blockers actually were experiencing pseudodyssynergia (a contraction of the external sphincter during voiding). This condition was documented by EMG and fluoroscopy. Patients thus identified responded to treatment with biofeedback and behavior modification in 83% of cases.
  o The presence of documented inflammation of the prostate and urethra does not rule out the presence of neuromuscular spasm of the pelvic floor. Whether the spasm comes first, resulting from dysfunctional voiding in subsequent urinary infections, or the infection comes first, triggering a chronic cycle of pain and pelvic spasm, is a chicken-or-egg conundrum. In either case, both the infection and the spasm must be treated concurrently to achieve long-term relief in these difficult cases.
  o While the urologist is best suited to address the prostatic inflammation, coordination of care with an interested physiotherapist for the management of biofeedback and nerve-root stimulation may prove very worthwhile.

Diet:

• The influence of diet on this condition is variable.
  
• Traditionally these patients have been warned to avoid excessive intake of prostate irritants, such as coffee, tea, soda (cola drinks and diet drinks may be especially irritating), spicy foods, and alcohol.

  o The physician should clarify that none of these items is known to cause actual physical damage or to worsen the long-term prognosis.
  o Nevertheless, responsible limitation of these items may help to control the day-to-day symptoms.

• A glass or two of wine or sherry may lessen nocturia complaints.
  
• Alkalinization of the urine seems to help some patients. A teaspoonful of baking soda (sodium bicarbonate) in a tall glass of warm water taken at bedtime may help reduce nighttime symptoms. Patients should be cautioned, however, regarding the risk of an excessive sodium load with higher oral intakes, especially in those under treatment for hypertension, fluid retention, or congestive heart failure. A potassium-based alkalinizer, such as potassium citrate (Urocit K) may prove more efficacious under these circumstances. Stephen Leslie, MD, reports anecdotally that he has found some patients to have very alkaline urine, which also can be irritating and cause discomfort and dysuria.

Activity:

• Hot tub baths

  o Sitz baths may provide partial relief from acute exacerbations.
  o Rather than a shallow, perineal dip, a deep tub bath in water as hot as can be comfortably tolerated seems to provide better overall temporary relief and relaxation.

MEDICATION
The goal of pharmacotherapy is to reduce morbidity and prevent complications.
It must be borne in mind that no antibiotic regimen has been proven efficacious in the treatment of chronic abacterial prostatitis. "Antibacterial agents are neither effective nor indicated in the treatment of non-bacterial prostatitis (see E.M. Meares, Jr, in the Bibliography). If U urealyticum or C trachomatis is suspected, a trial treatment of antibiotics may be considered.
In bacterial prostatitis, antibiotic therapy might be guided by culture findings from the prostatic secretions, from the ejaculate, from a urethral swab, or from the spun sediment of a VB3 urine. Even here, antibiotic choice is confounded by the fact that the organisms cultured from these sources may reflect urethral contaminants, rather than a true pathogen. Cultures of biopsies directly from the prostatic parenchyma have proven to be unreliable guides.
Abacterial prostatitis or prostatodynia is, by definition and by exclusion, without a documented bacterial origin. Antibiotics should have a very limited role in therapy for this condition. However, in desperation to do something for the patient, multiple courses of antibiotics frequently are prescribed, often for extraordinarily protracted periods of time. Some patients are maintained on chronic low-dose regimens, such as 1 capsule of Septra DS daily, and some patients experience symptomatic relief on these regimens. Whether this is a reflection of the strong placebo effect associated with treatment of this condition or the result of suppression of an undetected pathogen is purely a matter of speculation.
In approaching the antibiotic option, remember that no antibiotic is free of complications. For example, in the authors' institution, a patient has undergone a liver and renal transplant in response to a severe reaction to trimethoprim-sulfamethoxazole, which had been prescribed as a 1-month course of therapy for chronic prostatitis (with a sterile urine culture) that subsequently was shown to be the result of a missed diagnosis of bladder neck contracture. An attitude that any treatment "can't hurt" serves patients poorly.
The expense of these medications is not negligible, particularly when multiple prescriptions are provided, utilizing the newest, most expensive, wide-spectrum antibiotics.
Drug Category: Antibiotics -- As noted above, prostatodynia (CPPS in men) should, by definition, exclude men with a proven bacteriologic etiology. Therefore, antibiotics should not be deemed appropriate for the treatment of this condition. However, most practitioners are inclined to attempt at least 1 trial of long-term antibiosis. Clinical evidence, reviewing the results of all available clinical trials, found limited validation for the use of antibacterials, even in the face of chronic bacterial prostatitis. The cure rates for sterilization of prostatitic secretions, even for this more specific indication, ranged from 0-90% and correlated poorly with symptomatic responses. Limited evidence from retrospective studies suggests that quinolones (Cipro/Levaquin) may be more effective than trimethoprim-sulfamethoxazole (Bactrim/Septra). However, in the absence of a well-documented bacteriologic indication, this recommendation must be weighed against the significant cost differential between these 2 options.
The comment often is made, with regard to a blind trial of antibiotics for prostatodynia, that the antibiotics could not hurt. As a grim reminder of the rare, but devastating consequences attendant to the casual use of such antibiotics, this author currently is consulting in the management of a patient who is experiencing life-threatening complications following a liver/kidney transplant that was necessitated by his extremely adverse reaction to a course of trimethoprim-sulfamethoxazole. Tragically, the symptoms of chronic prostatitis, for which this antibiotic was prescribed, were later proven to be manifestations of a bladder neck contracture, not of prostatitis at all.

