Prostatitis

Comparative efficacy of non-pharmacological management for chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis protocol

BACKGROUND

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has posed a significant burden on affected individuals and healthcare systems. While pharmacological treatments are commonly used, non-pharmacological management strategies have gained attention for their potential benefits in improving CP/CPPS symptoms. However, the comparative efficacy of these non-pharmacological interventions remains unclear. The aim of this study is to assess the comparative effectiveness of non-pharmacological interventions for CP/CPPS regarding prostatic symptoms.

METHOD

This systematic review and network meta-analysis will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search will be conducted in electronic databases, including PubMed, Embase, Cochrane Library and Web of Science, to identify relevant studies. Eligible studies will include randomised controlled trials investigating non-pharmacological management strategies for CP/CPPS. Two independent reviewers will screen the retrieved citations, extract data and assess the risk of bias. Data synthesis will involve performing a network meta-analysis to compare the efficacy of different non-pharmacological interventions while considering both direct and indirect evidence.

ETHICS AND DISSEMINATION

The review does not require ethical approval. The findings of the review will be disseminated through publication in an academic journal, presentations at conferences and various media outlets.

PROSPERO REGISTRATION NUMBER

CRD42024506143.

The aryl hydrocarbon receptor agonist ITE reduces inflammation and urinary dysfunction in a mouse model of autoimmune prostatitis

OBJECTIVES

Prostate inflammation is linked to lower urinary tract dysfunction and is a key factor in chronic prostatitis/chronic pelvic pain syndrome. Autoimmunity was recently identified as a driver of prostate inflammation. Agonists of the aryl hydrocarbon receptor (AHR), a ligand-activated transcription factor, have been used to suppress autoimmunity in mouse models of colitis, rhinitis, and dermatitis, but whether AHR agonists suppress prostate autoimmunity has not been examined. Here, we test whether ITE (2-(1'H-indole-3'-carbonyl)-thiazole-4-carboxylic acid methyl ester), an AHR agonist, suppresses inflammation, allodynia, and urinary dysfunction in a mouse model of experimental autoimmune prostatitis (EAP).

METHODS

C57BL/6J adult male mice were immunized with rat prostate antigen to induce EAP or TiterMax Gold® adjuvant (uninflamed control). Mice were also treated with ITE (10 mg/kg/day IP) or DMSO (vehicle, 5 mg/kg/day IP) for 6 days. Using the Nanostring nCounter Inflammation Panel, we evaluated the impact of EAP and ITE on prostatic RNA abundance. We validated EAP and ITE-mediated changes in a subset of RNAs by RT-PCR and RNAScope in situ RNA detection.

RESULTS

EAP appeared to heighten histological inflammation in the dorsal prostate, induced tactile allodynia, and appeared to increase the frequency of non-voiding bladder contractions. ITE mitigated some actions of EAP. EAP changed abundance of 40 inflammation-related RNAs, while ITE changed abundance of 28 inflammation-related RNAs. We identified a cluster of RNAs for which ITE protected against EAP-induced changes in the abundance of H2-Ab1, S100a8, and S100a9. ITE also increased the abundance of the AHR-responsive Cyp1a1 RNA.

CONCLUSIONS

These findings support the hypothesis that ITE activates the AHR in the prostate and reduces autoimmune-mediated prostatitis in mice.

Acute Bacterial Prostatitis Caused by Staphylococcus saprophyticus: A Case Report

Acute bacterial prostatitis can burden patients with an abrupt onset of lower urinary tract symptoms. Proper treatment is necessary to prevent various complications that require hospitalization and surgical intervention. Thus, it is important to know what bacteria may cause this infection and what treatments may lead to a complete resolution. While acute bacterial prostatitis is usually caused by Escherichia coli, Enterobacteriae species, and various other species, Staphylococcus saprophyticus is a relatively unique cause that has seldomly been associated with any prostatic diseases. This case involves a 46-year-old Caucasian male with no previous history of prostate diseases who presented to the clinic with fevers, chills, diarrhea, and resolved urinary symptoms. Upon further clinical workup, the patient was found to have an elevated prostate-specific antigen level, along with a positive urinary culture for Staphylococcus saprophyticus. Following seven days of antibiotic treatment, prostate-specific antigen levels had significantly decreased, and the patient's symptoms had fully resolved. No further symptoms were noted after the completion of the full 28-day course of antibiotics. This paper explores how the patient's social, medical, and surgical history may have led to this type of infection. Focus will be placed on areas of research that need to be extended for future cases of acute bacterial prostatitis caused by Staphylococcus saprophyticus. This case intends to inform future clinical practice by identifying predisposing factors to prevent occurrence and by discussing treatment strategies to achieve infection resolution.

The emerging role of the urinary microbiome in benign noninfectious urological conditions: an up-to-date systematic review

PURPOSE

The goal of this systematic review was to examine the current literature on the urinary microbiome and its associations with noninfectious, nonmalignant, urologic diseases. Secondarily, we aimed to describe the most common bioinformatics used to analyze the urinary microbiome.

METHODS

A comprehensive literature search of Ovid MEDLINE using the keywords "microbiota" AND "prostatic hyperplasia," "microbiota" AND "urinary bladder, overactive," "microbiota" AND "pelvic pain," and "microbiota" AND "urolithiasis" OR "nephrolithiasis" OR "urinary calculi" AND "calcium oxalate" was performed to identify relevant clinical microbiome studies associated with noninfectious benign urological conditions published from 2010 to 2022. We included human studies that evaluated the urinary, stone, or semen microbiota, or any combination of the above-mentioned locations.

