Treatment of abacterial prostato-vesiculitis with nimesulide

Pharmacotherapy of prostatitis

IMPORTANCE OF THE FIELD

Prostatitis is a prevalent and morbid condition with a significant impact on a patient's quality of life. The four distinct prostatitis syndromes have different pathophysiologies, therapy and prognosis. Acute and chronic bacterial prostatitis is best treated with appropriate antibiotics that penetrate the prostate and kill the causative organisms. The most challenging category to treat is category III or chronic prostatitis/chronic pelvic pain syndrome.

AREAS COVERED IN THE REVIEW

This review covers the categories of prostatitis and currently recommended therapies, as well as novel approaches on the horizon.

WHAT THE READER WILL GAIN

Knowledge of the current framework for the diagnosis and management of the diverse prostatitis spectrum.

TAKE HOME MESSAGE

Prostatitis is a diverse group of syndromes. Chronic prostatitis/chronic pelvic pain syndrome is a multifactorial syndrome that requires a multimodal approach to effectively treat the patient. The UPOINT technique is used to clinically phenotype these patients and drive the selection of multimodal therapy.

Localization of cyclooxygenase-2 in mice testis and assessment of its possible role through suppressing its expression using nimesulide: a preferential cyclooxygenase-2 inhibitor

Present generation non-steroidal anti-inflammatory drugs (NSAID) are potent inhibitors of the enzyme cyclooxygenase-2 (COX-2). Even though they exhibit reduced incidence of gastrotoxicity, severe nephrotoxicity and other side effects have been widely reported with respect to usage of these drugs. Since COX-2 levels are not only upregulated by inflammation but also by other stimuli such as cytokines, growth factors, mitogens and steroid hormones, we investigated the localization of COX-2 and activity of both COX-1 and COX-2 in mice testis. To correlate the localization of COX-2 with its function we suppressed COX-2 expression with the aid of nimesulide a preferential COX-2 inhibitor. We found COX-2 was constitutively expressed in the Leydig cells of mice testis suggesting a role on testosterone synthesis. Suppression of COX-2 resulted in increased concentration of most of polyunsaturated fatty acids especially arachidonic acid (AA). Prostaglandin (PG) levels which showed an initial decline during nimesulide treatment had a reversible effect during prolonged treatment. These findings state that cyclooxygenase is constitutively expressed in mice testis and continuous inhibition of COX-2 interferes in maturation of sperm.

Prostatitissyndrom

Prostatitis syndrome is a multifactorial disease with a largely unknown etiology. Quite different therapeutic options are therefore recommended. According to the new NIH classification, pathogens can be cultured only in acute and chronic bacterial prostatitis. A long-term antimicrobial therapy, mainly with fluoroquinolones, is then recommended. Most patients suffer from chronic pelvic pain syndrome (CP/CPPS) which can be subdivided into inflammatory and non-inflammatory types. Whether the inflammatory CP/CPPS is an infectious disease remains uncertain. The effect of an antibiotic therapy therefore remains debatable. In case of proven or suspected functional infravesical obstruction, treatment with a-receptor blockers is recommended. Accompanying symptomatic therapy is also recommended. It is important, however, to keep the patient fully informed about the diagnostic and therapeutic limitations.

Chronic prostatitis/chronic pelvic pain syndrome in elderly men: toward better understanding and treatment

