ProstatitisProstatitis

Christian Beck, MDChristian Beck, MDDortmund GermanyDortmund Germany

HistoryHistory

• First described in 1815 by Legneau.First described in 1815 by Legneau.

• Main treatment was repeated Main treatment was repeated prostate massage.prostate massage.

• In 1930’s antibiotics came into In 1930’s antibiotics came into regular use.regular use.

• Evident that most forms of prostatitis Evident that most forms of prostatitis did not respond to Ab’s. did not respond to Ab’s.

Epidemiology (USA)Epidemiology (USA)

• McNaughton-Collins in 2000 noted 2 million McNaughton-Collins in 2000 noted 2 million physician visits for ‘prostatitis’ annually from physician visits for ‘prostatitis’ annually from 1990-1994 in USA1990-1994 in USA

• Commonest urological diagnosis in men < 50 Commonest urological diagnosis in men < 50 and 3and 3rdrd commonest in men > 50, 8% of commonest in men > 50, 8% of urology consultations.urology consultations.

• Urepik Study 1998 – 35% of men had at least Urepik Study 1998 – 35% of men had at least 1 symptom of prostatitis, with 8% describing 1 symptom of prostatitis, with 8% describing symptoms as problematic.symptoms as problematic.

Prostatitis: A Major Clinical Prostatitis: A Major Clinical Problem (Germany)Problem (Germany)

Incidence/prevalence: 4% -11% Incidence/prevalence: 4% -11%

8-12% of urologist office visits 8-12% of urologist office visits

Life time prevalence 14.8%Life time prevalence 14.8%

most common urological diagnosis in most common urological diagnosis in men <50men <50

Quality of Life is dismal (Quality of Life is dismal (depressing) !depressing) !

AetiologyAetiology

• Gram –ve enterobacteria account for Gram –ve enterobacteria account for 90% of acute bacterial prostatitis. (E. 90% of acute bacterial prostatitis. (E. coli, Klebsiella, Serratia, coli, Klebsiella, Serratia, Pseudomonas)Pseudomonas)

• Enterococcus (gram +ve) 5 – 10%, Enterococcus (gram +ve) 5 – 10%, and Staphs.and Staphs.

• Role of anaerobes are unknown.Role of anaerobes are unknown.• Anti-Chlamydial antibodies in 30% of Anti-Chlamydial antibodies in 30% of

chronic prostatitis, but < 1% culture chronic prostatitis, but < 1% culture organism.organism.

AetiologyAetiology

• Altered Prostatic Host Defence - phimosis; Altered Prostatic Host Defence - phimosis; unprotected penetrative anal rectal unprotected penetrative anal rectal intercourse; acute epididymitis; intercourse; acute epididymitis; indwelling urethral catheters and condom indwelling urethral catheters and condom catheter drainage.catheter drainage.

• Dysfunctional Voiding. Dysfunctional Voiding. • Intraprostatic Ductal Reflux – stones, Intraprostatic Ductal Reflux – stones,

carbon particles (Kirby et al 1982).carbon particles (Kirby et al 1982).• Pelvic Floor Musculature Abnormalities. Pelvic Floor Musculature Abnormalities. • Interstitial Cystitis.Interstitial Cystitis.• Psychological Cause Psychological Cause

InvestigationInvestigation

• Physical – Signs of infection, abdo tenderness, DRE (anal Physical – Signs of infection, abdo tenderness, DRE (anal tone, prostate, pain).tone, prostate, pain).

• Examination of Urine.Examination of Urine.

• Urodynamics (Video)Urodynamics (Video)• Rule out other cause – obstruction, OAB, dyssynergia.Rule out other cause – obstruction, OAB, dyssynergia.

• Cystoscopy?Cystoscopy?

• TRUSTRUS• Abscess, medial cysts, SV obstruction.Abscess, medial cysts, SV obstruction.• Not diagnostic for Chronic Prostatitis.Not diagnostic for Chronic Prostatitis.• Biopsy of no clinical benefit to management. Biopsy of no clinical benefit to management.