Drug Category: Muscle relaxants -- Tension myalgia of the pelvic floor muscles, combined with overall stress-related tension, can be partially relieved with use of muscle relaxants (see E.M. Meares, Jr, in the Bibliography).

Drug Category: Alpha-adrenergic blockers -- Alpha-adrenergic blockers have become a mainstay in the symptomatic treatment of this condition (see E.M. Meares, Jr, in the Bibliography). These agents, by relieving the secondary smooth muscle spasm within the bladder neck and prostatic urethra, afford the patient greater comfort in voiding. The dosage should be titrated progressively and administered at night to minimize the main adverse effect of orthostatic hypotension. The final dose must be individualized to meet the patient's needs. While the antihypertensive agent has been administered to patients already taking other blood pressure medications, coordinating the addition of this medication with the primary care physician or cardiologist who is prescribing the patient's other antihypertensive medications is wise.
Again, as with other medications, such as antibiotics, remember that the use of alpha-adrenergic blockade is not approved by the Food and Drug Administration (FDA) for the treatment of prostatodynia. One study has suggested an advantage for alpha-blockers in combination with antibiotics, over antibiotic therapy alone, in the treatment of chronic bacterial prostatitis.

FOLLOW-UP
Further Outpatient Care:

• Patients should keep a prostatodynia diary that has a page for each date, divided into the following 2 columns:

  1. A voiding diary records the time and approximate amount of each voiding, as well as the time and amount of each fluid intake.
  2. An environmental impact record details days when symptoms flare up and days when symptoms are unusually quiescent, and it involves every possible incidental of living, including, but not limited to, the following:

  • Type, time, and amount of food and beverage intake
    
  • Exercise or lack of activity, including bike riding, long car rides, prolonged sitting or standing
    
  • Sexual stimulation and whether or not it resulted in ejaculation
    
  • Lack of sexual stimulation
    
  • Unusual physical or emotional stress
    
  • Exposure to allergens such as animals, dust, or pollen

• Each day, when either a marked flare-up or an unusual abatement of symptoms occurs, the patient is encouraged to complete both columns of the diary in fullest possible detail.
  
• After a series of good days and bad days have been recorded, the patient can review these recordings with the physician, looking for patterns in diet, exposure, or activity that characterize either type of day.
  
• The idea is to reduce those factors associated with flare-ups and to maximize those factors associated with relief.
  
• This exercise should not be undertaken with the expectation of a cure but rather with the hope that clearer insight into some of the factors influencing the condition will provide the patient better control over this condition.

Deterrence/Prevention:

• Until the etiology(ies) of this condition is known, no specific strategy for avoiding it is possible.
  