RESULTS

A total of 25 human studies met the inclusion criteria: 4 on benign prostatic hyperplasia (BPH), 9 on overactive bladder (OAB), 8 on calcium oxalate stones, and 4 on chronic pelvic pain syndrome (CPPS). Specific taxonomic profiles in the urine microbiome were associated with each pathology, and evaluation of alpha- and beta-diversity and relative abundance was accounted for most of the studies. Symptom prevalence and severity were also analyzed and showed associations with specific microbes.

CONCLUSION

The study of the urogenital microbiome is rapidly expanding in urology. Noninfectious benign urogenital diseases, such as BPH, calcium oxalate stones, CPPS, and OAB were found to be associated with specific microbial taxonomies. Further research with larger study populations is necessary to solidify the knowledge of the urine microbiome in these conditions and to facilitate the creation of microbiome-based diagnostic and therapeutic approaches.

Surgical management of National Institutes of Health category II chronic bacterial prostatitis: a case series and scoping review of the literature

Background

National Institutes of Health (NIH) category II prostatitis refractory to antibiotic therapy can be challenging to treat. We present the outcomes from a case series of men who have undergone various surgical therapies to treat this condition. Additionally, we performed a scoping review of studies describing the characteristics and outcomes of patients surgically treated for chronic bacterial prostatitis (CBP).

Methods

This is a single-center retrospective case series of adult patients at Cleveland Clinic Glickman Urological and Kidney Institute with refractory NIH category II prostatitis managed with surgical intervention. PubMed was queried and all resulting articles were analyzed for relevance and parallel study designs.

Results

Twelve subjects underwent endoscopic procedures. Two of 12 (16.7%) subjects had CBP recurrence with E. Coli at 12 and 60 months; both patients initially had prostatic stones. One patient with CBP recurrence developed a urethral stricture. Seven subjects were treated with nerve-sparing robotic radical prostatectomy of whom two had concomitant prostate cancer. Three subjects had prostate stones, two of which extended beyond the surgical capsule. E. coli was the isolated pathogen for six patients with two of these being multi-drug resistant (MDR) E. coli. One patient in this group experienced recurrent urinary tract infections (UTIs) despite the surgery. Scoping review of available articles consistently failed to mention definitive diagnosis of CBP with prostatic secretion cultures or even urine cultures prior to surgical intervention and no studies were found on the curative outcomes of surgical intervention.

Conclusions

Our study provides one of the first single-center retrospective case series of patients with antibiotic refractory NIH category II CBP managed with surgical intervention. Overall, rate of cure between all surgical modalities was 84% (n=16). When disease is confined to the surgical capsule, endoscopic management is likely sufficient. Radical prostatectomy expectedly increased rates of postoperative erectile dysfunction and stress urinary incontinence compared to endoscopic intervention. However, in patients with disease beyond the capsule and/or concomitant prostate cancer, prior endoscopic treatment, or life-threatening UTI, radical prostatectomy may be justified.

An Interesting Case of Methicillin-Resistant Staphylococcus aureus Prostate Abscess in an Immunocompetent Patient

Prostate abscess is a rare complication of prostatitis, typically observed in patients with conditions such as immunodeficiency, diabetes, urinary tract abnormalities, and chronic indwelling catheters. Gram-negative bacteria such as Enterobacteriaceae are the most commonly detected organisms in prostate abscesses. Methicillin-resistant Staphylococcus aureus (MRSA) infections are rarely reported. The unique aspect of our case involves MRSA bacteria, further complicated by an MRSA prostate abscess, in a 61-year-old immunocompetent male. The patient, with a past medical history of hypertension and diabetes, presented to the emergency department complaining of nausea and vomiting for four days, with an associated subjective fever and right-sided abdominal pain. A computed tomography (CT) scan of the abdomen/pelvis with contrast showed a prostatic abscess, with abscess/phlegmon extending bilaterally into the seminal vesicles. Urine and blood cultures were positive for MRSA. Initially, Piperacillin/Tazobactam and Vancomycin were initiated. Subsequently, the treatment was switched to Daptomycin. The patient also underwent cystoscopy with urethral dilation, transurethral prostate resection, and unroofing. Although MRSA is not a typical causative agent of prostatitis, it should be considered in the differential diagnosis, especially when clinical improvement cannot be achieved with standard empirical treatment. Timely identification and appropriate treatment (such as drainage and antibiotics) are crucial for both patient survival and the prevention of complications.

