1. Prostatitis Christian Beck, MD Dortmund Germany

2. History First described in 1815 by Legneau.
Main treatment was repeated prostate massage.
In 1930’s antibiotics came into regular use.
Evident that most forms of prostatitis did not respond to Ab’s.

3. Epidemiology (USA)
McNaughton-Collins in 2000 noted 2 million physician visits for ‘prostatitis’ annually from in USA
Commonest urological diagnosis in men < 50 and 3rd commonest in men > 50, 8% of urology consultations.
Urepik Study 1998 – 35% of men had at least 1 symptom of prostatitis, with 8% describing symptoms as problematic.

4. Prostatitis: A Major Clinical Problem (Germany)
Incidence/prevalence: 4% -11%
8-12% of urologist office visits
Life time prevalence 14.8%
most common urological diagnosis in men <50
Quality of Life is dismal (depressing) !

5. Aetiology
Gram –ve enterobacteria account for 90% of acute bacterial prostatitis. (E. coli, Klebsiella, Serratia, Pseudomonas)
Enterococcus (gram +ve) 5 – 10%, and Staphs.
Role of anaerobes are unknown.
Anti-Chlamydial antibodies in 30% of chronic prostatitis, but < 1% culture organism.

6. Aetiology
Altered Prostatic Host Defence - phimosis; unprotected penetrative anal rectal intercourse; acute epididymitis; indwelling urethral catheters and condom catheter drainage.
Dysfunctional Voiding.
Intraprostatic Ductal Reflux – stones, carbon particles (Kirby et al 1982).
Pelvic Floor Musculature Abnormalities.
Interstitial Cystitis.
Psychological Cause

7. Investigation
Physical – Signs of infection, abdo tenderness, DRE (anal tone, prostate, pain).
Examination of Urine.
Urodynamics (Video)
Rule out other cause – obstruction, OAB, dyssynergia.
Cystoscopy?
TRUS
Abscess, medial cysts, SV obstruction.
Not diagnostic for Chronic Prostatitis.
Biopsy of no clinical benefit to management.

8. Examination of Urine 1968 Meares and Stamey - 4 glass test.
For Chronic Prostatitis only.
Simplified 2 glass test similar sensitivity and specificity to 4 glass test.
10 WBC’s per HPF is cut off for inflammatory and non-inflammatory category III prostatitis.

9. Examination of Urine CLASSIC STAMEY 4 GLASS TEST
Wagenlehner, F M E; Naber, K G; Bschleipfer, T; Brähler, E; Weidner, W
Prostatitis and Male Pelvic Pain Syndrome: Diagnosis and Treatment
Dtsch Arztebl Int 2009; 106(11): ; DOI: /arztebl

10. PROSTATITIS DIAGNOSIS
Donna R. Coffman, MD
Comparison of four-glass and two-glass premassage and postmassage test
Nickel JC, Shoskes D, Wang Y, et al: How does the pre-massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol 176(1): , 2006.
The Premassage postmassage test (PPMT) may offer an adequate screening test as an alternative that is simpler, faster, and less expensive than the four-glass test.

11. PRE-M
POST-M
Prostate massage

13. Classification

14. PROSTATITIS UNDER THE MICROSCOPE

15. Category I – Acute Bacterial
Not common
Perineal, external genitalia and suprapubic pain.
Dysuria, frequency and urgency.
Obstructive symptoms.
Febrile illness occasionally with severe sepsis.

16. Category I – Acute Bacterial
The patient typically complains of :
Urinary frequency, urgency, and dysuria.
Obstructive voiding complaints including hesitancy, poor interrupted stream, strangury, and even acute urinary retention are common. Tenesmus.
Perineal and suprapubic pain
Associated pain or discomfort of the external genitalia.
Significant systemic symptoms including fever, chills, malaise, nausea and vomiting, and even frank septicemia with hypotension
Approximately 5% of patients with acute bacterial prostatitis may progress to chronic bacterial prostatitis (Cho et al., 2005

17. Category I – Acute Bacterial
Send MSSU (Mid Stream Specimen of Urine) / blood cultures.
Antibiotics
i.v. if evidence of sepsis
Aminoglycoside, cephalosporins, or fluoroquinolones.
2 – 4 weeks treatment.
Surgery
SP catheter
TRUSS or CT to exclude abscess.
Abscess best drained by TUR.

