Prostatitis Syndrome Etiology, Diagnosis and New Treatment
Prostatitis is a common and major healthcare issue. It is estimated that one out of every two men will suffer from prostatitis symptoms at some times in his life, and this disabling condition accounts for approximately two million medical offices visits per year in the USA alone.
Indeed, prostatitis is overall the most frequently diagnosed illness in men under the age of 50 years. Prostatitis affects 10-04% of men of all age’s demographies and ethnicities. It has a significant negative impact on quality of life associated as it is with decreased sexual desire, erectile dysfunction and premature ejaculation. Several factors have been associated with chronic prostatitis, including smoking, high caloric diet with low consumption of fruit and vegetables and slow digestion, although the pathogenesis and actiopathogenic mechanisms of this disease have yet to be fully elucidated thus, inflammatory condition resulting in oxidative stress though the generation of lipid peroxidation products and irritants such as capsaicin in cayenne pepper and another red pepper, stimulate the sensory neurons of the bladder and lead to a sensation of irritation and pain in the bladder and prostate which is conveyed to the spinal cord and the brain and the release of neuropeptide, neurokinin and calcitonin gene-related peptide (CGRP). These neuropeptides produce edema and inflammation are implicated in the formation of radical oxygen species (ROS) and promotes contraction of the bladder and urethra may contribute to irritation and neurogenic inflammation in the urinary tract via stimulation of neurons expressing transient receptor potential vanilloid, calciumchannel, resulting in desensitization of bladder sensory nerve terminals, therefore alpha-adrenergic receptors antagonist such as alfuzocin and tamusulosin may inhibit the process.
This new mechanism of action may contribute to the efficiency of the alpha-adrenergic-antagonist on lower urinary tract symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome, as well as benign prostates enlargement.
The diagnosis of acute bacterial prostatitis does not generally present much difficulty for urologist. As well as chills and fever, the patient presents with a swollen prostate, which is extremely painful; consequently prostatic massage is contraindicated as the patient is unlikely to tolerate it and it may lead to sepsis.
Acute prostatitis is the result od sever infection of mainly gram0negative bacteria which can be easily isolated from the urine.
Once diagnosed, treatment consists of empiric therapy with antibiotics in combination with alpha-adrenergic-antagonist as well as alpha-reductase inhibitors. The selection of the antibiotics and course of which can then be adjusted according to the bacteria isolated and the results od bacterial susceptibility testing. Following improvement of clinical symptoms, oral antibiotics therapy is usually continued for a total of 2-4 weeks, although currently there is no consensus on the optimal treatment duration.
Chronic bacterial prostatitis poses more of a problem in terms of accurate diagnosis, as the symptoms are largely shared by chronic pelvic pain syndrome (PPS) and the patients can be asymptomatic between episodes. These patients may also have a recurrent urinary tract infection which may be the root cause of their chronic bacterial prostatitis.
Among patients with the symptoms of chronic prostatitis or chronic pelvic pain syndrome, only approximately 10% actually have bacterial infection. Some symptoms of chronic pain syndrome (CPS) especially pelvic pain, may be indistinguishable from those of interstitial cystitis (IC). The latter condition is more frequently seen in women than in men, so that the possibility of (IC) in men is often disregarded and the diagnosis is missed, especially if non-bladder-related symptoms are present. Not only the diagnosis of IC in general made much more frequently than 20 years ago but, according to (Parson) a recent survey has shown a female-male ratio of 5:1, this study has also shown that there was an overlap between men diagnosed with IC and those diagnosed with prostatitis, suggesting that both conditions may be part of the same disease process probably consisting of a dysfunction of lower urinary epithelium and potassium recycling. In a Canadian Study (Nickle) found that in such cases, interstitial cystitis was more common than prostatitis. Better diagnostic is needed before a diagnosis of interstitial cystitis is established, such as Cystossopy, hydrodistension of the bladder and bladderwall-biopsy, as well as noninvasive markers, such as methylhistamine or nitiric oxide assays in urine. The specific treatment of this disease is now the injection of the bladderwall with (Botox-A), this treatment is instituted in patient with chronic pain syndrome-resistant to firstline conventional treatment like Hydrodistension, GAG-Th, Antihistamine therapy. Botulinum neurotoxin subtype A (BoNTA) is a powerful biological toxin known to man. The toxin binds synaptic vesicle protein type 2 expressed on the neuronal surface at points where synaptic vesicles fuse with the cytoplasmatic membrane. The final consequence is blockade of neurotransmitter release into the synaptic cleft. Recently study revealed that the effect of BoNTA by injection this into the prostate alters the cellular dynamics by inducing apoptosis of glandular elements and a decrease in prostate weight. BoNTA clinical study has been recently revealed that this therapy as well as to have analgesic and anti-inflammatory effects similar to COX-2-inhibitors without systemic spreading, inhibiting proliferation, and downregulating ?1A-adrenergic receptors, so that multiregional injection of BoNTA (including intraprostatic injections) improve symptoms in 60% of CPPS patients. Therefore, intraprostatic BoNT-A injection might have therapeutic benefits for the human prostatic problems through modulation of neuronal activity.
To obtain an accurate diagnosis and differential chronic bacterial prostatitis from chronic pelvic pain syndrome, the Meares-Stamey Four-glass procedure is considered to be the definitive laboratory test.
The four-glass test consists of four-cultures taken from the following sample. (The first 10 ml of urine voided, a midstream sample taken 200 ml after first void, prostatic secretions following prostatic massage, and the first 10 ml of urine voided after the massage).
To facilitate the diagnostics the two-glass test is recommended for routine practice including a midstream urine sample and the first 10 ml of urine voided after the prostatic massage which shows similar specificity and sensitivity as the four-glass test.
However, one of these tests must be considered as an essential diagnostic step to enable correct and successful treatment of chronic bacterial prostatitis. For chronic bacterial prostatitis flouroquinolon antibiotics remain the drugs of choice, with their broad-spectrum activity and favourable pharmacokinetic properties.
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576