The Molecular Basis and Clinical Consequences of Chronic Inflammation in Prostatic Diseases: Prostatitis, Benign Prostatic Hyperplasia, and Prostate Cancer

Chronic inflammation is now recognized as one of the major risk factors and molecular hallmarks of chronic prostatitis, benign prostatic hyperplasia (BPH), and prostate tumorigenesis. However, the molecular mechanisms by which chronic inflammation signaling contributes to the pathogenesis of these prostate diseases are poorly understood. Previous efforts to therapeutically target the upstream (e.g., TLRs and IL1-Rs) and downstream (e.g., NF-κB subunits and cytokines) inflammatory signaling molecules in people with these conditions have been clinically ambiguous and unsatisfactory, hence fostering the recent paradigm shift towards unraveling and understanding the functional roles and clinical significance of the novel and relatively underexplored inflammatory molecules and pathways that could become potential therapeutic targets in managing prostatic diseases. In this review article, we exclusively discuss the causal and molecular drivers of prostatitis, BPH, and prostate tumorigenesis, as well as the potential impacts of microbiome dysbiosis and chronic inflammation in promoting prostate pathologies. We specifically focus on the importance of some of the underexplored druggable inflammatory molecules, by discussing how their aberrant signaling could promote prostate cancer (PCa) stemness, neuroendocrine differentiation, castration resistance, metabolic reprogramming, and immunosuppression. The potential contribution of the IL1R-TLR-IRAK-NF-κBs signaling molecules and NLR/inflammasomes in prostate pathologies, as well as the prospective benefits of selectively targeting the midstream molecules in the various inflammatory cascades, are also discussed. Though this review concentrates more on PCa, we envision that the information could be applied to other prostate diseases. In conclusion, we have underlined the molecular mechanisms and signaling pathways that may need to be targeted and/or further investigated to better understand the association between chronic inflammation and prostate diseases.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

A Systematic Review of the Zinc Content of the Normal Human Prostate Gland

The prostate gland is subject to various disorders. The etiology and pathogenesis of these diseases are not well understood. Moreover, despite technological advancements, the differential diagnosis of prostate disorders has become progressively more complex and controversial. It was suggested that the Zn level in prostatic tissue plays an important role in prostatic carcinogenesis and its measurement may be useful as a cancer biomarker. These suggestions promoted more detailed studies of the Zn content in the prostatic tissue of healthy subjects. The present study evaluated by systematic analysis presents the published data for Zn content analyzed in prostatic tissue of "normal" glands. This evaluation reviewed 1885 studies, all of which were published in the years from 1921 to 2020 and were located by searching the databases PubMed, MEDLINE, Scopus, Web of Science, Elsevier-Embase, and Cochrane Library. In addition, the personal archive of the author collected from 1966 to 2020 was also used. The articles were analyzed and "median of means" and "range of means" were used to examine heterogeneity of the measured Zn content in prostates of apparently healthy men. The objective analysis was performed on data from the 105 studies, which included 3735 subjects. It was found that the range of means of prostatic Zn content reported in the literature for "normal" gland varies widely from 17 to 547 mg/kg with median of means 109 mg/kg on a wet mass basis. The Zn content depends on many factors such as analytical method, age, level of androgens, dietary Zn intake, and the prostatic region and fraction of prostate tissue being studied. Finally, because of small sample size and high data heterogeneity, we recommend other primary studies be performed.

May the Cleaning of Prescriptive Documents Using Best Evidence Reduce the Cost of Prescribed Healthcare?

OBJECTIVES

Clinical practice is developing under influence of the evidence-based clinical practice guidelines (EBCPG). In Russia development of the documents prescribing the content of care is connected with the idea that they may be used as well for estimation of the cost of care. The outcome is the national healthcare legislation of 2011. It dictates that care should be planned, funded, provided, and evaluated in agreement with standards of healthcare (SHC)-documents prescribing the content of care. The objective of this study was to evaluate how the correction of the SHC with the relevant EBCPG may change the cost of the prescribed care.

METHODS

We selected the random sample of the SHC from the approved by the Ministry of Health for primary healthcare (SPHC) and specialized healthcare (SSHC). We analyzed interventions comparing SHC to the relevant EBCPG. Not recommended interventions were considered unnecessary. If the recommended by EBCPG intervention was missed in the SHC, then it increased the cost. We take the drug costs and the costs of interventions from the relevant ministerial registries. We calculated the total cost of the SHC by summing up the cost of each medical intervention/medications specified in the SHC.

RESULTS

SPHC and SSHC both contain medical interventions and drugs that should not be provided. The total cost of all SHC included became lower: SPHC cost decreased by 66%, SSHC by 19%. The smaller change of the cost of SSHC is explained by the fact that the major part of the total cost of SSHC is the stay in a hospital.

CONCLUSION

Correction of the SHC using EBCPG may reduce the cost of care.

Chronic Pelvic Pain Syndrome in a Rural Area: Are We Paying Attention?

Introduction Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a chronic, debilitating illness that mostly affects males under the age of 50 years. It is associated with myriad presentations. The National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) score was developed to measure the impact of the disease and assess the treatment outcomes. Additionally, the UPOINT [urinary (U), psychosocial (P), organ-specific (O), infection (I), neurologic/systemic (N), and tenderness of pelvic floor skeletal muscles (T)] classification system has been developed to enable a 'phenotypic approach' to the treatment. Objective The objective of this study was to determine the NIH-CPSI scores as well as the positive subdomain numbers and distribution of the UPOINT classification in patients with CP/CPPS. Materials and methods A total of 100 consecutive male patients presenting to a single centre with symptomatic CP/CPPS were included in this study. Results The mean age of the patients was 34.4 years. The average total NIH-CPSI score was 24.9. The average number of positive UPOINT domains was 2.28. The positive domains were urinary (90), psychosocial (60), organ-specific (43), infection (15), neurological (12), and tenderness (8). Discussion The NIH-CPSI scores and UPOINT subdomain scores compared favourably with other studies conducted in the region. The lower infection subdomain score as compared to other studies may be due to the widespread use of antibiotics among patients in the region prior to presenting to a urologist. Conclusion The use of the UPOINT classification to guide treatment is feasible even in a rural setting, such as in Kashmir.

