Background • Chronic Prostatitis Syndrome (CPS) is a frequent debilitating disease in the urological world. • Reluctance of many urologists to be involved with this problem may be related to the fact that these patients seldom show a full response to treatment .
CPS is defined as a complex of symptoms which may arise in the prostate or in the neighbouring pelvic organs as implied in the NIH classification ( Category III ) . • It may have different aetiologiesmaking treatment difficult and often unrewarding.
infection can be demonstrated in some cases and suspected in other ones. • Antibacterial treatment is often adopted as first measure. • Additional treatment modalities, many of them need Further trials .
No uniformly accepted : definition, classification, and guidelines for diagnostic work-up or treatment, so CPS has been termed : ‘‘a wastebasket of clinical ignorance.’’
Objective We aim to present an updated review of the literature, some personal views and discuss the main controversial points.
United Kingdom National guideline for the management of prostatitis (2012) Clinical Effectiveness Group British Association of Sexual Health and HIV
Epidemiology • CPS is more frequent than is commonly thought. • diagnosis is made yearly in 1–2 million people in the USA in men 18 yr old or older . • 35–50% of men are affected by prostatitis at some time in life  • 25% of urologic outpatient visits is due to Symptoms of CPS .
 Collins MM, Stafford RS, O’Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol 1998;159:1224–8.  De la Rosette JJMCH, Hubregtse RM, Karthaus HFM, Deb- ruyne F. Results of a questionnaire among Dutch urol- ogists and general practitioners concerning diagnosis and treatment of patients with prostatitis syndromes. EurUrol 1992;22:14–9
Definition CPS cannot rigidly defined but a suggested definition is : the presence of typical symptoms of pain or discomfort in the genital or pelvic region for more than 3 months within the past 6 months
Classification 1- NIH Classification : • presence of bacteria in the prostatic fluid, semen or urine after prostatic massage, or even in the prostatic tissue, demonstrates a bacterial infection of the prostate. • presence of leukocytes either in semen or in expressed prostatic fluid demonstrates inflammation. • failure to identify either bacteria or leukocytes rules out infection and inflammation.
2-Histopathologic Classification: • The most common pattern is Lymph. Infilitratein the stromaadjacent to the prostatic acini . • does not apply to most clinical cases: biopsies or surgical specimens .  Nickel JC, True LD, Krieger JN, et al. Consensus develop- ment of a histopathological classification system for chronic prostatic inflammation. BJU Int 2001;87:797–805.
3-ICS-Classification: • organs that may be affected by a painful sensation . • In a workshop attended by Italian urologists in 2001, it was felt that the ICS classification should be incorporated in the current classifications of chronic pelvic pain. •  Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Subcommittee of the Interna- tional Continence Society. NeurourolUrodyn 2002;21:
4-Clnical Classification: categorizes the phenotype of the patients into one or more of six clinically domains: urinary, Phsycosocial, organspecific,infection, neurologic/systemic and tenderness.
Aetiology • Unknown aetiology, may be multifactorial. • Proposed mechanisms incl -Infection . - Immunological. - Autoimmunity - Neuromuscular spasm/ pelvic floor muscle dysfunction. - Intraprostaticurinre reflux.
- Deposition of uric acid crystals in the prostatic parenchyma . - increased intraprostatic pressure - Neurogenicinflamation. - Functional somatic syndrome - Chronic pain syndrome.
C. trachomatis, Mycoplasmahominis, Mycoplasma genitalium, and Ureaplasmaurealyticum: its role in CPS is still controversial, despite many arguments indicating they may be causative agents include such cases under the heading of chronic bacterial rather than nonbacterial prostatitis . •  Pavone-Macaluso M, Di Trapani D, Pavone C. Prostatitis, prostatosis and prostalgia. psychogenic or organic disease? Scand J UrolNephrol 1991;Suppl 138:77–89.
C. trachomatis was detected by : - anti-chlamydiaeIgAin prostatic fluid with >10 leuko/hpf were found in 29% of cases, also present in serum and ejaculate . - in situ hybridisation(biotin-labelled DNA probe) on paraffin-embedded biopsy specimens. - polymerase chain reaction (PCR) in urine and semen
Clinical manifistation • Urological pain  including: perineal pain lower abdominal pain penile pain (especially peniletip) testicular pain rectal and lower back pain ejaculatory pain • variable irritative and obstructive symptoms and/or ejaculatory disturbance, sexual disturbances . • The symptoms usually remain constant although some men have large fluctuations in the severity of symptoms over time .