Examination of UrineExamination of Urine

• 1968 Meares and Stamey - 4 glass test.1968 Meares and Stamey - 4 glass test.

• For Chronic Prostatitis only.For Chronic Prostatitis only.

• Simplified 2 glass test similar sensitivity and Simplified 2 glass test similar sensitivity and specificity to 4 glass test.specificity to 4 glass test.

• 10 WBC’s per HPF is cut off for inflammatory 10 WBC’s per HPF is cut off for inflammatory and non-inflammatory category III prostatitis.and non-inflammatory category III prostatitis.

Examination of UrineExamination of Urine CLASSIC STAMEY 4 GLASS TESTCLASSIC STAMEY 4 GLASS TEST

Wagenlehner, F M E; Naber, K G; Bschleipfer, T; Brähler, E; Weidner, WWagenlehner, F M E; Naber, K G; Bschleipfer, T; Brähler, E; Weidner, W

Prostatitis and Male Pelvic Pain Syndrome: Diagnosis and TreatmentProstatitis and Male Pelvic Pain Syndrome: Diagnosis and Treatment

Dtsch Arztebl Int 2009; 106(11): 175-83; DOI: 10.3238/arztebl.2009.0175Dtsch Arztebl Int 2009; 106(11): 175-83; DOI: 10.3238/arztebl.2009.0175

PROSTATITIS DIAGNOSISPROSTATITIS DIAGNOSIS

Donna R. Coffman, MDDonna R. Coffman, MD

Comparison of four-glass and two-glass premassage Comparison of four-glass and two-glass premassage and postmassage testand postmassage test

Nickel JC, Shoskes D, Wang Y, et al: How does the pre-massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol 176(1):119-124, 2006.

The Premassage postmassage test (PPMT) may offer an adequate screening test as an alternative that is simpler, faster, and less expensive than the four-glass test.

Prostate massagePRE-M POST-M

ClassificationClassification

PROSTATITIS UNDER THE PROSTATITIS UNDER THE MICROSCOPEMICROSCOPE

Category I – Acute BacterialCategory I – Acute Bacterial

• Not commonNot common

• Perineal, external genitalia and suprapubic pain.Perineal, external genitalia and suprapubic pain.

• Dysuria, frequency and urgency.Dysuria, frequency and urgency.

• Obstructive symptoms.Obstructive symptoms.

• Febrile illness occasionally with severe sepsis.Febrile illness occasionally with severe sepsis.

Category I – Acute BacterialCategory I – Acute Bacterial

The patient typically complains of :The patient typically complains of :• Urinary frequency, urgency, and dysuria. Urinary frequency, urgency, and dysuria. • Obstructive voiding complaints including hesitancy, poor Obstructive voiding complaints including hesitancy, poor

interrupted stream, strangury, and even acute urinary interrupted stream, strangury, and even acute urinary retention are common. Tenesmus.retention are common. Tenesmus.

• Perineal and suprapubic pain Perineal and suprapubic pain • Associated pain or discomfort of the external genitalia. Associated pain or discomfort of the external genitalia. • Significant systemic symptoms including fever, chills, Significant systemic symptoms including fever, chills,

malaise, nausea and vomiting, and even frank malaise, nausea and vomiting, and even frank septicemia with hypotension septicemia with hypotension

Approximately 5% of patients with acute bacterial Approximately 5% of patients with acute bacterial prostatitis may progress to chronic bacterial prostatitis prostatitis may progress to chronic bacterial prostatitis (Cho et al., 2005(Cho et al., 2005

Category I – Acute BacterialCategory I – Acute Bacterial

• Send MSSU (Mid Stream Specimen of Send MSSU (Mid Stream Specimen of Urine) / blood cultures.Urine) / blood cultures.

