Is CPPS a result of an active bacterial infection?

Despite numerous highly sensitive studies, the evidence remains weak

If you surf the internet, you will come across several prominent, official-looking websites that state that the cause of chronic prostatitis/CPPS is bacterial infection. See the webmaster’s blog post about this. But there is almost no solid evidence for believing that bacteria are involved. In fact, it merely serves to confuse men and prolong their suffering.

Here are some quotes that give the game away. From the 2001 American Urological Association Meeting:

“Bacterial infection explains 5 to 10% of cases [of chronic prostatitis]. Therefore we cannot provide an etiology to 90 to 95% of symptomatic men. An enormous body of literature has failed to convincingly demonstrate that a fastidious organism is responsible for CP/ CPPS.”

Everyone agrees that about 5% of men with chronic prostatitis have frank, culturable bacterial infections (usually because in some men prostatic stones act as reservoirs of infection, or more commonly because a fleshy structural abnormality in the prostatic urethra causes urinary turbulence and/or a reservoir for bacteria).

“In our work we have found that chronic bacterial prostatitis is not very common, and when we do find it, there are usually no symptoms unless there is also bladder infection. The most troublesome problem is actually recurrent cystitis.”
Dr Schaeffer (Professor and Chairman, Department of Urology, Northwestern University Medical School, Chicago)

“In studies of 656 men [with pelvic pain suggestive of chronic prostatitis], we seldom found chronic bacterial prostatitis. It is truly a rare disease.”
Dr. Weidner (Professor of Medicine, Department of Urology, University of Giessen, Giessen, Germany)

But do bacteria also cause nonbacterial prostatitis (CPPS) and other chronic painful inflammatory conditions of the bladder, prostate, epididymis and testes? Many sufferers believe intuitively that they are infected. After all, sex, guilt, pain, and infection are all associated in our psyche. But is there a scientific basis for this belief?

The latest information suggests that bacteria are not important players in chronic prostatitis/CPPS. A 2003 study found no difference in colonization rates between patients and controls. Read it here. Yet another 2003 study found bacteria to be unimportant, read it here.

In a careful 1999 study, Dr Shoskes et al found that the bacteria everyone expect to cause prostatitis were usually absent from CP/CPPS sufferers. On the other hand an unusual species was found with great regularity, yet it is not thought to be the cause of the condition.

Studies using extremely sensitive PCR techniques have found almost 30% of normal, symptom-free men have bacteria living harmlessly in their prostates, while more than half of CP/CPPS patients don’t. Yet some people still urge patients to insist on 7-day cultures! But do these cultures really help? A Texan urologist recently wrote:

In 2 years of 7 day “hold” EPS cultures in perhaps 300 men, I never came up with a single uropathogen in a private practice setting. I found the test to be 1) Unnecessary 2) Expensive 3) Misleading 4) Unhelpful. It didn’t change therapy, cost a lot, gave a lot of “false positives” for normal flora, and didn’t change the treatment offered or outcome in my experience. I don’t use it now. I’m not saying it shouldn’t be done in research or academic settings, but it’s not useful in the private practice setting that I live in.

Many people cite the presence of pus cells (or white blood cells – WBCs) in the expressed prostatic secretions (EPS) or urine as proof of an infection. But simple inflammation from any cause produces pus cells, so it is untrue to say that pus cells, in any quantity, denote infection.

prostate stroma

To put it very simply, the prostate has parenchyma (the epithelial lining) – referred to as “epithelium” in the picture adjacent – and stroma: this is the connective tissue meshwork that supports the epithelium where the blood and lymphatic vessels are. The Krieger and True histopathology study showed that most of the WBCs they found are not in the epithelium but rather in the stroma. So, the main processes related to pain perception are concentrated in the stroma where nerve endings are.

With more and more scientific evidence gathering against them, the supporters of the bacterial infection theory are dwindling. Their credo is exemplified by the so-called Manila Protocol (now defunct), wherein patients are treated with numerous antibiotics while undergoing daily prostate massage. No one has reported being cured by this protocol since the mid-1990s, when there was an initial surge of enthusiasm for the protocol after it was promoted by the “Prostatitis Foundation”, a US-based organisation run by an octogenarian cattle farmer. (This topic is exhaustively discussed at our forum). Futhermore, a 2006 study found no difference in outcomes between men treated with antibiotics alone, or with antibiotics combined with prostate massage.

Discussing the need for evidence-based medical treatment for prostatitis syndromes, Dr. Mary McNaughton-Collins made clear in her presentation to the 3rd international prostatitis meeting sponsored by NIH in October 2000, that prescribing antibiotics for CPPS is “unfounded hogwash without any basis.”

It’s time to look elsewhere.

Any Need for Cultures?

This new research convincingly demonstrates that a positive localizing culture is an unimportant finding, as prostate “infections” are just as common in asymptomatic controls as they are in CPPS patients.

J Urol. 2003 Sep;170(3):818-22.
Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls

Conclusions: … There is no difference in rates of localization of cultures [rates of infection] for men with CPPS compared to control [normal] men.