There are several exclusion criteria for the diagnosis : • Active urethritis . • urogenital cancer . • urinary tract disease . • functionally significant urethral stricture . • neurological disease affecting the bladder . 1.Kreiger JN,Nyberg Jr, L and Nickel JC. NIH Consensus Definition and Classification of Prostatitis. NEJM 1999;81(3):236-237 60. Krieger JN, Egan KJ, Ross SO, et al. Chronic pelvic pains represent the most prominent urogenital symptom of ‘chronic prostatitis’. Urology 1996;48:715-722. 61. Propert KJ, McNaughton Collins M, Leiby BE, O’Leary MP, Kusek JW and Litwin MS. A prospective study of symptoms and quality of life in men with chronic prostatitis/ chronic pelvic pain syndrome: the National Institutes of Health chronic prostatitis cohort study. J Urol 2006;175:619-623
Symptom index (NIH CPSI) developed by the NIH and the Chronic Prostatitis Collaborative Research Network for: quantitative measure of symptoms and quality of lifeassessing changes in symptom severity and impact during follow up, and as an outcome measure following treatment .  Litwin MS, Collins MM, Fowler FJ, et al., and the Chronic Prostatitis Collaborative Research Network. The National Institutes of Health Chronic ProstatitisSymp- tom Index development and validation of a new out- come measure. J Urol 1999;162:369–75.
Total score: - Calculate and report a pain and urinary score (range 0-31), referred to as the symptom scale score: Mild =0-9. moderate=10-18. severe=19-31.
Diagnosis • No agreement on the criteria to be used for the diagnosis of CPS. • No guidelines have been developed so far to diagnostic work-up . • Our diagnostic efforts should be directed also to identify aetiologic agents, if any, to detect signs of inflammation and classify the patient into one of the four CPS categories.
Initial screening should involve taking a complete history, examination including digital rectal examination, urinalysis and MSU microscopy and culture. • Diagnosis is usually made on a typical history and not on examination or investigation findings [66,67,68].
66. McNaughton Collins M, MacDonald R and Wilt TJ. Diagnosis and Treatment of chronic abacterialprostatitis: a systematic review. Ann Intern Med 2000;133:367-381 • 67. Nickel JC Clinical Evaluation of the patient presenting with prostatitis. EurUrol 2003. (Suppl) 68;1-4. • 68. Nickel JC. Clinical Evaluation of the Man with Chronic Prostatitis/chronic pelvic pain syndrome. Urol 2002;60(suppl 6A):20-23.
Lower urinary tract localisation study (4-glass test) • cannot accurately differentiate between men with CP/CPPS and men without symptoms . • results of the test do not correlate with duration, frequency and severity of symptoms . • has not been standardised . • It is not widely used in clinical practice [17,71] and may not alter patient management . Therefore the test cannot be recommended in the routine investigation of CP/CPPS, should be confined to research centers.
17. McNaughton Collins M, Fowler FJ, Elliott DB, et al. Diagnosing and Treating Chronic Prostatitis; do urologists use the four-glass test? Urology 2000;55(3);403-407. • 70. Muller CH, Berger R, Mohr LE and Kreiger J. Comparison of microscopic methods for detecting inflammation in expressed prostatitis secretions. J Urol 2001;166:2518-2524 • 71. Luzzi GA, Bignell C, Mendel D and Maw RD. Chronic Prostatitis/Chronic Pelvic Pain Syndrome: a national survey of genito-urinary medicine clinics. Int J STD AIDS 2002;13(6):416-419. • 72.Thin RN. Diagnosis of chronic prostatitis: overview and update. Int J STD & AIDS 1997;8(8):475-81.