• AntibioticsAntibiotics• i.v. if evidence of sepsisi.v. if evidence of sepsis•Aminoglycoside, cephalosporins, or Aminoglycoside, cephalosporins, or

fluoroquinolones.fluoroquinolones.•2 – 4 weeks treatment. 2 – 4 weeks treatment.

• SurgerySurgery•SP catheter SP catheter •TRUSS or CT to exclude abscess.TRUSS or CT to exclude abscess.•Abscess best drained by TUR.Abscess best drained by TUR.

Category II – Chronic Bacterial Category II – Chronic Bacterial Prostatitis.Prostatitis.

• 5 – 15% of Prostatitis5 – 15% of Prostatitis

• Recurrent UTI’s in 25 – 40%Recurrent UTI’s in 25 – 40%

• May be asymptomatic between episodes or May be asymptomatic between episodes or have a long history of CPPS.have a long history of CPPS.

• Treat with AntibioticsTreat with Antibiotics• Fluoroquinolones (Cipro- Levo- and Ofloxacine) most Fluoroquinolones (Cipro- Levo- and Ofloxacine) most

effective.effective.• 12 weeks of treatment. 12 weeks of treatment. • 60 – 85% bacteriological cure.60 – 85% bacteriological cure.• 40% symptom cure.40% symptom cure.

Category IIIa – Chronic Pelvic Pain Category IIIa – Chronic Pelvic Pain Syndrom (CPPS Inflammatory)Syndrom (CPPS Inflammatory)

• Pain – Perineum, suprapubic and penile but can Pain – Perineum, suprapubic and penile but can be testes, groin and lower back.be testes, groin and lower back.

• Pain during or after ejaculation.Pain during or after ejaculation.

• LUTS (storage and voiding symptoms)LUTS (storage and voiding symptoms)

• Erectile dysfunction is increased.Erectile dysfunction is increased.

• Symptoms present for > 3 months.Symptoms present for > 3 months.

• Sickness Impact Profile – QL scores similar to Sickness Impact Profile – QL scores similar to MI, angina and Crohn’s.MI, angina and Crohn’s.

Category IIIb – Chronic Pelvic Pain Category IIIb – Chronic Pelvic Pain Syndrom (CPPS non-bacterial)Syndrom (CPPS non-bacterial)

• Same presenting features as IIIa, but < Same presenting features as IIIa, but < 10 WBCell’s per HPField on Expressed 10 WBCell’s per HPField on Expressed Prostatic Sekretion and VB3.Prostatic Sekretion and VB3.

• NIH – Chronic Prostatitis Symptom NIH – Chronic Prostatitis Symptom Index.Index.

Category IV – Asymptomatic Category IV – Asymptomatic Inflammatory ProstatitisInflammatory Prostatitis

• As name suggests!!As name suggests!!

• WBC’s or bacteria in EPS or VB3 or WBC’s or bacteria in EPS or VB3 or histological examination of gland.histological examination of gland.

• Present with obstruction, raised PSA, Present with obstruction, raised PSA, infertility. infertility.

Classification: NIHClassification: NIH

Cat I: Acute Bacterial ProstatitisCat I: Acute Bacterial Prostatitis

Cat II: Chronic Bacterial ProstatitisCat II: Chronic Bacterial Prostatitis

Cat III: Chronic Pelvic Pain Syndrome (CPPS)Cat III: Chronic Pelvic Pain Syndrome (CPPS)Cat IIIA: Inflammatory CPPSCat IIIA: Inflammatory CPPS

Cat IIIB: Non-inflammatory CPPSCat IIIB: Non-inflammatory CPPS

Cat IV:Cat IV: Asymptomatic Inflammatory Asymptomatic Inflammatory Prostatitis Prostatitis (AIP)(AIP)

90%

CPPSCPPS

CPPSCPPS

CPPS TreatmentCPPS Treatment

• AntibioticsAntibiotics– Campbells: The Campbells: The Randomized Controlled Trial- t try in IIIa ry in IIIa

and continue if beneficial, no consensus with IIIb.and continue if beneficial, no consensus with IIIb.– Nickel et al Urology. 2003 Oct; 62(4) :614-7. RCT Nickel et al Urology. 2003 Oct; 62(4) :614-7. RCT

comparing Levofloxacin versus Placebo – comparing Levofloxacin versus Placebo – decrease in NIH-CPSI score, but same as placebo.decrease in NIH-CPSI score, but same as placebo.

