Prostatitis is a common cause of visits to primary care physicians and urologists. In practice, the clinical diagnosis of prostatitis depends on the history and physical examination, but there is no characteristic physical finding or diagnostic laboratory test. Patients with prostatitis experience considerable morbidity and may remain symptomatic for many years. Unfortunately, there is limited understanding of the pathophysiology and optimal treatment for most patients.
To improve diagnosis and treatment of prostatitis, the National Institutes of Health (NIH) established an International Prostatitis Collaborative Network. This group evaluated the literature and clinical practice and convened 2 consensus conferences (1 in 1995 and in 1998) to establish a new definition and classification of prostatitis syndromes. This consensus classification will serve as the framework for international studies to determine the causes and optimal strategies for patient management.
The NIH arrived at a definition of prostatitis in about the year 2000. The NIH consensus classification of prostatitis syndromes includes 4 categories:
- Acute bacterial prostatitis
- Chronic bacterial prostatitis
- Chronic prostatitis/CPPS
- Asymptomatic inflammatory prostatitis
Diagnostic Criteria for NIDDK-Sponsored Research Studies
The following criteria were approved for research studies on chronic nonbacterial prostatitis/CPPS.
- male, at least age 18
- pain or discomfort in the pelvic area (penis, scrotum, perineum, or thereabouts) for at least 3 months
- the presence of cancer of the genitourinary tract
- active urinary stone disease
- herpes of the genitourinary system
- bacteriuria (100,000 colonies in a midstream urine) within the past 3 months
- antibiotic therapy within the past 3 months
- peri-rectal inflammatory disorders
- inflammatory bowel disease
- history of pelvic radiation or systemic chemotherapy
- history of intravesical chemotherapy
- documented gonorrhea, chlamydia, mycoplasma, or trichomonas infection of the urinary tract within the past 3 months
- clinical epididymitis within the past 3 months
- urethral stricture of 12 French or smaller
- neurological disease or disorder affecting the bladder
- prostate surgery (not including cystoscopy) within the past 3 months
Patients with chronic bacterial prostatitis experience recurrent episodes of bacterial urinary tract infection caused by the same organism, usually E coli, another Gram-negative organism, or enterococcus. Between symptomatic episodes of bacteriuria, lower urinary tract cultures can be used to document an infected prostate gland as the focus of these recurrent infections. Acute and chronic bacterial prostatitis represent the best understood, but least common, prostatitis syndromes.
More than 90% of symptomatic patients have chronic prostatitis/chronic pelvic pain syndrome. This new term recognizes the limited understanding of the causes of this syndrome for most patients and the possibility that organs other than the prostate gland may be important in the cause of this syndrome. The new consensus definition recognizes urological pain complaints as a primary component of this syndrome and includes several exclusion criteria (such as presence of active urethritis, urogenital cancer, urinary tract disease, functionally significant urethral stricture, or neurological disease affecting the bladder). Patients with the inflammatory subtype of chronic prostatitis/chronic pelvic pain syndrome have leukocytes in their expressed prostatic secretions, postprostate massage urine, or semen. In contrast, patients with the noninflammatory subtype have no evidence of inflammation.
Asymptomatic inflammatory prostatitis is diagnosed in patients who have no history of genitourinary tract pain complaints. Such patients are usually diagnosed during evaluation for other genitourinary tract issues. For example, many men undergo prostate biopsy for evaluation for possible prostate cancer because of an elevated serum prostate-specific antigen level. Prostatitis is the most common noncancer diagnosis (based on histological criteria) in these men. Other asymptomatic patients undergo evaluation for infertility. Excess concentrations of leukocytes in the seminal fluid are a common finding in such patients.
What is Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP/CPPS)?
The “prostatitis” diagnosis is assigned to 8% and 1% of patients by urologists and primary care physicians, respectively. There are an estimated 2 million outpatient visits for prostatitis per year in the US. There are more outpatient visits for prostatitis than for BPH or prostate cancer. Dr Nickel (2001) found a 9.7% prevalence of prostatitis-like symptoms in the community. The most conservative study puts the incidence at around 3%, which means at least 4.5 million men in the US and 90 million worldwide. In 2002 a lot of research emerged to show that IC and CPPS are one and the same, and Dr CL Parsons from UC San Diego has suggested both conditions should be renamed as Lower Urinary Dysfunctional Epithelium (LUDE), researchers have settled on "UCPPS".
Chronic prostatitis / chronic pelvic pain syndrome (CP/CPPS) has a wide range of symptoms, with some confusion at the moment due to possible overlap with other conditions. For instance, some men report frequent urination and others don’t. Some report sexual dysfunction and erectile difficulties, others don’t – they can have intercourse daily. In addition, men with sterile orchialgia, epididymitis and urethritis are usually excluded from chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), but recently some experts have said that these men also have CP/CPPS, which not only targets the prostate. Many men who are told they have prostatitis are misdiagnosed. Inflammation may be centred in the bladder. This condition is called Interstitial Cystitis, which features painful, frequent urination, although IC expert C. Lowell Parsons says only 15 % of men with IC have frequency and urgency.
Prostatitis CP/CPPS Symptoms
Roughly speaking, when cultures are negative, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) can be described as persistent relapsing pain or discomfort in any of the following areas:
- Between rectum and testicles (perineum)
- Tip of the penis (not related to urination)
- Below the waist, in your pubic or bladder area
- Pain or burning during urination
- Pain or discomfort after ejaculation
- A sensation of pain in the lower back and upper legs
- A sensation of pain in the groin and above the bladder
- A sensation of pain or burning high up in the penis (urethra)
- A sensation of not emptying the bladder completely after finishing urinating
- Lowering of libido (sexual desire)
- Fatigue, sometimes to the point of being bedridden
- Discolored semen (yellowish, from dead white blood cells – a sign of inflammation)
- pain after ejaculation, lasting from hours to days
- Impaired memory, find it hard to concentrate
- painful lymph nodes
- catch colds easily
Many people believe that the disease is a generalized, whole-body disorder, not merely isolated to the lower genitourinary tract. This idea has been proved to be true in BPS/IC recently.
The condition is notorious for waxing and waning. The pain can recede for hours and even days, then return inexplicably with force. In addition, people experience remissions which can last months to years, then have another flare-up.
From the 2001 AUA Meeting comes the following definition:
- The principal symptom is pain or discomfort in the pelvic region or thereabouts lasting 3 months or more.
- Younger men, median age 43 years.
- Pain is most severe symptom and most commonly reported symptom (Alexander and Trissel 1996) (Krieger and others 1996).
- Symptoms are episodic, wax and wane, variable periodicity.
- Most common site of pain is perineum but wide variation in places throughout the pelvic region that are reported as uncomfortable.
- Voiding symptoms, irritative contributing more than obstructive symptoms.
- Sexual function impairment although most men potent.
- Pain after ejaculation is a very specific complaint that distinguishes prostatitis from BPH or normal men (Litwin and others 1999)
The quality of life for a patient with Chronic Prostatitis is similar to that experienced by patients with acute myocardial infarction, unstable angina or active Crohn disease. — J. Curtis Nickel, MD
Some patients experience so much pain that the condition is handled much like a chronic pain syndrome that occurs secondary to cancer. Therapy may begin with judicious use of narcotics until the patient experiences some relief. — Keith B. Armitage, MD