Introduction

infection (Category II) of the prostate with

lar dysfunction or immunologic reaction can

uropathogenic organisms, usally Enterobacteria­

progress because of persisting initiating factors

ceae sp. (particularly E. coli but also Klebsiella sp.,

(persistence of bacteria, dysfunctional voiding,

Pseudomonas sp.and other Enterobacteriaceae sp.)

anatomic variance of prostate ducts or perineal

and occasionally gram positive Enterococci sp.19

trauma) or the pathology could persist even with

Category II is associated with similar organisms

eradication or amelioration of these factors

but there is some evidence that other organisms

through self perpetuating stimulatory loops

such as Chlamydia sp., Mycoplasma sp. and per­

(inflammation by autoimmune mechanism while

haps even anaerobic bacteria, Corynebacterium sp.

peripheral neuropathy can progress because of up

and in some specific cases (such as immunocom­

regulation of the local pelvic neuroloop and“wind

promised patients) fungi, viruses, etc. may also be

up” of the spinal cord). The patients who suffer

involved.20 In both categories, lower urinary tract

from chronic prostatitis for many months or

infection is associated with the acute exacerbation

many years eventually develop a typical neuro­

of symptoms (and in the case of Category I, per­

pathicpainpattern,associatedwithlocalmuscular

haps even urosepsis). Effective treatment usually

dysfunction. This process is further influenced by

eradicates the offending organism in Category I,

supratentorial CNS mechanisms such as depres­

but in Category II,the patient may continue to have

sion and maladaptive coping behaviors.23

a prostate nidus of infection resulting in the typical

clinical picture of recurrent lower urinary tract

The Diagnosis of the Prostatitis

infections with the same organism. Some patients

suffering from these recurrent episodes of infec­

Syndrome

tion may develop symptoms between acute epi­

sodes or may progress to Category III with chronic

Category I: Acute bacterial prostatitis patients

symptoms, negative cultures and no improvement

with antibiotics.