– De Rose et al Urology. 2004 Jan;63(1):13-6. RCT De Rose et al Urology. 2004 Jan;63(1):13-6. RCT comparing mepartricin v placebo for 2 months comparing mepartricin v placebo for 2 months (26 patients). NIH-CPSI scores 60% and 20% (26 patients). NIH-CPSI scores 60% and 20% reduced. With significant improvements in pain reduced. With significant improvements in pain and QoL. and QoL.

CPPS TreatmentCPPS Treatment

-Blockers-Blockers•CPPS causes obstructive LUTS.CPPS causes obstructive LUTS.

•Campbells – few small studies show improvement Campbells – few small studies show improvement in flow and symptoms, esp when combined with in flow and symptoms, esp when combined with Ab’s. No RCT.Ab’s. No RCT.

•Alexander et al Ann Intern Med. 2004 Oct Alexander et al Ann Intern Med. 2004 Oct 19;141(8):581-9. RCT of Cipro v Tam v both v 19;141(8):581-9. RCT of Cipro v Tam v both v placebo = No difference but all caused slight placebo = No difference but all caused slight decrease in symptom score. Only 6 weeksdecrease in symptom score. Only 6 weeks

•Mehik et al Urology. 2003 Sep;62(3):425-9. RCT of Mehik et al Urology. 2003 Sep;62(3):425-9. RCT of Xatral (Xatral (Alfuzosin) Alfuzosin) v placebo for 6 months. Modest v placebo for 6 months. Modest but significant reduction in pain and symptom but significant reduction in pain and symptom score. score.

CPPS TreatmentCPPS Treatment

• Anti-Inflammatory AgentsAnti-Inflammatory Agents

•NSAID’s improve pain and symptoms.NSAID’s improve pain and symptoms.

•Nickel et al J Urol. 2005 Apr;173(4):1252-5. Nickel et al J Urol. 2005 Apr;173(4):1252-5. RCT of pentosan polysulfate sodium (used RCT of pentosan polysulfate sodium (used for for Interstitial cystitis/painful bladder Interstitial cystitis/painful bladder syndrome)syndrome) versus placebo in CPPS. 300mg versus placebo in CPPS. 300mg TDS for 16 weeks. Slight improvement over TDS for 16 weeks. Slight improvement over placebo, only significant in QoL score. placebo, only significant in QoL score.

CPPS TreatmentCPPS Treatment

• Hormone TherapyHormone Therapy• Nickel et al BJU Int. 2004 May;93(7):991-5. RCT of Nickel et al BJU Int. 2004 May;93(7):991-5. RCT of

Finasteride v Placebo slight improvement but not properly Finasteride v Placebo slight improvement but not properly powered.powered.

• PhytotherapyPhytotherapy• Saw Palmetto – no effectSaw Palmetto – no effect• Bee Pollen Extract (a bioflavonoid) showed slight Bee Pollen Extract (a bioflavonoid) showed slight

improvements. improvements.

CPPS TreatmentCPPS Treatment

• Prostate MassageProstate Massage• Campbell’s no good evidence to support use. Campbell’s no good evidence to support use.

• Perineal or Pelvic Floor Massage or Perineal or Pelvic Floor Massage or Myofascial Trigger point releaseMyofascial Trigger point release

• What?What?