Pyospermia: background and controversies

Pyospermia (or leukocytospermia) is suspected based on the presence of >1 × 10⁶ round cells/mL of ejaculate and diagnosed using peroxidase stain revealing >1 × 10⁶ white blood cells/mL. The presence of white blood cells is a concern for overt infections or excessive inflammation, both of which have been postulated to negatively impact bulk semen parameters and fertilization capability. The threshold for pyospermia has been debated upon in the literature, as has the optimal treatment method. In the absence of clinical infectious symptoms, it appears that antibiotics, anti-inflammatory agents, and/or frequent ejaculation may improve bulk semen parameters in men with pyospermia. Further research is needed to adequately assess the effect of these methods on pregnancy and live birth outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or in vitro fertilization.

A uropathogenic E. coli UTI89 model of prostatic inflammation and collagen accumulation for use in studying aberrant collagen production in the prostate

Bacterial infection is one known etiology of prostatic inflammation. Prostatic inflammation is associated with prostatic collagen accumulation and both are linked to progressive lower urinary tract symptoms in men. We characterized a model of prostatic inflammation using transurethral instillations of Escherichia coli UTI89 in C57BL/6J male mice with the goal of determining the optimal instillation conditions, understanding the impact of instillation conditions on urinary physiology, and identifying ideal prostatic lobes and collagen 1a1 prostatic cell types for further analysis. The smallest instillation volume tested (50 µL) distributed exclusively to the bladder, 100- and 200-µL volumes distributed to the bladder and prostate, and a 500-µL volume distributed to the bladder, prostate, and ureter. A threshold optical density of 0.4 E. coli UTI89 in the instillation fluid was necessary for significant (P < 0.05) prostate colonization. E. coli UTI89 infection resulted in a low frequency, high volume spontaneous voiding pattern. This phenotype was due to exposure to E. coli UTI89, not catheterization alone, and was minimally altered by a 50-µL increase in instillation volume and doubling of E. coli concentration. Prostate inflammation was isolated to the dorsal prostate and was accompanied by increased collagen density. This was partnered with increased density of protein tyrosine phosphatase receptor type C+, procollagen type I-α1+ copositive cells and decreased density of α2-smooth muscle actin+, procollagen type I-α1+ copositive cells. Overall, we determined that this model is effective in altering urinary phenotype and producing prostatic inflammation and collagen accumulation in mice.

[Acute prostatitis associated with noncancerous prostate at the Lubumbashi University Clinics: epidemioclinical and therapeutic features]

Introduction

les prostatites aiguës sont une entité fréquente en urologie. L'objectif de cette étude était d'analyser les aspects épidémio-cliniques et thérapeutiques des prostatites aiguës sur des prostates non tumorales aux Cliniques Universitaires de Lubumbashi.

Méthodes

il s'est agi d'une étude descriptive transversale et rétrospective rapportant une série de 25 patients souffrant de prostatite aiguë documentée et pris en charge aux Cliniques Universitaires de Lubumbashi durant une période de quatre ans soit de 2015 à 2018. Tous les patients porteurs de tumeurs prostatiques ont été exclus de notre étude. Les données ont été recueillies sur base d´une fiche d´enquête reprenant différents paramètres d´étude répartis en 3 catégories à savoir les données épidémiologiques comprenant l´âge, la période d´étude, la résidence, les données cliniques reprenant les signes subjectifs, les signes objectifs, l´état général, les éléments du toucher rectal ainsi que les données paracliniques réparties en laboratoires et imagerie.

Résultats

la prostatite aiguë sur prostate non tumorale a représenté 1,27% de l´ensemble de la pathologie chirurgicale et 7,66% en urologie. La tranche d´âge la plus touchée était celle de 19 à 37 ans avec 64% des cas, l´âge moyen est de 33,16±2,4 ans. Dix-sept patients (68%) étaient suivis en ambulatoires et 8 (32%) en hospitalisation. Sur le plan clinique, la fièvre au-delà de 38,5°celsius était retrouvée chez 15 patients (60%), la dysurie chez 11 patients (44%), rétention aiguë d´urine chez 3 patients (12%), les brulures mictionnelles chez 8 patients (32%), syndrome douloureux chez 21 patients (84%), la sensibilité prostatique au toucher rectal chez 18 patients (72%). Sur le plan de l´imagerie, l´échographie a été le seul examen réalisé et ce, chez 16 patients (64%). Sur le plan biologique, le bilan inflammatoire était quasi-systématique chez tous nos patients (100%) comprenant la NFS, la VS, la CRP; l´hémoculture réalisée chez 4 patients (16%) parmi lesquels 3 étaient positives. Tous nos patients avaient réalisé l´examen cytobactériologique des urines ou des sécrétions prostatiques recueillies par un massage prostatique. La culture d´urine était stérile chez 6 patients (24%) et positive chez 19 patients (76%) avec Escherichia coli comme germe le plus retrouvé, chez 16 patients sur les 19 (84,21%). Tous nos patients ont été mis sous anti-inflammatoire en intra-rectale et les fluoroquinolones ont été les antibiotiques les plus utilisés dans notre série chez 18 patients (64%) parmi lesquels 12 en monothérapie. Six cas sur les 25 (24%) étaient associés à une orchi-épidydimite. La durée de traitement allait de 2 semaines à 4 semaines avec comme critère d´arrêt de traitement soit la stérilisation des sécrétions ou des urines soit la disparition de la leucocyturie. Ainsi, sur les 19 patients avec culture positive à l´admission, 14 ont réalisé une deuxième culture (73,68%) à 2 semaines de traitement parmi lesquels 3 (12%) étaient encore positives et ont dû réaliser une troisième culture 4 semaines après le début de traitement. L´évolution était bonne chez 22 patients (88%) avec une rémission complète des signes cliniques et biologiques et 3 cas (12%) ont évolué vers une persistance des signes et un passage à la chronicité, aucun cas d´évolution vers un abcès prostatique.