18. Category II – Chronic Bacterial Prostatitis.
5 – 15% of Prostatitis
Recurrent UTI’s in 25 – 40%
May be asymptomatic between episodes or have a long history of CPPS.
Treat with Antibiotics
Fluoroquinolones (Cipro- Levo- and Ofloxacine) most effective.
12 weeks of treatment.
60 – 85% bacteriological cure.
40% symptom cure.

19. Category IIIa – Chronic Pelvic Pain Syndrom (CPPS Inflammatory)
Pain – Perineum, suprapubic and penile but can be testes, groin and lower back.
Pain during or after ejaculation.
LUTS (storage and voiding symptoms)
Erectile dysfunction is increased.
Symptoms present for > 3 months.
Sickness Impact Profile – QL scores similar to MI, angina and Crohn’s.

20. Category IIIb – Chronic Pelvic Pain Syndrom (CPPS non-bacterial)
Same presenting features as IIIa, but < 10 WBCell’s per HPField on Expressed Prostatic Sekretion and VB3.
NIH – Chronic Prostatitis Symptom Index.

21. Category IV – Asymptomatic Inflammatory Prostatitis
As name suggests!!
WBC’s or bacteria in EPS or VB3 or histological examination of gland.
Present with obstruction, raised PSA, infertility.

22. Classification: NIH Cat I: Acute Bacterial Prostatitis
Cat II: Chronic Bacterial Prostatitis
Cat III: Chronic Pelvic Pain Syndrome (CPPS)
Cat IIIA: Inflammatory CPPS
Cat IIIB: Non-inflammatory CPPS
Cat IV: Asymptomatic Inflammatory Prostatitis (AIP)
90%

23. CPPS

24. CPPS

25. CPPS Treatment Antibiotics
Campbells: The Randomized Controlled Trial- try in IIIa and continue if beneficial, no consensus with IIIb.
Nickel et al Urology Oct; 62(4) : RCT comparing Levofloxacin versus Placebo – decrease in NIH-CPSI score, but same as placebo.
De Rose et al Urology Jan;63(1):13-6. RCT comparing mepartricin v placebo for 2 months (26 patients). NIH-CPSI scores 60% and 20% reduced. With significant improvements in pain and QoL.

26. CPPS Treatment -Blockers CPPS causes obstructive LUTS.
Campbells – few small studies show improvement in flow and symptoms, esp when combined with Ab’s. No RCT.
Alexander et al Ann Intern Med Oct 19;141(8): RCT of Cipro v Tam v both v placebo = No difference but all caused slight decrease in symptom score. Only 6 weeks
Mehik et al Urology Sep;62(3): RCT of Xatral (Alfuzosin) v placebo for 6 months. Modest but significant reduction in pain and symptom score.

27. CPPS Treatment Anti-Inflammatory Agents
NSAID’s improve pain and symptoms.
Nickel et al J Urol Apr;173(4): RCT of pentosan polysulfate sodium (used for Interstitial cystitis/painful bladder syndrome) versus placebo in CPPS. 300mg TDS for 16 weeks. Slight improvement over placebo, only significant in QoL score.

28. CPPS Treatment Hormone Therapy Phytotherapy
Nickel et al BJU Int May;93(7): RCT of Finasteride v Placebo slight improvement but not properly powered.
Phytotherapy
Saw Palmetto – no effect
Bee Pollen Extract (a bioflavonoid) showed slight improvements.

29. CPPS Treatment Prostate Massage
Campbell’s no good evidence to support use.
Perineal or Pelvic Floor Massage or Myofascial Trigger point release
What?
Cornel et al Eur Urol May;47(5): Epub 2005 Jan 22. RCT of biofeedback showed significant reduction in NIH-CPSI scores.
Other smaller studies give similar results.