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common of the prostatitis syndromes. It is characterised by pelvic pain, with or without voiding symptoms. CP/CPPS accounts for 2 million office visits in the US alone. Recent epidemiological studies have shown that CP/CPPS can affect men at any age, including those in their 80s. The aetiology is unknown but proposals include infectious, autoimmune, neurologic and psychiatric causes. Men with CP/CPPS are much more likely to have had a past medical history of cardiovascular, neurologic, psychiatric or infectious disease (particularly sinusitis) as compared with asymptomatic individuals. Although leucocytes are commonly found in the prostatic fluid of these men, they do not correlate with the symptoms. The clinical evaluation now includes a validated, self administered symptom score, the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), which was designed as an outcome measure for treatment trials. This can aid in diagnosis and follow-up of patients' response to therapy. Treatment for CP/CPPS is empiric and limited by a lack of randomised, placebo-controlled clinical trials. Antimicrobials are commonly used to treat the symptoms of CP/CPPS. However, the finding that asymptomatic men have equal or greater numbers of bacteria which localise to the prostatic fluid, compared with men with CP/CPPS, has raised doubts about the contribution of infection to the symptoms. Other commonly used drugs include alpha-adrenoceptor antagonists, anti-inflammatory drugs, tricyclic antidepressants and anticholinergic agents. The adverse effects of these medications are a concern in older men with CP/CPPS. Other therapies available include minimally invasive procedures such as microwave thermotherapy and transurethral needle ablation, and now neuromodulation devices.Although much progress has been made, particularly in the last 7 years, considerable work still remains to be done to determine the aetiology and pathogenesis of CP/CPPS, and to develop mechanism based therapy that is shown to be effective in controlled trials.

Inflammation and anti-inflammatory therapy in chronic prostatitis

Anti-inflammatory medications have been used for the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), given that inflammation and pain are traditionally associated with this condition. The National Institutes of Health (NIH) classification divides category III into (1) category IIIA--patients with white blood cells (WBCs) in their expressed prostatic secretions, post-prostate massage urine (voided bladder urine-3 [VB3]) or semen; and (2) category IIIB--those without WBCs. However, recent studies indicate that the ability of WBC count alone to distinguish men with symptoms from those without appears limited. Other markers of inflammation, such as cytokines, may correlate better with clinical findings. The mechanisms of inflammation continue to be investigated, including contributions from reactive oxygen species, autoimmune response, neurogenic inflammation, and even endocrine dysfunction. There have been few controlled studies of anti-inflammatory therapy for chronic prostatitis. In the only randomized double-blind placebo-controlled trial, the NIH-Chronic Prostatitis Symptom Index (CPSI) total, domain, and pain scores significantly decreased from baseline in all groups, but the difference was not statistically significant. Other medications that have some theoretic anti-inflammatory properties have shown promising early results. Further study of currently available anti-inflammatory medications may be warranted, especially in longer trials, which may allow resolution of the significant placebo effect commonly seen in the short term in men with CPPS. Further discussion is needed to either validate, modify, or abolish the distinction between category IIIA and IIIB in the NIH classification.

An evidence-based approach to the treatment of prostatitis: is it possible?

The classification of prostatitis has been re-evaluated, and the National Institutes of Health (NIH) has defined the separate groups more thoroughly. Furthermore, the development of the NIH chronic prostatitis symptom index (CPSI) has allowed the symptoms to be measured and the effect of interventions calculated. A search of the literature finds that the quality of treatment trials in prostatitis is poor and the level of evidence for many of the existing strategies is lacking; there is a total absence of any meta-analyses of randomized controlled trials (level 1a). The bulk of literature consists of small descriptive studies (level III) or opinions from respected authorities (level IV). The advent of the NIH-CPSI has provided the opportunity for well-designed trials to be performed where the symptom outcomes can be quantified. This opportunity will be of greatest value in type III prostatitis where symptom amelioration is the main target of therapy and a number of treatment options abound.

Host defense mechanisms in urinary tract infections

The host response to urinary tract infections is directed against both bacterial surface antigens, as well as bacterial products. The local response is perhaps the most important, with prevention of binding and tissue invasion as the hallmarks. Once an infection is established, the humoral immune system is most active in curtailing the damage and clearing the infecting organism. The prostate has a specialized complex of defenses that serves to reduce the incidence of infections in males.

Prostatitis: evolving management strategies

Concepts regarding the etiology, diagnosis, and management of prostatitis have changed more in the last 3 years than they have in the last 3 decades. Urologists (and all physicians) no longer need to avoid patients with this disease. It is hoped that the new management strategies that are evolving will eventually benefit the majority of patients sustaining prostatitis.