Conclusion

la prostatite aiguë sur prostate non tumorale reste une entité nosologique urologique très préoccupante dont la prise en charge doit être rigoureuse d´autant plus que la population à risque est celle en période d´intense activité sexuelle. L´usage de l´échographie endorectale, la proscription du massage prostatique doivent s´intégrer dans la prise en charge aux cliniques universitaires de Lubumbashi.

Prostatic Artery Embolization Is Safe and Effective for Medically Recalcitrant Radiation-Induced Prostatitis

Purpose

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) represents 90% of all chronic prostatitis cases and may occur after radiation therapy (RT) for localized prostate cancer. Medical therapy is effective in approximately 50% of cases, with no therapy demonstrating consistent efficacy in refractory cases. Prostatic artery embolization (PAE) is effective in men with lower urinary tract symptoms and benign prostatic hyperplasia. We report clinical improvement after PAE in a case series of men with CP/CPPS after RT.

Methods and Materials

Nine men (median age 72 years; range, 61-83 years) with CP/CPPS after RT for prostate cancer underwent PAE. Baseline International Prostate Symptom Score was recorded in 5 patients (median 23; range, 4-26), Chronic Prostatitis Symptom Index score in 6 patients (median 22.5; range, 6-34), and quality of life (QoL) score in 8 patients (median 5; range, 2-6). Median baseline prostate volume was 49 cm³ (range, 22-123 cm³). Patients were followed up at 6 and 12 weeks with QoL, International Prostate Symptom Score, and/or Chronic Prostatitis Symptom Index score and magnetic resonance imaging.

Results

Technical success (ie, bilateral embolization) was achieved in 78% (n = 7) of patients with the other 2 patients having undergone unilateral embolization with no major complications. Clinical success was seen in 89% (n = 8) of patients and QoL improved in 78% (n = 7) during the follow-up period.

Conclusion

CP/CPPS after RT for localized prostate cancer is a highly morbid condition, with medical therapy successful in only 50% of cases. PAE may be a successful therapy for medically recalcitrant CP/CPPS, and further studies are necessary to understand the best patient selection and scenario for PAE in the setting of CP/CPPS.

Distinct lipid signatures are identified in the plasma of rats with chronic inflammation induced by estradiol benzoate and sex hormones

INTRODUCTION

Prostatitis is likely to occur in younger or middle-aged men, while prostate cancer is likely to occur in older men. Although amino acids and lipids as biomarkers of prostate cancer have been examined using prostate cancer cell lines/tissues, no previous studies have evaluated amino acids or lipids as potential chronic prostatitis biomarkers.

OBJECTIVES

The study's aim was to identify amino acids and lipids that could serve as potential biomarkers of chronic prostatitis.

METHODS

We profiled the amino acids and lipids found in plasma from rats collected in a previous study. In brief, a total of 148 Sprague-Dawley rats (offspring) were dosed with estradiol benzoate (EB) on postnatal days (PNDs) 1, 3 and 5, and subsequently dosed with testosterone (T)/estradiol (E) tubes via subcutaneous implants from PND 90 to 200. Plasma was collected on PNDs 30, 90, 100, 145 and 200. Analysis was conducted with a Xevo TQ-S triple-quadrupole mass spectrometer using a Biocrates AbsoluteIDQ p180 kit.

RESULTS

Plasma acylcarnitines [(C2, C16:1, C18, C18:1, C18:1-OH, and C18:2)], glycerophospholipids (lysophosphatidylcholine-acyl, -di-acyl, and -di-acyl acyl-alkyl) and sphingomyelins [SM (OH) C16:1, SM C18:0, SM C18:1, and SM C20:2] significantly increased on PND 145, when chronic inflammation was observed in the dorsolateral prostate of rats dosed with EB, T, and E. No statistical significances of amino acid levels were observed in the EB + T + E group on PND 145.

CONCLUSION

Exposure to EB, T, and E altered lipid levels in rat plasma with chronic prostate inflammation. These findings suggest that the identified lipids may be predictive chronic prostatitis biomarkers. The results require confirmation through additional nonclinical and human studies.

