Prostatitis cpps and anxiety triggers and truth
The laboratory diagnosis of acute bacterial prostatitis is straightforward and easily accomplished in clinical laboratories. Chronic bacterial prostatitis, and especially chronic idiopathic prostatitis most often referred to as ASD Fraktion 2 von Prostatitis prostatitispresents a real challenge to the clinician and clinical microbiologist.
Despite these diagnostic criteria, the etiology of chronic idiopathic prostatitis is unknown. While this review covers the entire spectrum of microbially caused acute prostatitis including common and uncommon bacteria, viruses, fungi, and parasites and microbially associated chronic prostatitis, a special focus has been given to chronic idiopathic prostatitis. The idiopathic syndrome is commonly diagnosed in men but is poorly treated.
Recent data convincingly suggests a possible bacterial etiology for the condition. Provocative molecular studies have been published reporting the presence of 16S rRNA bacterial sequences in prostate biopsy tissue that is negative for ordinary bacteria by routine culture in men with chronic idiopathic prostatitis.
Additionally, special culture methods have indicated that difficult-to-culture coryneforms and coagulase-negative staphylococci are present in expressed prostatic secretions found to be negative by routine culture techniques. Treatment failures are not uncommon ASD Fraktion 2 von Prostatitis chronic prostatitis. Literature reports suggest that antimicrobial treatment failures in chronic idiopathic prostatitis caused by organisms producing extracellular slime might result from the virulent properties of coagulase-negative staphylococci or other bacteria.
While it is difficult to definitively extrapolate from animal models, antibiotic pharmokinetic studies with a murine model have suggested that treatment failures in chronic prostatitis are probably a result of the local microenvironment surrounding the persistent focal and well-protected small bacterial biofilms buried within the prostate gland.
These conclusions support the molecular and culture data implicating bacteria as a cause of chronic idiopathic prostatitis. Prostatitis is a common urologic condition that many clinicians find difficult to treat effectively.
It has been estimated that up to half of all men suffer from symptoms of prostatitis at some time in their lives Culture diagnosis of acute bacterial prostatitis is straightforward and easily accomplished in the laboratory. On the other hand, the microbiologic diagnosis of chronic prostatitis and chronic idiopathic nonbacterial prostatitis more commonly referred to ASD Fraktion 2 von Prostatitis prostatodynia represents a particular challenge. Chronic idiopathic prostatitis, when diagnosed clinically, has a poor record of treatment success.
A large study of prostatitis patients indicated that nearly one-third were diagnosed with prostatodynia, which is a significant fraction of the ASD Fraktion 2 von Prostatitis population The recent literature suggests that the condition referred to as chronic idiopathic nonbacterial prostatitis may actually have an infectious etiology 183238 Some patients relate the onset of their symptoms to sexual activity—sometimes associated with acute urethritis 7 —while others have indicated no relationship with sexual activity.
The use of antimicrobial therapy may or may not elicit transient relief of symptoms. A number of organisms have been reported to possibly cause this syndrome: Trichomonas vaginalis 2534 — 36Chlamydia trachomatis 1891267genital mycoplasmas 1073staphylococci 3853coryneforms 1860and genital viruses 4 These data are controversial, since other researchers have either failed in their attempts to demonstrate the presence of these microorganisms in clinical specimens or have found them in only rare circumstances 617 The major difficulty in interpreting these microbiologic findings is the presence of contaminating, indigenous microbiota.
Specimens such as voided urine, urethral swabs, and expressed prostatic secretions EPSused to evaluate a patient with suggestive symptoms, become contaminated with organisms colonizing the distally contaminated urethra. Although the ideal specimen would be uncontaminated prostatic tissue, there are few reports of this in the literature. The microbiological workup of these specimens is further complicated by the presence of inhibitory substances known to exist in the prostatic secretions 21 and the history of multiple previous courses of antibiotics When first recognized as causing disease, bacteria were seen to be relatively stable vegetative cells that grew and expressed toxic by-products in vitro.
These organisms tended to be quite virulent, and so associating them with particular diseases ASD Fraktion 2 von Prostatitis straightforward. Since then, technologic developments have revealed a spectrum of microbial agents, including viruses, fungi, and protozoa, with each group being diverse and continually changing. The interaction of these organisms within the host can lead to the enhancement or depression of their individual properties CWDB, production of extracellular slime, biofilms.
Clinical expression, i. Clinical microbiologists and treating physicians who face this tangled scenario when confronted with patients suffering from chronic idiopathic prostatitis must objectively quantitate and define the process that has led to the illness. Because cryptic organisms, whether intra- or extracellular, are ubiquitous, proving their role in disease requires more than the mere demonstration of their presence.
The concept of normal microbiota is a statistical one that is derived from the immunocompetence of most of the population. This precept is particularly relevant for patients with chronic idiopathic prostatitis. Bacteriologic advances, which include the use of specialized culture media and stains, electron microscopy, and PCR for amplifying microbial sequences in tissues and body fluids, have revealed an increasing number of previously unidentifiable organisms in a variety of pathologic conditions 1958 The present trend toward ASD Fraktion 2 von Prostatitis sequence-based identification of difficult-to-culture and nonculturable organisms in chronic idiopathic prostatitis will ultimately achieve this end.