• This condition, in some cases, may be the sequela of sexually transmitted disease, and, if so, more vigorous treatment of the sexually transmitted disease and/or more lengthy antibiotic treatment (>4 wk) for an initial bout of acute prostatitis may reduce the percentage of those cases that progress to a chronic, incurable state.

MISCELLANEOUS

Speial Concerns:

• Prostatodynia, now CPPS, is not a syndrome; it is not a discrete, narrowly defined constellation of consistent symptoms and objective findings ultimately traceable to a single, known etiology.
  
• CPPS in the male is a catch-all category of convenience into which physicians arbitrarily group the heterogeneous admixture of male patients who meet 3 criteria.

  1. Physicians can find no objective explanation for their multivariate, long-standing complaints.
  2. A significant number of their complaints relate to anatomical structures located within an arbitrary radius of the prostate gland (somewhere below the umbilicus and above the mid thigh).
  3. Physicians can offer no satisfactory treatment, let alone a cure, for their symptoms.

• Ultimately, a cure for CPPS will be found by those who make distinctions among cases rather than those who place all cases into one category.

  o Clinical investigators who are able to recognize within this hapless conglomeration a discrete subset of patients whose symptoms and findings can be proven to relate to a single, common etiologic factor will achieve meaningful success in treatment.
  o Identification of that factor and development of an effective remedy will provide a cure for that particular subset of CPPS patients.
  o In this way, multiple, individualized cures (as opposed to 1 cure) for CPPS will be achieved progressively for one subset of patients at a time.

• The key to enabling this painstaking, multidirectional journey to success lies in wider encouragement and more effective funding of well-designed clinical, bench-top, and translational research projects.
  
• Public awareness of the prevalence of this condition, its devastating effects in terms of personal suffering, and its remarkable financial impact in terms of work-loss, hospitalizations, polypharmacy, and endless office visits needs far greater promotion.
  
• Funding for research from both private and public sectors needs to be increased.
  
• The patients experiencing this condition and the physicians who care for them must have the courage to be more vocal in demanding higher priority in terms of immediate care and in terms of long-term research.

Prostatitis, Bacterial

Authored by Edward David Kim, MD, Associate Professor, Department of Urology, University of Tennessee School of Medicine
Edward David Kim, MD, is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Illinois State Medical Society, and Texas Medical Association
Edited by Jong M Choe, MD, FACS, Director of Continence and Urodynamic Center, Assistant Professor, Department of Surgery, Division of Urology, University of Cincinnati College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Assistant Clinical Professor, Department of Urology, Medical College of Ohio

INTRODUCTION
Background: Chronic bacterial prostatitis represents an infection of the prostate gland. This condition must have bacterial growth in culture of the prostatic fluid or postmassage urine specimen by definition. The expressed prostatic secretions (EPS) usually shows greater than 10 white blood cells per high power field (wbc/hpf) and macrophages.
The hallmark is the occurrence of relapsing urinary tract infections, most often by the same pathogen. Chronic bacterial prostatitis is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS) and prostatodynia.
Pathophysiology: The prostate gland is an accessory sex gland, providing approximately 15% of the ejaculate. The base of the prostate abuts the bladder neck, while the apex is in continuity with the membranous urethra, resting on the urogenital diaphragm.
The adult prostate weighs approximately 20 g, but may increase in size dramatically with age. The approximate dimensions are 4.4 cm transversely at the base, 3.4 cm in length, and 2.6 cm in anteroposterior diameter. Antibacterial factors within the prostate, such as zinc, help to prevent infection.
Frequency:

• In the US: It is estimated that 25% of all men evaluated for urological problems in the US have symptoms of prostatitis. Approximately 50% of men will experience symptoms of prostatitis at some time in their life. However, less than 5-10% of men with symptoms of prostatitis have bacterial prostatitis.