Fosfomycin for bacterial prostatitis: a review

There has been growing interest in fosfomycin for the treatment of bacterial prostatitis due to evidence suggesting that it achieves adequate prostatic concentrations for antimicrobial effect, has activity against resistant micro-organisms, and has a low-toxicity profile. This review evaluated the current clinical evidence for fosfomycin in acute and chronic bacterial prostatitis to elucidate the clinical implications of fosfomycin in an era of increasing antimicrobial resistance. PubMed, Scopus, EMBASE, Web of Science, Google Scholar and ClinicalTrials.gov were searched for studies published in the English language from January 1984 to November 2019. The inclusion criteria were met if the study reported the use of fosfomycin (more than one dose) to treat bacterial prostatitis. Ten observational studies were identified that met the inclusion criteria. The evidence for the use of fosfomycin in acute bacterial prostatitis is sparse. The majority of the available evidence is for chronic bacterial prostatitis caused by Escherichia coli. Despite the implementation of variable dosing regimens, extended courses of fosfomycin appear to be safe and effective in achieving clinical and microbiological cure. In these studies, the use of fosfomycin was restricted to cases of treatment failure, intolerance to first-line therapy, or multi-resistant organisms. However, given the development of resistant organisms and the undesirable adverse effects of many first-line therapeutic options, fosfomycin has the potential to be considered as an effective first-line alternative for acute and chronic bacterial prostatitis in the future. Further studies, including randomized controlled trials, would be helpful to firmly establish its optimal dosing regimen, efficacy and place in therapy.

Chronic oral exposure to glycated whey proteins increases survival of aged male NOD mice with autoimmune prostatitis by regulating the gut microbiome and anti-inflammatory responses

Glycated whey proteins have been shown to be protective against type 1 diabetes in our previous studies, suggesting their potential application as medical food. To determine if the protection could be extended to other autoimmune diseases, aged male non-obese diabetic (NOD) mice that develop a wide spectrum of autoimmune pathologies, including spontaneous autoimmune prostatitis, were used. After a 6-month oral exposure to whey protein-derived early glycation products (EGPs), EGP-treated NOD mice had an increased survival rate, decreased macrophage infiltration in the anterior lobe and decreased inflammation in the prostate when compared to the mice that received non-reacted controls. The systemic immunity was regulated towards anti-inflammation, evidenced by an increase in serum IL-10 level and decreases in total splenocytes, splenic M1 macrophages, CD4+ T cells, CD8+ T cells and B cells. Consistent with an overall anti-inflammatory status, the gut microbiome was altered in abundance but not diversity, with increased Allobaculum, Anaerostipes, Bacteroides, Parabacteroides and Prevotella and decreased Adlercreutzia and Roseburia at the genus level. Moreover, increased Bacteroides acidifaciens correlated with most of the immune parameters measured. Collectively, chronic oral exposure to EGPs produced an anti-inflammatory effect in aged male NOD mice, which might contribute to the protective effects against spontaneous autoimmune prostatitis and/or other organ specific autoimmune diseases.

Male CP/CPPS: where do we stand?

INTRODUCTION

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), commonly encountered in urologic practice, carries with it a stigma of poor understanding, ineffective treatment, and significant financial and quality of life burden.

MATERIALS AND METHODS

This clinically practical review is based on the authors' personal clinical experience in interpretation and application of currently available evidence.

RESULTS

Significant progress has been made in terms of classification and evaluation of the disease, leading to encouraging improvements in treatment outcomes. The Chronic Prostatitis Symptom Index (CPSI) is a helpful tool in clinical evaluation and has proven invaluable for research purposes, while UPOINT has demonstrated the heterogeneity of the disease and provides physicians with a uniquely patient-centered approach to treatment. The importance of the microbiome in the evaluation of CP/CPPS patients has yet to be fully appreciated. While personalized, multi-modal therapy appears to be the key to treatment, the addition of pelvic floor physiotherapy (PFPT) with injection of trigger points, and psychosocial therapies to the multi-modal approach armamentarium are promising advances. Innovative interventional approaches are encouraging but require study.

CONCLUSIONS

While encouraging therapies have been added to personalized, multi-modal treatment strategies, newer innovative therapies appear promising for improved treatment of CP/CPPS patients.

Can expressed prostatic secretions effect prostate biopsy decision of urologist?

Objectives:

To evaluate the frequency of NIH category IV prostatitis, and the use of expressed prostatic secretions tests in an effort to improve the reliability of prostate specific antigen as an indicator, to avoid unnecessary prostate biopsy.

Materials and Methods:

178 expressed prostatic secretion positive patients with serum prostate specific antigen levels of ≥ 2.5 ng / mL were included in present prospective study. The diagnostic evaluation included detailed history and physical examination, digital rectal examination, urine analysis, urine culture, and expressed prostatic secretions tests. Transrectal ultrasonography was used both to measure prostate volume and conduct 12 core prostate biopsy.

Results:

The prevalence of NIH category IV prostatitis was 36.9% (178 / 482) in our population of men. In our study patients (n: 178) prostate biopsy results were classified as; 66 prostatitis, 81 BPH, and 31 Pca. In asymptomatic prostatitis group, expressed prostatic secretion mean leucocyte ratio was higher compared to other two groups (p < 0.0001). The relation between number of expressed prostatic secretion leucocytes and prostatitis, benign prostate hyperplasia, and prostate cancer is analyzed. If 16 is taken as the cut of number for leucocyte presence, its sensitivity is 0.92 (AUC = 0.78 p = 0.01).

Conclusions:

The number of leucocytes in expressed prostatic secretion is higher in the chronic prostatitis group. If the leukocyte presence of 16 and above is taken as the cut off point, the sensitivity becomes 0.92 (AUC = 0.78). We firmly believe that our new cut off value may be used as to aid prostate specific antigen and derivates while giving biopsy decision.