30. CPPS Treatment
Balloon dilatation and needle ablation – some benefit in small series, none properly controlled.
Microwave therapy
3 studies comparing MT v sham. All showed benefit over sham. 1 study showed 75% improvement with MT, but sham gave 52% improvement.
TURF therapy (TEMPRO)
My study presented on WCE in Munich (Oktober 2009) showed 43% improvement.

32. CPPS Treatment Surgery TURP/BNI only if evidence of obstruction.
TURP in refractory Cat. II reported.
TURP in CPPS – no evidence
Radical prostatectomy – one case reported
‘No definitive clinical series or long-term follow-up has ever been presented, and this type of surgery should not be encouraged or recommended at this time’.

33. Intraprostatic injection in prostatitis cathegory IIIa And IIIb(CPPS)
Antibiotics
Zinc
Periprostatic BOTOX
Antibiotics and esracain
Antibiotics and steroids
ROUTS OF INJECTION
Transrectal
Perineal
transurethral
Us guided

34. Intraprostatic injection chronic bacterial prostatitis(II)

35. Intraprostatic injections
Possible side effects
Pain
Hematuria
Dysuria
Hemospermia

36. Algorithm or Treatment of CPPS

37. HYPERTHERMIA How to convey heat to the prostate:
Transrectal (microwave)
Transurethral (microwave)
Interstitial (laser, Nanoparticles)
Tempro or Tuna (radiofrequency)
Hifu (ultrasound)
All treatments cause some degree of prostate tissue denaturation and if high temperatures are achieved, even tissue necrosis

38. TURF
Thermotherapy ,5° c
No cooling needed

39. TURF MECHANISM – Principle of Operation
RF produces electromagnetic radiation with oscillating electrical and magnetic fields. The design of the antenna seems to affect the heating pattern more than the wave frequency does.
Heat is produced while the radiowaves are absorbed by the tissue.

40. LOCAL EFFECT OF TURF
heating in excess of 50°C is followed by coagulation necrosis
Histopathological effect of thermotherapy appears to be related to the induction of cell death
induced necrosis was shown to disrupt periurethral  -adrenergic receptors reflecting denervation of smooth muscle cells consisting with the increased urinary flow rate after TURF
It was demonstrated that TURF increased the sensory threshold (Schwelle) in the posterior urethra by 30%, resulting in the reduction of irritative symptoms

41. Heat Distribution Heating point center For BPH: 55 to 60° C
For Prostatitis: 48 to 53,5°C
(depending on Age)

42. Heating Point
Balloon
Heating Point Center

43. Contraindications for TURF
Urinary Tract Infektion
Penile implants
Artificial sphincter
Urethral stricture
Previous prostate surgery
Leriche syndrome (is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries).
Prostates under 30 gr or over 100gr.

44. Treatment Protocol for Prostatitis
Insertion of catheter
(containing the Applicator)
Inflation of catheter balloon
& repositioning of catheter
Temperature is raised to 39° C
(for at least 3 min) than gradually raised
to 48 or 53,5°C for additional 57 min.
Following treatment - immediate removal
of catheter (post-treatment catheter
insertion is optional)
Interval between treatments: min. 1 month

45. Is prostatitis a premalignant lesion

46. Is prostatitis a premalignant lesion
Prostate carcinogenesis and inflammation: emerging insights
Patrick j. et al.,
Carcinogenesis (7):

47. Is prostatitis a premalignant lesion
Review
Nature Reviews Cancer
Inflammation in prostate carcinogenesis
Angelo M. De Marzo, Elizabeth A. PlatzSiobhan Sutcliffe, Jianfeng Xu, Henrik Grönberg, Charles G. Drake, Yasutomo Nakai, William B. Isaacs & William G. Nelson 

48. Is prostatitis a premalignant lesion

49. Is prostatitis a premalignant lesion
BJU