Bacterial infection of the prostate gland may occur as a result of ascending urethral infection or by reflux of infected urine into prostatic ducts emptying into the posterior urethra. Other possible routes of infection include invasion of rectal bacteria through direct extension or by lymphogenous or hematogenous spread There is an association between bacterial prostatitis and urinary tract infection UTIincluding host responses that result in excessive numbers of polymorphonuclear leukocytes and macrophages in the prostatic secretions.
It has been demonstrated that positive cultures segmented cultures [see Specimen Collection and Bacteriologic Culture, below] can localize the etiologic agent s to the prostatic secretions. When the patient has acute bacterial prostatitis, ASD Fraktion 2 von Prostatitis is an abrupt onset of fever and genitourinary ASD Fraktion 2 von Prostatitis constitutional signs and symptoms. Chronic bacterial prostatitis is a more subtle illness, which is characterized by relapsing, recurrent UTI and persistence of bacteria in the prostatic secretory system despite multiple courses of antibacterial therapy A third syndrome, chronic idiopathic prostatitis sometimes called abacterial prostatitis or nonbacterial prostatitis ASD Fraktion 2 von Prostatitis prostatodynia may or may not be associated with excessive numbers of inflammatory cells in the prostatic secretions and with lack of culturally documented bacteriuria.
The prostatic secretions from many patients appear normal. In a study by Brunner et al. The recent literature suggests that there is no clear reason to distinguish prostatodynia from nonbacterial prostatitis since subjects with prostatodynia may at times have excessive numbers of leukocytes in their expressed prostatic secretions, demonstrate negative routine bacterial urine cultures, and undergo similar ASD Fraktion 2 von Prostatitis for both conditions.
During the past few years, molecular data and cultures performed with special media discussed below strongly suggested that chronic idiopathic prostatitis may actually be a cryptic bacterial infection of the prostate gland that is usually missed or undetected by ASD Fraktion 2 von Prostatitis conventional cultures in clinical microbiology laboratories.
The definitions of abacterial prostatitis or nonbacterial prostatitis and prostatodynia are still controversial. For the purposes of this review, these conditions will be grouped into one and referred to as chronic idiopathic prostatitis. Additionally, our primary focus will be on recent findings s rather than on the historical literature about prostatitis.
Quantitative bacteriologic cultures confirm the diagnosis of bacterial prostatitis when the infectious agent s is localized to the prostate gland i. The technique for obtaining segmented cultures of the male lower urinary tract was first described in by Meares and Stamey The sampling conditions require a sufficiently full bladder, and the samples must be collected by using rigorous aseptic techniques.
The first step ASD Fraktion 2 von Prostatitis the examination must not be preceded by urethral swabbing. All urine samples must have a well-defined volume. Prostatic secretions are obtained by a systematic massage of each lobe of the prostate gland.
Bacterial prostatitis is confirmed by the presence of bacteria in the prostatic secretions and in the VB 3 voided bladder postprostatic massage urine sample in numbers greatly exceeding the bacterial counts of the VB 1 and VB 2 urine specimens. The traditional criterion for diagnosing chronic bacterial prostatitis is a fold increase in the concentration of culturable microorganisms when the bacterial count of the postmassage urine sample or expressed prostatic secretion sample is compared with that of the first-void VB 1 urine sample 43 The segmented-culture technique is not widely ASD Fraktion 2 von Prostatitis in primary care settings, and even most urologists appear to have abandoned the procedure because of its labor intensity and overall costs.
InNickel 46 proposed a simple and cost-effective screen for prostatitis which involves the culture and microscopic examination of urine before and after prostatic massage. This pre- and postmassage test PPMT was applied to a series of 53 patients as well as 59 patients for whom segmented-culture results were available from the literature. In these selected populations, the PPMT alone led to the same diagnosis in ASD Fraktion 2 von Prostatitis Based on these findings, this method warrants further investigation and may motivate researchers to review their prostatitis data and stimulate discussion.
Importantly, physicians ASD Fraktion 2 von Prostatitis then be convinced to adopt a simpler diagnostic plan for prostatitis because it is far more efficient in terms of diagnosing the disease than is doing no work-up of the patient for localization of infection. Most of the urinary pathogens ASD Fraktion 2 von Prostatitis also the causative agents of acute and chronic prostatitis. Escherichia coli predominates as a cause ASD Fraktion 2 von Prostatitis culturable prostatitis. Other members of the Enterobacteriaceaesuch as KlebsiellaEnterobacteriaProteusand Serratiacan be isolated from patients with acute and chronic prostatitis, as can the pseudomonads and less common gram-negative bacteria.
