Editorial: Emerging Concepts in the Management of Prostatitis/Chronic Pelvic Pain Syndrome
Anthony J. Schaeffer Department of Urology Northwestern University Medical School Chicago, Illinois
The etiology of the chronic pelvic pain syndrome remains an enigma. Traditional thinking implicates the prostate as a primary source of the discomfort and bacteria and/or inflammatory cells as the cause of prostate malfunction. To this end, a lot of time and effort have been spent using traditional culture and more sophisticated polymerase chain reaction techniques to identify putative bacterial pathogens that could infect the prostate and lead to the development of the chronic pelvic pain syndrome. Previous studies using sophisticated polymerase chain reaction technology have failed to identify evidence of bacteria in prostatic tissue obtained from young, presumably healthy cadaver specimens. Traditional techniques to identify bacteria in the prostate are based on localization studies that identify bacteria in prostatic fluid and/or post-prostatic massage voided urine. Obviously, contamination of these specimens from urethral organisms is a common concern and the significance of low numbers of bacteria in expressed prostatic secretions is questionable.
To avoid this problem, Lee et al (2003) performed transperineal tissue biopsies of the prostate. Contamination of the skin was negligible. Using aggressive culture techniques, they identified low numbers of nonpathogenic bacteria in about 30% of the patients and controls. Older men were more likely to have positive cultures, as were those with inflammation in the prostatic fluid. None of the counts was high enough and/or associated with recognized pathogenic bacteria and, therefore, these bacteria are probably colonizing bacteria rather than infecting strains. Since the patients in these studies were older, it is likely that in time urethral bacteria colonized the prostatic ducts. However, these bacteria apparently do not lead to a host response and, particularly, there is no evidence that they are associated with symptoms.
It is well recognized that even if pathogenic bacteria are present in the prostate, as in men with established chronic bacterial prostatitis, they do not cause chronic pelvic pain unless acute urinary tract infection develops. Taken together, these data suggest that bacteria do not have a significant role in the development of the chronic pelvic pain syndrome. The clinical observation that antimicrobial therapy reduces symptomatology in men with chronic pelvic pain syndrome is being tested in a double-blinded NIH controlled study.
Since antimicrobials may have anti-inflammatory activity, it is possible that these drugs may benefit the patient by reducing inflammation rather than eradicating bacteria.