• Cornel et al Eur Urol. 2005 May;47(5):607-11. Epub Cornel et al Eur Urol. 2005 May;47(5):607-11. Epub 2005 Jan 22. RCT of biofeedback showed significant 2005 Jan 22. RCT of biofeedback showed significant reduction in NIH-CPSI scores.reduction in NIH-CPSI scores.

• Other smaller studies give similar results.Other smaller studies give similar results.

CPPS TreatmentCPPS Treatment

• Balloon dilatation and needle ablation – some Balloon dilatation and needle ablation – some benefit in small series, none properly controlled.benefit in small series, none properly controlled.

• Microwave therapyMicrowave therapy• 3 studies comparing MT v sham. All showed benefit over 3 studies comparing MT v sham. All showed benefit over

sham. 1 study showed 75% improvement with MT, but sham. 1 study showed 75% improvement with MT, but sham gave 52% improvement.sham gave 52% improvement.

• TURF therapy (TEMPRO)TURF therapy (TEMPRO)• My study presented on WCE in Munich (Oktober 2009) My study presented on WCE in Munich (Oktober 2009)

showed 43% improvement.showed 43% improvement.

CPPS TreatmentCPPS Treatment

• SurgerySurgery•TURP/BNI only if evidence of obstruction.TURP/BNI only if evidence of obstruction.

•TURP in refractory Cat. II reported.TURP in refractory Cat. II reported.

•TURP in CPPS – no evidenceTURP in CPPS – no evidence

•Radical prostatectomy – one case reportedRadical prostatectomy – one case reported ‘ ‘No definitive clinical series or long-term follow-up has ever No definitive clinical series or long-term follow-up has ever

been presented, and this type of surgery should not be been presented, and this type of surgery should not be encouraged or recommended at this time’. encouraged or recommended at this time’.

Intraprostatic injection in Intraprostatic injection in prostatitis cathegory IIIa And prostatitis cathegory IIIa And IIIb(CPPS)IIIb(CPPS)• AntibioticsAntibiotics

• ZincZinc

• Periprostatic BOTOXPeriprostatic BOTOX

• Antibiotics and esracainAntibiotics and esracain

• Antibiotics and steroidsAntibiotics and steroidsROUTS OF INJECTION

TransrectalPerinealtransurethral

Us guided

Intraprostatic injection chronic Intraprostatic injection chronic bacterial prostatitis(II)bacterial prostatitis(II)

Intraprostatic injectionsIntraprostatic injections

• PainPain

• HematuriaHematuria

• DysuriaDysuria

• HemospermiaHemospermia

Possible side effects

Algorithm or Treatment of Algorithm or Treatment of CPPSCPPS

HYPERTHERMIAHYPERTHERMIA

How to convey heat to the prostate:How to convey heat to the prostate:Transrectal (microwave)Transrectal (microwave)

Transurethral (microwave)Transurethral (microwave)

Interstitial (laser, Nanoparticles)Interstitial (laser, Nanoparticles)

Tempro or Tuna (radiofrequency)Tempro or Tuna (radiofrequency)

Hifu (ultrasound)Hifu (ultrasound)All treatments cause some degree of prostate tissue denaturation and if high temperatures are achieved, even tissue necrosis

TURFTURF

• Thermotherapy 48 - 53,5° cThermotherapy 48 - 53,5° c

• No cooling neededNo cooling needed

TURF MECHANISM – TURF MECHANISM – Principle of OperationPrinciple of Operation

RF produces RF produces electromagnetic radiationelectromagnetic radiation with oscillating electrical and magnetic with oscillating electrical and magnetic fields. The design of the antenna fields. The design of the antenna seems to affect the heating pattern seems to affect the heating pattern more than the wave frequency does.more than the wave frequency does.

Heat is produced while the radiowaves Heat is produced while the radiowaves are absorbed by the tissue. are absorbed by the tissue.