Obligate anaerobes have rarely been implicated as a cause of prostatitis. Gram-positive bacteria, particularly the cocci, remain controversial as possible etiologic agents. Recently, coagulase-negative staphylococcal species and coryneforms have been found in segmented ASD Fraktion 2 von Prostatitis including prostatic secretions and are postulated to play a role in chronic idiopathic prostatitis 38 It ASD Fraktion 2 von Prostatitis generally agreed that Enterococcus faecalis can cause chronic bacterial prostatitis and related recurrent enterococcal bacteriuria.
Although many published reports have indicated that gram-positive bacteria other than enterococci rarely cause bacterial prostatitis 43emerging molecular data and special culture results suggest that these organisms and other less well known bacteria may well be true pathogens in the poorly understood condition referred to as chronic idiopathic prostatitis 18323853 Since the infectious etiology of acute and chronic recurrent prostatitis in which a single or multiple bacterial isolates can be clearly identified is well understood and accepted, this review ASD Fraktion 2 von Prostatitis focus on the microbiology of the more controversial syndrome of chronic idiopathic prostatitis.
Clinically, this condition frustrates the patient and physician due to its chronicity and resistance to therapy. The syndrome is usually characterized by persistent perineal pain and by functional and somatic urologic complaints, including abnormal urine flow, frequency, urgency, and dysuria. The diagnosis of chronic idiopathic prostatitis is differentiated from that of acute prostatitis by a lack of prostatic inflammation with no significant leukocytes or bacteria in the expressed secretions, and the patients are not acutely ill.
Recent studies suggest that ASD Fraktion 2 von Prostatitis etiology of chronic idiopathic prostatitis may be of bacterial origin 18 Three types of provocative data have demonstrated the presence of bacteria in prostatic specimens tissue and secretions that were negative by traditional clinical microbiologic tests: i bacterial gene sequences encoding 16S rRNA and tetracycline resistance tetM-tetO-tetS were present in prostatic tissue 32 ; ii culture findings indicated that coagulase-negative staphylococci were the most common isolates in patients with prostatodynia chronic idiopathic prostatitis 3853 ; and iii culture of difficult-to-grow coryneforms in EPS and direct microscopic observation of these pleomorphic bacteria in EPS thought to be negative by routine culture were reported 18 In a provocative study by Krieger et al.
These individuals had no evidence of structural or functional lower genitourinary tract abnormalities, bacterial prostatitis by traditional clinical tests, or urethritis or urethral pathogens by bacteriologic culture.
Multiple bacterial sources of 16S rRNA were observed in individual patients based on direct sequencing and repetitive cloning. In a case-control design, it is impossible to conclusively determine the cause and effect; however, these data suggest that the prostate harbors bacteria that are not detectable by conventional microbiologic culture. These molecular studies are particularly significant because tissue specimens from prostate biopsies were obtained from a population of men who could not be diagnosed by optimal clinical and microbiologic methods.
Therefore, potential study subjects were excluded, unlike in earlier studies 148 — 1012162225333536425373 if they exhibited bacteriuria, bacterial prostatitis, or urethritis or if they had a urethral culture that was positive for urogenital pathogens.
The most convincing finding is the strong correlation between inflammation in the EPS and detection of bacterial gene sequences in prostatic tissue. It is unlikely that the demonstrated molecular evidence represents contamination because of the extreme care reported to have been taken in procuring and handling the clinical samples, including the use of a double-needle biopsy method ASD Fraktion 2 von Prostatitis limit skin contamination and positive and negative controls incorporated in the ASD Fraktion 2 von Prostatitis experiments as well as an internal housekeeping gene control.
It will be important to classify the sequences at the bacterial genus and species level, since this has not yet been accomplished for the amplified bacterial nucleic acids derived from prostate tissue. Identification, cloning, and sequencing of prokaryotic DNA in prostatic tissue may help elucidate the etiologic agents of chronic prostatitis syndromes.
In a study from our laboratory, Lowentritt et al. This research evaluated segmented cultures of urine and EPS from 22 patients and 16 controls.
The most commonly isolated organism, Staphylococcus epidermidishas also been implicated by Nickel and Costerton 53 and Wedren et al. Another coagulase-negative Staphylococcus species isolated in this study, Staphylococcus haemolyticuswas reported by Gunn and Davis 26 and Sanchis-Bayarri et al. It has been postulated that these coagulase-negative staphylococci probably possess virulence factors that may be operative in chronic idiopathic prostatitis Coagulase-negative staphylococci have been shown to adhere to urothelial cells 40 and cellular proteins including laminin, fibronectin, vitronectin, and collagen 55which may allow ascending infection and subsequent colonization of the prostate.
Furthermore, these bacteria produce an extracellular slime substance with antiphagocytic and antichemotactic ASD Fraktion 2 von Prostatitis that affect neutrophils as well as antiproliferative characteristics that affect lymphocytes Thus, extracellular slime ASD Fraktion 2 von Prostatitis may ASD Fraktion 2 von Prostatitis impair host defenses. Extracellular slime substance also has cytoprotective properties, which can protect bacteria from exposure to otherwise bactericidal levels of antibiotics, and hence can lead to recrudescent infections resistant to therapy