Chronic Nonbacterial Prostatitis

The term prostatitis means prostate inflammation but often also implies infection (infectious causes are discussed later). However, prostatitis encompasses many different clinical entities (Table 40-7). Chronic nonbacterial prostatitis, also

Table 40-6 Serum Creatinine Levels and Chronic Kidney Disease*

Serum Creatinine (mg/dL) MDRD Study Equation

European American

African American

Cockcroft-Gault Equation

Age (yr)

Men

Women

Men

Women

Men

Women

30

1.47

1.13

1.73

1.34

1.S3

1.S6

40

1.39

1.0S

1.6S

1.27

1.67

1.42

S0

1.34

1.03

1.SS

1.22

1.S0

1.2S

60

1.30

1.00

1.S3

1.1S

1.33

1.13

70

1.26

0.97

1.49

1.1S

1.17

0.99

S0

1.23

0.9S

1.46

1.12

1.00

0.SS

Modified from Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern

Med 2003;139:137-147, E148-E149.

*These values correspond to a GFR of 60 mL/min/1.73 m2.

MDRD, Modification of diet in renal disease.

Table 40-7 NIH and NIDDK Classification System for Prostatitis

Category

Name

Defining Characteristics

I

Acute bacterial prostatitis

Acute prostate infection

II

Chronic bacterial prostatitis

Recurrent prostate infection

IIIa

Chronic nonbacterial prostatitis—inflammatory chronic pelvic pain syndrome

No infection; white cells evident in semen, prostatic secretions, or postprostate massage voided urine

IIIb

Chronic nonbacterial prostatitis—noninflammatory chronic pelvic pain syndrome

No infection; no white cells in semen, prostatic secretions, or postprostate massage voided urine

IV

Asymptomatic inflammatory prostatitis

No subjective symptoms; white cells in prostatic secretions or prostate tissue

From McNaughton-Collins M, Joyce GF, Wise M, Pontari MA. Prostatitis. In Litwin MS, Saigal CS (eds). Urologie Diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Washington, DC, US Government Printing Office, 2007; NIH Pub No 07-5512, p 13.

Table 40-7 NIH and NIDDK Classification System for Prostatitis known as chronic pelvic pain syndrome, is poorly understood and better classified as a functional urinary tract disorder. Patients with chronic nonbacterial prostatitis can experience genital, ejaculatory, perineal, back, pelvic, or rectal pain; irritative voiding symptoms; and sexual dysfunction. Unlike those with category II prostatitis, however, patients with nonbacterial prostatitis do not experience recurrent UTIs (Stevermer and Easley, 2000). Physical examination may be normal or reveal a tender prostate.

Chronic nonbacterial prostatitis negatively affects quality of life and is associated with depression, anxiety, and soma-tization (McNaughton-Collins, 2003). A potentially helpful clinical tool is the validate National Institutes of Health (NIH) Chronic Prostatitis Symptom Index, which can help define a patient's symptoms (McNaughton-Collins et al., 2007). Treatment is problematic because the underlying pathogenesis is uncertain and the evidence base poor. Alpha-adrenergic blockers reduce pain and improve quality of life (Erickson et al., 2008). There is not enough evidence to recommend routine antibiotic use (McNaughton-Collins et al., 2001). Patients with NIH category IIIa prostatitis can receive a trial of a fluoroquinolone antibiotic for 2 to 4 weeks or a prolonged course (4-6 weeks total) if they benefit. However, antibiotics in categories IIIb and IV prostatitis appear ineffective (Erickson et al., 2008; Wagenlehner and Naber, 2003). Allopurinol, 5a-reductase inhibitors, anti-inflammatory drugs, biofeedback, pentosan (Elmiron), prostate massage, thermotherapy and sitz baths are alternatives of uncertain effectiveness (McNaughton-Collins and Wilt, 2002). As in other somatic syndromes, patients benefit from a supportive physician relationship focused on quality of life rather than cure.

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