Mortality/Morbidity: Chronic bacterial prostatitis is not associated with mortality. However, acute bacterial prostatitis (discussed in another chapter) represents a potentially lethal process if untreated.
The morbidity of chronic bacterial prostatitis is its relapsing nature. Chronic bacterial prostatitis may be difficult to eradicate because of the persistence of bacteria within the prostatic acini.
Race: No racial predilections have been identified.
Sex: Occurs only in males.
Age: Chronic bacterial prostatitis typically affects men aged 40-70 years. This age group is similar to those men who have symptoms of benign prostatic hyperplasia.

CLINICAL
History:
Relapsing urinary tract infections, interspersed with asymptomatic periods, are common in chronic bacterial prostatitis. While some men are diagnosed because of asymptomatic bacteriuria, most have varying degrees of irritative voiding symptoms, such as dysuria, frequency and urgency.
In addition, feelings of a vague discomfort in the pelvis and perineum may be present. Fevers and chills are uncommon. The rectal palpation of the prostate is not painful, and has no specific findings. Prostatic fluid and postmassage urine cultures, which should be obtained for precise diagnosis, demonstrate bacterial growth.

• Characteristics of chronic bacterial prostatitis

  o Most common cause of relapsing urinary tract infection (UTI) in males
  o Asymptomatic periods between episodes of recurrent bacteriuria
  o Obstructive or irritative voiding symptoms
  o Vague discomfort in pelvis and perineum
  o Physical findings on palpation unremarkable
  o Must have EPS or postmassage urine culture for precise diagnosis

• Symptoms of prostatitis

  o Genitourinary pain
  o Dysuria
  o Clear discharge
  o Recurrent UTI

• The spectrum of organisms grown in culture in chronic bacterial prostatitis is essentially the same as in acute bacterial prostatitis. Most infections are caused by a single pathogen, but a polymicrobial infection is not unusual. Obligate anaerobic bacteria rarely cause prostatic infection.

Localization cultures need not demonstrate greater than 100,000 cfu/ml for the diagnosis. Instead, the presence of a greater than 10-fold bacterial growth in the EPS or VB3 specimens compared to the VB1 and VB2 is important.

• Common bacterial pathogens

  o Escherichia coli (80%)
  o Klebsiella species
  o Enterobacter
  o Proteus enterococci species
  o Pseudomonas
  o Others

Physical:
The physical examination, including the prostate examination by digital rectal examination, is typically normal.

• The prostate may have areas of firmness related to chronic inflammation. While prostatic calculi are associated with a higher risk of chronic bacterial prostatitis, they are rarely palpable on prostate examination because of their location typically deep within the prostate gland.
  
• In contrast, acute bacterial prostatitis is characterized by a very tender, warm, swollen, firm gland. When acute bacterial prostatitis is suspected, prostate massage should be avoided because of the risk of causing bacteremia.
  
• While chronic bacterial prostatitis may be associated with symptoms of perineal, scrotal, and low back discomfort, the physical examination is typically normal.

Causes:
The actual routes of prostatic infection are unknown in most cases, but various etiologies may be found. Ascending urethral infection is a known route because of the frequency of previous gonococcal prostatitis in the past, as well as the finding of identical prostatic fluid and vaginal culture organisms in many couples. Intraprostatic urinary reflux has been demonstrated in human cadavers, and may play a role.

• Routes of Infection

  o Ascending urethral infection
  o Reflux of infected urine into prostatic ducts
  o Migration of rectal bacteria via direct extension or lymphogenous spread
  o Hematogenous infection

• The relapsing nature is in part due to the ductal anatomy of the peripheral zone of the prostate. The anatomy of the ductal system prevents dependent drainage of secretions. Ductal fibrosis and prostatic calculi, if present, further inhibit the drainage of secretions.
  
• E coli accounts for 80% of chronic bacterial prostatitis. The other members of the Enterobacteriaceae family, Klebsiella species, Pseudomonas aeruginosa and Proteus also are known pathogens.
  
• The role of the gram-positive organisms Staphylococcus epidermitis and <>is controversial. These organisms may normally colonize the anterior urethra.
  
• Chlamydia trachomatis has been implicated as a cause of chronic bacterial prostatitis. However, this organism is unlikely to play a major role in the etiology of chronic bacterial prostatitis.
  
