Chronic Prostatitis and Chronic Pelvic Pain Syndrome (CPPS)
Review literature: (Nickel et al, 2003) (Schaeffer et al, 2002). EAU guidelines (Fall et al, 2010).
NIH-Definitions of Chronic Prostatitis
Literature: (Krieger et al, 1999).
Category I: Bacterial Acute Prostatitis
See section bacterial prostatitis.
Category II: Chronic Bacterial Prostatitis
Chronic bacterial prostatitis is characterized by symptoms of prostatitis (pain, voiding symptoms) for more than 3 months with recurrent bacterial urinary tract infection.
Category III: Chronic Pelvic Pain Syndrome
The chronic pelvic pain syndrome (CPPS) is characterized by pain and voiding symptoms for more than 3 months, without detection of bacterial pathogens using standard microbiological methods. The CPPS is divided into two subcategories:
Category IIIA: Inflammatory CPPS
The inflammatory CPPS is characterized by a chronic pelvic pain syndrome with signs of prostate inflammation (leukospermia or white blood cells in expressed prostate secretion). The culture of semen, EPS and urine after post-prostatic massage are negative.
Category IIIB: Noninflammatory CPPS
The noninflammatory CPPS is characterized by a chronic pelvic pain syndrome without signs of prostatic inflammation (see category IIIA).
Category IV: Asymptomatic Inflammatory Prostatitis
Patients with asymptomatic inflammatory prostatitis have evidence for prostate inflammation (leukospermia, white blood cells in expressed prostate secretions, positive cultures or inflammation in tissue biopsies) without pelvic pain or voiding symptoms.
Epidemiology of Chronic prostatitis
Complaints due to chronic prostatitis are common. Chronic prostatitis is the most common urologic diagnosis in male patients under the age of 50 years. 5% of men between the age of 20–50 years will have an episode of prostatitis. The incidence of chronic prostatitis is around 3/1000 and peaks between 20–49 years of age and over the age of 70.
Etiology (Causes) of Chronic Prostatitis and CPPS
The etiology of chronic prostatitis and chronic pelvic pain syndrome (CPPS) is heterogeneous, which can be seen looking at the definitions of chronic prostatitis. Depending on the different forms of chronic prostatitis, infectious causes (chronic bacterial prostatitis), micturition disorders, or other etiological factors (CPPS) prevail. Chronic prostatitis has probably a multifactorial etiology with both triggering causes and disease-sustaining causes. In the further course of chronic prostatitis, the pain sensation may become independent from the underlying disease due to neuromodulatory processes, which complicates treatment.
Chronic Infection with Bacteria:
Enterobacteria, Chlamydia trachomatis, Ureaplasma urealyticum, ... The detection of pathogens responsible for prostatitis is difficult, since contamination from the urethra as well as non-pathogenic bacteria in the prostate are common. Molecular biological markers of bacterial infection are increased in patients with CPPS; nevertheless the detection of pathogens is negative in over 80% of patients.
Urine and bacteria may enter via reflux into the prostate and lead to inflammation. This theory is supported by urinous components of prostate stones. In the biofilm of the prostate stones, bacteria can persist despite adequate antibiotic treatment or inflammatory response and maintain a chronic infection.
Urodynamic Abnormalities in CPPS:
Micturition problems may be a cause of chronic prostatitis or CPPS. The following findings are detected more frequently in CPPS: poor urine flow, bladder neck obstruction, hypersensitivity of the bladder during filling and detrusor-sphincter-dyscoordination. Furthermore, pelvic floor muscle abnormalities are common in CPPS. Voiding dysfunctions may promote intraprostatic reflux and autonomic reflexes and lead to chronic neurogenic pain.
Musculoskeletal Causes of CPPS:
Tendinopathy of the pelvic floor, myofascial trigger points or myogeloses cause pain with activation of the pelvic floor. In addition, there is evidence for a neurogenic inflammation as a mechanism of CPPS. This leads to painful micturition or sexuality and leads to avoidance behaviour and chronic pain.
Male Form of Interstitial Cystitis:
Symptoms of chronic prostatitis resemble the pain and discomfort of women with bladder pain syndrome or interstitial cystitis. Furthermore, similarities are found in cystoscopy, potassium instillation and urodynamic studies. The etiology of interstitial cystitis is unclear.
Depression and personality disorders are more frequent in patients with CPPS than in controls. The reasons are unclear.
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