A 2-glass Test (PPMT) has been suggested by Nickel  using only two urine specimens, one before and another after prostatic massage. If positive , no additional cultures are needed. If negative , we ask the patient to submit for: -culture a midstream specimen . -search for Chlamydia and Ureaplasma organisms in : -urine after massage . -semen culture . • Microscopic examination of EPS is still highly recommended although it is seldom performed. Inflammatory prostatitis was judged to be present if the EPS contained ≥10 WBCs/ hpf. • Semen cultures are considered to be positive if >50,000 colonies/ml are obtained.  Nickel JC. The pre and post massage test (PPMT): a simple screen for prostatitis. TechnUrol 1997;3:38–43.
STI screen In selected patients: • Urine cytology – if the patient has microscopic haematuriawith frequency, urgency and dysuria urine cytology should be performed to help exclude lower urinary tract malignancy . • PSA is recommended by abnormal prostate on digital rectal examination . PSA can be elevated during active inflammation of the prostate . • Simple urodynamics – may identify bladder neck dysfunction, bladder outflow obstruction and incomplete bladder emptying particularly in those with urinary symptoms. • Uroflowmetryis recommended in the assment of all patients. • 73. Nickel JC, Adern D and Downey J. Cytologic Evaluation if Urine is Important in Evaluation of Chronic Prostatitis. Urology 2002;60(2):225-227 • 74. Referral guidelines for suspected cancer in adults and children: guidelines for suspected urological cancer. Reference CG27. www.nice.org.uk • 75. Nadler RB, Schaeffer AJ, Knauss JS, et al. Total Prostate specific Antigen is elevated and statistically, but not clinically significant, in patients with chronic pelvic pain syndrome/ prostatitis (abstract) 2003;J Urol 169(suppl 4):27. • 76.Kohn IJ, Te AE, Kaplan SA. The role of urodynamics in evaluating patients with chronic prostatitis. In; Nickel JC (Ed) Textbook of Prostatitis. ISIS Medical Media, Oxford, pp 227-232
Imagingplays a secondary role for the diagnostic work-up of patients with CPS. traditional radiography : KUB, IVU, and cystography, has been abandoned.Urethrogram is indicated only if there is suspicion of a urethral stenosis. • Transrectal ultrasound (TRUS) is not useful in differentiating the various forms of chronic prostatitis. TRUS may identify prostatic calcification but the significance of this is uncertain. It may rarely identify a treatable prostatic abscess or cyst, seminal vesicle or ejaculatory duct abnormality . • Prostatic Biopsy histological,biological, evluation ; still as research tool only. • Cystoscopyis not recommended except in case of hematuria. • 77. Ludwig M, Weidner W, Schroeder-Printzen I, Zimmerman O and Ringert RH. Transrectal prostatic sonography as a useful diagnostic means for patients with chronic prostatitis or prostatodynia. Br J Urol 1994;73(6):664-8. • 78. De La Rosette JJ, Karthaus HF, Debruyne FM. Ultrasonographic findings in patients with non-bacterial prostatitis. UrolInt 1992;48:323-326.
Management General advice Patients should be given a detailed explanation of their condition with reassurance : non-malignant condition not a sexually transmitted infection tendency to persist . The cause has not been determined with certainty 79. Turner JA, Ciol MA, Von Korff M and Berger R. Health Concerns of patients with nonbacterial prostatitis/pelvic pain. Arch Intern Med 2005;165:1054-1059.
Treatment • No reliably effective treatments for CP/CPPS [66,80,81], Few randomised, controlled trials are available and no large scale, well-designed trials have been conducted. • Multimodal therapy has been proposed but this is not based on evidence from randomised trials . • should be individualised as CP/CPPS is not a standardised disease or specific inflammatory process but rather a clinical syndrome. • 66. McNaughton Collins M, MacDonald R and Wilt TJ. Diagnosis and Treatment of chronic abacterialprostatitis: a systematic review. Ann Intern Med 2000;133:367-381 • 80. Dimitrakov JD, Kaplan SA, Kroenke K, Jackson JL and Freeman MR. Management of Chronic Prostatitis/ Chronic Pelvic Pain Syndrome: An Evidence-Based Approach. Urology 2006;67(5):881-888. • 81. Jang T and Schaeffer A. (2005) Chronic prostatitis. Clinical Evidence. Volume 13. www.clinicalevidence.com • 83. Alexander RB, Propert KJ, Scaheffer AJ, et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomised, double-blind trial. Ann Intern Med 2004;141:581-9.