• NIH classification of prostatitis: Based upon specific etiologies, the NIH classified the various forms of prostatitis in 1995. The most common prostatitis is type III, the chronic pelvic pain syndrome category.

  o Type I acute bacterial prostatitis

• Well-defined infectious disease of the lower urinary tract
• Bacterial cause, most commonly E coli
• Frequently presents with bacteremia
  
  

o Type II chronic bacterial prostatitis: Focus of this chapter
o Type III chronic abacterial prostatitis (CPPS)

a) Inflammatory CPPS b) Noninflammatory CPPS

• Most common prostatitis
  
• Nonbacterial
  
• Based upon findings in expressed prostatitic secretions
  
• Empiric trial of antimicrobials usually warranted (fluoroquinolone or TMP-SMX)


o Type IV asymptomatic inflammatory prostatitis

• Often found on biopsies or surgical specimens
  
• No treatment warranted
  
• Biopsy typically triggered by elevated PSA

DIFFERENTIALS
Chronic Pelvic Pain
Chronic Prostatitis
Perianal Abscess
Prostate Hyperplasia, Benign
Prostatitis, Bacterial
Prostatitis, Tuberculous
Prostatodynia
Ureteral Stricture
Urinary Tract Infection, Males
Urinary Tract Obstruction

Other Problems to be Considered:
Acute prostatitis
Bacteriuria
Cystitis
Prostatic abscess

WORKUP
Lab Studies:

• The various prostatitis syndromes have been classified based on expressed prostatic secretion (EPS) and urine culture findings. This classification system is important for therapy, because the various categories are treated differently. The presence of 10 or more white blood cells per high power field in the EPS is considered clinically significant inflammation.

EPS findings are detailed as follows:

o Chronic bacterial prostatitis

The EPS in this condition usually is associated with greater than 10 wbc/hpf and should be obtained. Unlike patients with acute bacterial prostatitis, these patients are not acutely ill. Urine culture shows no growth unless the patient develops an acute UTI, in which case culture would demonstrate the same spectrum of organisms as in acute bacterial prostatitis.

o Acute bacterial prostatitis

Expressed prostatic secretions (EPS) should not be obtained in acute bacterial prostatitis for risk of potentiating bacteremia. If the EPS is obtained inadvertently, sheets of white blood cells are present. Significant bacterial growth is present in the voided urine from the presence of an accompanying cystitis.

o Non-bacterial prostatitis

In this condition, significant inflammation is present within the prostate as characterized by greater than 10 WBC/HPF. However, routine bacterial culture does not demonstrate growth of organisms. Cultures for fungi, Chlamydia, Ureaplasma, and Mycoplasma rarely demonstrate growth.

o Prostatodynia

No inflammation in the EPS or bacterial growth in culture is present. "Pelviperineal pain" is an appropriate name to describe the symptoms in this condition.

Imaging Studies:

• Imaging studies are not necessary for the diagnosis and treatment of chronic bacterial prostatitis. The criterion standard for diagnosis is the 3-cup bacterial localization study.
  
• Transrectal ultrasonography cannot diagnose chronic bacterial prostatitis. While hypoechoic lesions and calcifications within the prostate may suggest the infection and inflammation associated with chronic bacterial prostatitis, these findings are highly nonspecific.

Other Tests:

• If a patient with chronic bacteriuria does not have chronic bacterial prostatitis as demonstrated on the 3-cup test, then referral to a urologist is advisable. Chronic bacteriuria should prompt an investigation for underlying causes, such as urinary stasis, infection stones, abscess, and obstruction.

  o In this situation, evaluation of the upper urinary tract with radiologic imaging such as an IVP, renal ultrasound, or CT scan often is performed.
  o In addition, chronic bacteriuria in the absence of chronic bacterial prostatitis may prompt evaluation of the bladder with a cystoscopy.