Review of Guidelines for the Evaluation and Treatment of Leukocytospermia in Male Infertility

Leukocytospermia is an ill-defined and poorly understood condition affecting up to 30% of male factor infertility. Current guidelines on leukocytospermia vary significantly, although it has been linked to increased rates of infertility, uncertainty about its clinical significance, diagnosis, and treatment remains. The guidelines are conflicting with sparse data scattered across different specialties and continents. This study aims to compare and contrast available international guidelines and recommendations. In addition to these guidelines, we sought to consolidate the findings of trials over the last several decades. English language articles on human observational studies, retrospective, prospective, clinical trials and randomized control trials were searched for using the following terms: "leukocytospermia, pyospermia, and male infertility." Articles about treatment and management of leukocytospermia that were published between January 2010 and April 2018 were included, as well as four articles referenced in best practice and guideline statements from urological and andrological associations. Disagreements on this topic are highlighted as some guidelines describe no correlation between leukocytospermia and infertility while others show that treatment leads to improvement of sperm quality by many measures including improved pregnancy rate. Various treatments have been suggested including antibiotics, anti-inflammatory medications, and frequent ejaculation. There is a need for definitive characterization of Leukocytospermia as an infectious or inflammatory marker and a re-evaluation of the leukocyte concentration threshold. Additional studies investigating rates of conception as a measure of outcome are needed, to provide greater level of evidence and generalizability of leukocytopsermia management.

A Classic Herbal Formula Danggui Beimu Kushen Wan for Chronic Prostatitis: From Traditional Knowledge to Scientific Exploration

Chronic prostatitis (CP) is a chronic inflammation in the prostate with unsatisfactory management. Danggui Beimu Kushen Wan (DBKW) is a classic formula developed 1800 years ago for patients with difficult urination and it has been widely utilized for CP in modern days. However, scientific understanding of DBKW on CP has not been systematically reviewed. First, we searched the Encyclopedia of Traditional Chinese Medicine for the etiologies and pathogeneses of CP-like symptoms and DBKW and compared their similarities and differences from traditional Chinese medicine and conventional medicine perspectives. Then, we searched 21 electronic databases to identify potential clinical and experimental studies. Characteristics of included studies, ingredients, herb frequency, and possible mechanisms of actions were descriptively summarized. Risk of bias of randomized controlled trials (RCTs) was evaluated using the Cochrane risk of bias assessment tool. A total of 290 studies were identified. Six clinical studies, including four RCTs and two case series, and eight experimental studies were included. Clinical studies indicated that DBKW used alone or as an adjunct therapy significantly reduced the CP symptom scores and decreased the expressed prostatic secretions-pH when compared to antibiotics or α-blocker. Most RCTs have high or unclear risk of bias. Experimental studies revealed that DBKW may have effects on anti-inflammation, antibacteria, antioxidation, sex hormone regulation, and immunoregulation. DBKW demonstrated a great potential in the treatment of CP. High-quality RCTs and network pharmacological studies should be considered for future research.

The evolving clinical picture of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): A look at 1310 patients over 16 years

INTRODUCTION

Two decades of increasing understanding of etiopathogenesis and clinical phenotyping produces an impression the clinical face of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is changing. We sought to retrospectively analyze trends in CP/CPPS patients presenting to our clinic for evaluation over a 16-year period.

METHODS

Patients with CP/CPPS presenting to a tertiary clinic were evaluated prospectively from 1998-2014 with Chronic Prostatitis Symptom Index (CPSI) and UPOINT (urinary, psychosocial, organ-specific, infection, neurogenic, and tenderness) categorization. Patients were stratified in four cohorts, based on year of presentation, and we retrospectively analyzed variations in symptom scores and patterns, UPOINT categorization, and treatment modalities amongst cohorts.

RESULTS

Mean age of the 1310 CP/CPPS patients was 44.7 years, while mean CPSI pain, urination, and total scores were 10.6, 4.8, and 23.3, respectively. The most prevalent UPOINT domain, urinary (U) (71.8%) was associated with a higher CPSI urination score (6.3), more frequent penile tip pain (37%), dysuria (48%), and more treatment with alpha-blockers (70%). Increase in UPOINT domains was associated with higher CPSI pain, quality of life (QoL), and total scores. Trends over time included increased prevalence of psychosocial (P), organ (O), and tenderness (T) domains, as well as increased use of alpha-blockers, neuromodulation, and phytotherapy as treatment modalities. There was little variation in age, CPSI scores, and pain locations over time.

CONCLUSIONS

The changing clinical face of CP/CPPS reflects the increased recognition of psychosocial (P domain) and pelvic floor pain (T domain), along with the concomitant use of associated therapies. There was little variation of pain/urinary symptom patterns and QoL.

Do antibiotics decrease prostate-specific antigen levels and reduce the need for prostate biopsy in type IV prostatitis? A systematic literature review

INTRODUCTION

Inflammation of the prostate can be a cause of elevated prostate-specific antigen (PSA) in men referred for suspected prostate cancer. This systematic review assesses the evidence for antibiotic therapy in patients with type IV (asymptomatic) prostatitis with regard to reduction of PSA levels and discrimination between prostate cancer and inflammation.

METHODS

MEDLINE, EMBASE, and the Cochrane registry were searched for papers reporting on cohorts of men with elevated PSA and type IV prostatitis that were treated with antibiotics.

