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Active Bacterial Infection

Despite numerous highly sensitive studies, the evidence remains contradictory and weak

From the 2001 American Urological Association Meeting:

"Bacterial infection explains 5 to 10% of cases. 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 (perhaps because prostatic stones act as reservoirs of infection, or because of a fleshy structural abnormality).

"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, we seldom found chronic bacterial prostatitis. It is truly a rare disease. Most of those were E-coli. Found Klebsiella and proteal species. In these patients, we try to eliminate bacteria and then eliminate inflammation. In successfully treated patients, ph decreased, but in treatment failures, ph remained high. Antibiotic therapy gives patient new hope and they feel better. But there is questionable symptomatic response."
Dr. Weidner (Professor of Medicine, Department of Urology, University of Giessen, Giessen, Germany)

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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 recent 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 plain inflammation from any cause produces pus cells, so it is untrue to say that pus cells, in any quantity, denote infection.

To put it very simply, the prostate has parenchyma (the epithelial lining) - referred to as "epithelium" in the picture above - 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. No one has reported being cured by this protocol in the last decade, according to internet reports.

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 Curtis Nickel*, Kingston Ontario, Canada; Richard B Alexander, Baltimore, MD; Anthony J Schaeffer, Chicago, IL; J Richard Landis, Jill Knauss, Kathleen J Propert, Cpcrn Study Group, Philadelphia, PA

Introduction and Objectives: To determine if leukocyte counts and localization rates for bacterial cultures of segmented urine samples (VB1, VB2, VB3), expressed prostatic secretion (EPS) and semen are different in men diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CPPS) compared to men without urinary symptoms ("controls").

Methods: Men (n=463) enrolled in the NIH Chronic Prostatitis Cohort (CPC) Study and age-matched men without urinary symptoms (n=121) had leukocyte counts performed and 5-day bacterial cultures on specimens obtained from a standard 4 glass test (VB1, VB2, EPS, VB3) and semen. All analyses are adjusted for clinical center using generalized Mantel-Haenszel methods.

Results: The frequency of leukocytes by various cutpoints (1+ = 1 or more leukocytes in specimen etc) and bacterial culture localization in segmented urine specimens, EPS and semen are shown in the table below as are selected composite criteria for classification of Category IIIA.

Conclusions: Men with CPPS have statistically higher leukocyte counts in all segmented urine samples and EPS, but not in semen, compared to controls. However, the clinical significance of these elevated leukocyte counts requires further investigation, particularly because of the high prevalences among the controls. There is no difference in rates of localization of cultures for men with CPPS compared to control men.


Meanwhile, at some centers the search for a cryptic (unculturable) bacterium continues ...