Procedures:

• Three cup test: This test represents the classic method for the diagnosis of bacterial prostatitis. The technique was described initially by Meares and Stamey in 1968.

  o VB1: The voided bladder 1 (VB1) specimen represents any bacterial growth within the urethra. The patient is asked to retract the foreskin, if present, and cleanse the meatus. The VB1 is the first 5-10 mL of voided urine and should be collected in a sterile cup.
  o VB2: After the VB1 collection, the patient urinates another 100-150 mL of urine. The next 10-15 mL is collected into a sterile cup and represents VB2, the bladder component of any bacterial growth.
  o EPS: The expressed prostatic secretion (EPS) represents the prostate contribution. The EPS is obtained by massaging and compressing the prostate gland until a drop of fluid is obtained. The VB3 is examined under a high power field in a microscope. The presence of greater than 10 WBC/HPF is abnormal and consistent with prostatic inflammation.
  o In addition to white blood cells, the EPS may contain oval bodies, which are macrophages that contain fat. These oval bodies are also indicative of inflammation.
  o VB3: The VB3 represents a mixture of prostatic fluid and bladder urine. The VB3 is the first 5-10 ml of urine obtained after the prostate massage for the EPS. Similarly, this VB3 is sent for culture.

• The 3-cup test is performed best when the bladder urine is sterile. If the bladder urine is not sterile, an oral antibiotic such as nitrofurantoin may be prescribed to achieve bladder urine sterilization. Nitrofurantoin achieves excellent bladder concentrations, but does not produce significant intraprostatic levels.

Histologic Findings:
Chronic bacterial prostatitis is not diagnosed with a prostate biopsy. However, men having a prostate biopsy performed for the diagnosis of prostate cancer may show focal areas of inflammation characterized by a lymphocytic response. The pathology report often is listed as "chronic prostatitis."
While this type of finding may represent chronic bacterial prostatitis, it also may represent non-bacterial prostatitis. The history of chronic urinary tract infections provides the clinical diagnosis.

TREATMENT
Medical Care:
The mainstay for treatment of chronic bacterial prostatitis is the use of oral antimicrobial agents. The most effective medications are fluoroquinolones and trimethoprim-sulfamethoxazole.
All other oral agents are unlikely to successfully eradicate the pathogenic bacteria within the prostate because of suboptimal tissue penetration.
Longer courses of antibiotic use are associated with better treatment outcomes. Relapse is not uncommon.

• The reasons for relapsing urinary tract infections are the poor penetration of most antimicrobial agents into the prostatic fluid and/or bacterial sequestration, which protects them from antimicrobial exposure. Only small molecular size, un-ionized, lipid-soluble drugs not firmly bound to plasma proteins are able to diffuse across the epithelial membrane.
  
• Those antimicrobial agents that most effectively penetrate into the prostatic fluid, such as fluoroquinolones and trimethoprim-sulfamethoxazole, are good treatment choices for chronic bacterial prostatitis.

Treatment should be guided by urine culture results. Failure of an initial course of therapy (typically about 4 weeks) should prompt longer courses of treatment. Best results have been observed with a 12-week course of therapy, although patient compliance may be difficult with longer durations of treatment.
High bactericidal activity has been demonstrated against the Enterobacteriaceae group of bacteria and Pseudomonas aeruginosa using fluoroquinolones, a class of antimicrobial agents that inhibits bacterial DNA replication and protein synthesis.
Fluoroquinolones generally are ineffective against the Streptococci, including enterococcus, and anaerobes. Penicillin derivatives, while effective against gram-positive organisms, generally are ineffective in treating bacterial prostatitis because of poor prostate penetration.

• While zinc supplements have been suggested as a medical therapy, clinical results have not been significant. A zinc-containing polypeptide called prostatic antibacterial factor (PAF) may be an important antimicrobial factor within the prostate.
  Prostate fluid is also rich in spermine, which has activity against gram-positive bacteria. Other factors of potential importance in prostate fluid include magnesium, calcium, and lysozyme. Other local immune factors are also under investigation.
  
• Barbalias et al have suggested that the use of alpha-blockers in combination with fluoroquinolones would have significantly superior symptom resolution and bacteriologic cure rated compared to fluoroquinolone treatment alone. Further study is necessary to define the benefit of the addition of alpha-blocker therapy.
  