RESULTS

The search yielded 160 papers, of which 11 met the inclusion criteria: two randomized trials and nine cohort studies. In total, the studies reported on 1011 patients with type IV prostatitis, of whom 926 were treated with antibiotics. PSA normalization was seen after antibiotic treatment in 33.2% of patients (95% confidence interval [CI] 24.9-42.8). Meta-analysis of the randomized trials did not demonstrate a higher likelihood of PSA normalization in the antibiotics arm as compared to the control arm (odds ratio [OR] 1.27; 95% CI 0.58-2.76; p=0.553). Four studies performed prostate biopsies in all patients. Although three of these studies demonstrated lower prevalence of prostate cancer in patients in whom PSA had normalized, meta-analysis failed to show a statistically significant difference (OR 0.39; 95% CI 0.06-2.49; p=0.319).

CONCLUSIONS

The available evidence does not support antibiotic therapy for differentiation between benign and malignant cause of elevated PSA in men with type IV prostatitis.

Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome

Prostatitis comprises of a group of syndromes that affect almost 50% of men at least once in their lifetime and makeup the majority of visits to the Urology Clinics. After much debate, it has been divided into four distinct categories by National Institutes of Health namely (1) acute bacterial prostatitis; (2) chronic bacterial prostatitis; (3) chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) which is further divided into inflammatory and non-inflammatory CP/CPPS; and (4) asymptomatic inflammatory prostatitis. CP/CPPS has been a cause of great concern for both patients and physicians because of the lack of presence of thorough information about the etiological factors along with the difficult-to-treat nature of the syndrome. For the presented manuscript an extensive search on PubMed was conducted for CP/CPPS aimed to present an updated review on the evaluation and treatment options available for patients with CP/CPPS. Several diagnostic criteria’s have been established to diagnose CP/CPPS, with prostatic/pelvic pain for at least 3 mo being the major classifying symptom along with the presence of lower urinary tract symptoms and/or ejaculatory pain. Diagnostic tests can help differentiate CP/CPPS from other syndromes that come under the heading of prostatitis by ruling out active urinary tract infection and/or prostatic infection with uropathogen by performing urine cultures, Meares-Stamey Four Glass Test, Pre- and Post-Massage Two Glass Test. Asymptomatic inflammatory prostatitis is confirmed through prostate biopsy done for elevated serum prostate-specific antigen levels or abnormal digital rectal examination. Researchers have been unable to link a single etiological factor to the pathogenesis of CP/CPPS, instead a cluster of potential etiologies including atypical bacterial or nanobacterial infection, autoimmunity, neurological dysfunction and pelvic floor muscle dysfunction are most commonly implicated. Initially monotherapy with anti-biotics and alpha adrenergic-blockers can be tried, but its success has only been observed in treatment naïve population. Other pharmacotherapies including phytotherapy, neuromodulatory drugs and anti-inflammatories achieved limited success in trials. Complementary and interventional therapies including acupuncture, myofascial trigger point release and pelvic floor biofeedback have been employed. This review points towards the fact that treatment should be tailored individually for patients based on their symptoms. Patients can be stratified phenotypically based on the UPOINT system constituting of Urinary, Psychosocial, Organ-specific, Infectious, Neurologic/Systemic and symptoms of muscular Tenderness and the treatment algorithm should be proposed accordingly. Treatment of CP/CPPS should be aimed towards treating local as well as central factors causing the symptoms. Surgical intervention can cause significant morbidity and should only be reserved for treatment-refractory patients that have previously failed to respond to multiple drug therapies.

Lower urinary tract symptoms associated with prostatitis

Approximately 50% to 60% of men with chronic prostatitis experience troublesome lower urinary tract symptoms (LUTS). Individual interventions yield statistically significant but minimally important improvements in clinical trials. Research has shown that categorizing patients with prostatitis by phenotype is an effective way to rationally select therapy and maximize the impact on symptom reduction and improve quality of life.

Paucisymptomatic infectious prostatitis as a cause of fever without an apparent origin. A series of 19 patients

According to the literature, prostatitis is a rare cause of prolonged fever without an apparent origin. However, this syndrome can be easily diagnosed using specific tests, either two-glass pre- and post-prostatic massage or the Meares-Stamey four-glass test. A retrospective study over a 5-year period (between August 1st 2006 and July 31st 2011) was performed. All patients who met the criteria for microbiological prostatitis were included and assigned to one of two groups, either a study group [paucisymptomatic infectious prostatitis (PIP)] or a control group [classic infectious prostatitis (CIP)]. Epidemiological, clinical, microbiological, and treatment-related variables were collected. A comparative study between both groups was performed. Thirty-nine patients were diagnosed with prostatitis. The main risk factors were unprotected anal intercourse, human immunodeficiency virus (HIV) infection, recent travel, and recurrent urinary tract infections. The most significant differences between the PIP (19 patients) and CIP (20 patients) groups were higher frequency of elevated inflammatory markers, higher frequency of monomicrobial etiology, and longer treatment. In monomicrobial prostatitis, the most common causative agents were coagulase-negative Staphylococcus spp., Escherichia coli, and Corynebacterium glucuronolyticum. According to the findings of this study, we believe that prostatitis should be included as a possible diagnosis in a man who complains of prolonged fever without an apparent origin and having at least one of the following risk factors: unprotected anal intercourse, HIV infection, recent travel, and recurrent urinary tract infections.