present with lower urinary tract infection symp­

Category III: By definition, these patients do

toms (dysuria, urgency, frequency, suprapubic

not have urinary tract infections.There is still dis­

pain/discomfort, hematuria), varying degrees of

agreement among experts on how to classify

urinary obstructive voiding symptoms (includ­

patients who do not have infection (or recurrent

ing acute urinary retention) and generalized

urinary tract infections), but uropathogenic bac­

symptoms such as fever.19 On physical examina­

teria are localized to the prostate during evalua­

tion the patient is usually uncomfortable, may

tion.2,20 The reason for this controversy is the fact

be feverish, a tender bladder may be palpable,

that normal asymptomatic control men localize

the prostate is usually soft (often referred to as

such bacteria to the prostate gland in similar

“boggy”) and usually exquisitely tender. The

prevalence as patients clinically categorized as

white count may be elevated and white cells will

Category III CP/CPPS.21 Similarly, CP/CPPS does

be present in the urine (or evidence of infection

not necessarily imply inflammation in the pros­

on dipstick examination). Urine culture and in

tate (histological prostatitis). In fact, there is little

cases where the patient is clinically septic, blood

correlation between prostate inflammation and

culture are procured, but therapy is initiated

symptoms in this condition and it is now recog­

immediately. An ultrasound or bladder scan

nized that patients without symptoms may have

may be indicated to determine if the patient is in

prostate inflammation (Category IV).21 It is

acute urinary retention.23

becoming quite evident that the symptom com­

Category II: Chronic Bacterial Prostatitis is

plex associated with Category III CP/CPPS is not

traditionally associated with recurring or relaps­

secondary to a single defined etiologic agent but

ing lower urinary tract infection, usually with

is rather a syndrome consisting of a continuous

the same organism and usually without clinical

spectrum, initiated and propagated by multiple,

sepsis.2,20,23 The patient may or may not be symp­

and likely inter­related factors.22,23 The initiators

tomatic between episodes of treated infection. If

could be infection, high pressure dysfunctional

symptomatic, the symptoms may be indistin­

voiding, trauma or some unknown toxin in a

guishable from those of patients with Category

genetically or anatomically susceptible man. This

III. This category is suspected in men with

initiating event results in either injury and/or

relapsing symptoms associated with bacteriuria

inflammation. The initial neuropathy, muscu­

who experience improvement in symptoms with

298

Practical Urology: EssEntial PrinciPlEs and PracticE

antibiotic therapy. The optimal time to make the

clinical trials in CP/CPPS.28 Nine separate

diagnosis is between episodes of acute exacerba­

items that could be answered by most patients

tions employing some form of lower urinary

in about 5 min addressed all these important

tract localization study. The traditional tech­

issues. The 6 major locations or type of pain or

nique to localize infection to the prostate gland

discomfort, the frequency of pain or discom­

was the Meares­Stamey 4­glass test24 which

fort and the severity of pain or discomfort are

included culture of the first initial voided urine

rated on a scale of 0–21. The irritative and

(voided bladder 1 or VB1), the midstream urine

obstructive voiding symptoms are rated on a

(voided bladder 2 or VB2), expressed prostatic

score of 0–10 while the impact on quality of life

secretion (EPS) obtained following prostate

is rated on a score of 0–12. Each of these

examination and the initial stream urine speci­

domains can be assessed independently or the

men collected after prostate massage (voided

3 can be added together for a total NIH­CPSI

bladder 3 or VB3). If the colony count of uro­

score of 0–43. The CPSI is a valuable tool for

pathogenic bacteria were significantly higher in

the practicing physician to evaluate a patient at

EPS and/or VB3 compared to VB1 and VB2, then

initial presentation and to follow him over time

a diagnosis of chronic prostate infection can be

to assess treatment outcomes.29,30 The NIH­

made and patient classified as Category II.

CPSI is presented in Fig. 22.1.

However the 4­glass test is cumbersome, expen­

A rather comprehensive evaluation routine

sive, and most physicians, including urologists

should be followed when assessing CP/CPPS

have abandoned it.25 A simpler 2­glass test

patients, particularly during the initial visit.31

compares the bacterial culture results of the

Physical examination may detect suprapubic,

pre­massage urine (Pre­M or VB2) to the post­

perineal, prostate, pelvic floor or external geni­

massage urine specimen (post­M or VB3).26 A

talia discomfort or pain or it may be completely

higher bacterial count in the Post­M specimen

noncontributory. The lower abdominal, genital,

compared to the Pre­M specimen is indicative of

perineal, rectal and focused neurogenic exami­

chronic prostate infection. This Pre and Post

nations are primarily necessary to rule out other

Massage test (PPMT) provides almost as accu­

causes for the patients’ symptoms. Urinalysis

rate localization data as the more difficult 4­glass

and urine cytology (particularly important if

test and can be easily employed in any clinical

the patient has hematuria or irritative obstruc­

practice situation.27

tive voiding symptoms) are collected along with

Category III: By definition chronic prostati­

the pre­M urine specimen. Following pelvic and

tis/chronic pelvic pain syndrome (CP/CPPS) is

prostate examination, prostate massage is

associated with genitourinary and/or pelvic

undertaken to produce either EPs or more easily

pain with no evidence of infection.2,4 Patients

a post­M specimen of urine for culture.

have one or more of perineal, ejaculatory,

Microscopy of the EPS and/or Post­M (VB3)

penile, testicular, suprapubic and penile pain/

specimen can determine if the patient should be

discomfort with variable irritative and/or

classified as Category IIIA or IIIB, but at the

obstructive voiding symptoms and perhaps

present there is no clinical indication to actually

some degree of associated sexual dysfunction.

do this step since no clinical trial to date has

Patients experience waxing and waning symp­

determined a differential treatment effect

toms that are extremely bothersome and

between these two categories.21,32 That may

impact on activities. Since this category is a

change in the future. If the patient is at an age

syndrome defined by a symptom complex it is

that prostate cancer is a possibility, a serum

imperative that a comprehensive symptom

prostate specific antigen (PSA) can be collected.

inventory documenting the location, severity,

Other urologic tests such as cystoscopy, urody­

frequency of the pain, any urinary symptoms

namics and imaging (transrectal ultrasound,

and impact on activities and quality of life is

CAT scan, etc.) are optional and indications are

undertaken. This can now be accomplished by

based on specific findings from history, urinaly­

administering the NIH Chronic Prostatitis

sis, cytology and physical examination.

Symptom Index (CPSI), a validated and sensi­

Table 22.2 represents a suggested diagnostic

tive symptom assessment tool developed for

plan for the prostatitis syndromes.