LOCAL EFFECT OF TURFLOCAL EFFECT OF TURF

• heating in excess of 50°C is followed by heating in excess of 50°C is followed by coagulation coagulation necrosisnecrosis

• Histopathological effect of thermotherapy appears Histopathological effect of thermotherapy appears to be related to the induction of cell deathto be related to the induction of cell death

• induced necrosis was shown to disrupt periurethral induced necrosis was shown to disrupt periurethral -adrenergic receptors reflecting -adrenergic receptors reflecting denervation of denervation of smooth muscle cellssmooth muscle cells consisting with the increased consisting with the increased urinary flow rate after TURF urinary flow rate after TURF

• It was demonstrated that TURF It was demonstrated that TURF increased the increased the sensory thresholdsensory threshold (Schwelle) in the posterior (Schwelle) in the posterior urethra by 30%, resulting in the urethra by 30%, resulting in the reduction of reduction of irritative symptomsirritative symptoms

60

Heat DistributionHeat Distribution

For BPH: 55 to 60° C

For Prostatitis: 48 to 53,5°C

(depending on Age)

For BPH: 55 to 60° C

For Prostatitis: 48 to 53,5°C

(depending on Age)

Heating point center

Heating PointHeating Point

Heating Point Center

Balloon

Contraindications for TURFContraindications for TURF

• Urinary Tract InfektionUrinary Tract Infektion• Penile implantsPenile implants• Artificial sphincterArtificial sphincter• Urethral strictureUrethral stricture• Previous prostate surgeryPrevious prostate surgery• Leriche syndrome Leriche syndrome ((is is atheroscleroticatherosclerotic

occlusive disease involving the occlusive disease involving the abdominal aortaabdominal aorta and/or both of the and/or both of the iliac arteriesiliac arteries).).

• Prostates under 30 gr or over 100gr.Prostates under 30 gr or over 100gr.

Treatment Protocol for Treatment Protocol for ProstatitisProstatitis

Insertion of catheter Insertion of catheter (containing the Applicator)(containing the Applicator)

Inflation of catheter balloonInflation of catheter balloon& repositioning of catheter& repositioning of catheter

Temperature is raised to 39° CTemperature is raised to 39° C(for at least 3 min) than gradually raised(for at least 3 min) than gradually raised

to 48 or 53,5°C for additional 57 min.to 48 or 53,5°C for additional 57 min.

Following treatment - immediate removal Following treatment - immediate removal of catheter (post-treatment catheter of catheter (post-treatment catheter

insertion is optional)insertion is optional)

Interval between treatments: min. 1 monthInterval between treatments: min. 1 month

Is prostatitis a premalignant Is prostatitis a premalignant lesionlesion

Is prostatitis a premalignant Is prostatitis a premalignant lesionlesion

Prostate carcinogenesis Prostate carcinogenesis and inflammation: and inflammation: emerging insightsemerging insights

Patrick j. et al.,Patrick j. et al., Carcinogenesis 2005 26(7):1170-1181Carcinogenesis 2005 26(7):1170-1181

Is prostatitis a premalignant Is prostatitis a premalignant lesionlesionReviewReviewNature Reviews CancerNature Reviews Cancer

256-2692007256-2692007

Inflammation in prostate Inflammation in prostate carcinogenesiscarcinogenesis

Angelo M. De Marzo, Elizabeth A. Angelo M. De Marzo, Elizabeth A. PlatzSiobhan Sutcliffe, Jianfeng Xu, Henrik PlatzSiobhan Sutcliffe, Jianfeng Xu, Henrik Grönberg, Charles G. Drake, Yasutomo Grönberg, Charles G. Drake, Yasutomo Nakai, William B. Isaacs & William G. Nakai, William B. Isaacs & William G. Nelson Nelson 

Is prostatitis a premalignant Is prostatitis a premalignant lesionlesion

Is prostatitis a premalignant Is prostatitis a premalignant lesionlesion

BJU