• Non-steroidal anti-inflammatory agents, hot sitz baths, and prostatic massage are oftenused clinically for symptomatic relief. Their benefit in bacteriologic eradication of organisms is not established, however. Frequent prostate massage was used extensively several decades ago, before studies of fluoroquinolones and TMP-SMX were available.
  
• Tetracycline, minocycline, and doxycycline have also been used. They are not considered first-line therapy, but may be quite helpful if a Pseudomonas infection is present. Paulson reported a 70% bacteriologic cure rate with 4 weeks of minocycline, but studied only 10 men and 30% developed significant vestibular toxicity. More recent studies indicate a 35% bacteriologic cure rate with minocycline.

Penicillins are ineffective, with the exception of carbenicillin indanyl sodium at 500 mg/day. Carbenicillin may be effective for Enterobacteriaceae or Pseudomonas infections. Large-scale studies are not available.

Surgical Care:
The "radical" transurethral prostatectomy (TURP) has been suggested as a surgical treatment for resection of all infected prostatic tissue. Because most of the inflammation is located in the peripheral zone of the gland, an extensive resection of the gland is required to remove all infected and potentially infected tissue down to the level of the true prostatic capsule.
Only one series of 10 patients, most having prostatic calculi, has been reported, but all men were considered cured (Meares 1986). This procedure is indicated, although only rarely, for those men failing one year of medical pharmacotherapy with well-documented bacterial infections.

• The Role of Prostatectomy in Chronic Bacterial Prostatitis

  o Rarely indicated
  o "Radical" transurethral prostatectomy (TURP) suggested
  o Possibly more effective in men with prostatic calculi

• Intraprostatic injection of antimicrobial agents

  o Suggested in an effort to obtain high concentrations of antimicrobial agents in the prostatic parenchyma.
  o Plomp et al noted a 66% bacteriologic cure rate in 29 men with thiamphenicol. Jiminez-Cruz et al noted a 59% cure rate in 51 men with aminoglycoside injection. Unfortunately, these studies have significant methodological flaws so the conclusions cannot be considered definitive.
  o Rarely used.

Consultations:
Consultation with a urologist may be appropriate for those men with relapsing chronic bacterial prostatitis, or when the diagnosis is unclear.
· A urologist may be able to properly perform the bacterial localization studies necessary to diagnose chronic bacterial prostatitis. In the author's experience, most primary care physicians are not comfortable or experienced with obtaining VB1, VB2, EPS, and VB3 specimens.

Diet:
Diet does not have an important role in treating chronic bacterial prostatitis. Some physicians have advocated the avoidance of spicy and caffeine-containing foods; however, there has not been any evidence of benefit in chronic bacterial prostatitis.

Activity:
Activity does not have a prominent role in the treatment of chronic bacterial prostatitis although we often advise patients to avoid bicycling or other activities that may put pressure on the perineal region.

• The role of ejaculation in the treatment of chronic bacterial prostatitis is unknown. One theory is that frequent ejaculation may help clear prostatitic secretions, thereby allowing for quicker resolution.

MEDICATION
The goal of pharmacotherapy is to treat the infection and reduce morbidity.
Drug Category: Fluoroquinolones -- These agents are concentrated in the prostate and are lipid-soluble.

Drug Category: Fluoroquinolones

Drug Category: Trimethoprim-sulfamethoxazole -- Trimethoprim is concentrated in the prostate and is lipid-soluble.

FOLLOW-UP
Further Outpatient Care:

• After completion of a 4-week course of a fluoroquinolone or TMP-SMX, repeating the 3-cup test is advisable. The recurrent and persistent nature of chronic bacterial prostatitis encourages efforts for eradication confirmed by negative bacterial cultures.
  
• Persistent bacterial growth should be treated with another 4-week trial of antibiotics. Repeat susceptibility testing is necessary.

Prognosis:

• A 4-6 week course of TMP-SMX results in 33-50% bacteriologic cure rates.
  
• A 4-6 week course of fluoroquinolone therapy is equally as successful, if not more, as TMP-SMX. A 63% durable response rate at 30 months after treatment was reported by Weidner et al.