Download Role of Urodynamics

Use of Antibiotics in Chronic Prostatitis
Syndromes
Daniel Shoskes MD, MSc, FRCS(C)
Cleveland Clinic Florida
Epidemiology of Chronic Prostatitis
• Estimated prevalence 8-14%
– Mehik A et al BJU Int 2000; 86 (4): 443
• Up to 50% of men treated for symptoms of
prostatitis at least once in life
• Sickness impact equivalent to MI, Crohn's or
angina
– Wenninger K et al J Urol 1996; 155 (3): 965.
• Mental QOL impact equivalent to severe
diabetes
NIH Classification of Prostatitis
• Category I
– Acute Bacterial Prostatitis
• Category II
– Chronic Bacterial Prostatitis
• Category III
– Chronic Pelvic Pain Syndrome
• Category IV
– Asymptomatic Inflammation
Category II Prostatitis
• No controversy
– recurrent UTI, uropathogen, EPS positive between
attacks
• Some controversy
– no UTI, uropathogen localized to EPS
• Much controversy
– non-uropathogen localized to EPS
– role of Staph, Strep, anaerobes, yeast, biofilm
Culture of EPS and Semen
• 202 patients in NIH study had 4 glass test + semen,
cultured for 2 and 5 days
• Significant proportion of cultures negative at 2 days
were positive at 5 days (2-/5+)
– VB1 14.6%, VB2 6.9%, EPS 23.3%, VB3 9.3% and semen
20%
– Strep and Corynebacteria found in all samples
– Staph and E. coli ONLY EPS, VB3 and Semen
– 3 of 7 positive E. coli cultures in study were 2-/5+
– 63% of EPS and 52% of semen 2-/5+ were absent in VB1 or
VB2
Antibiotic Selection in Prostatitis
• high pKa, lipid soluble
• primary concern for gram -ve, enterococcus
• secondary concern for gram +ve, chlamydia,
anaerobes
• quinolones, macrolides, tetracyclines,
sulphas
• nitrofurantoin does NOT penetrate prostate
Cipro for E. coli Chronic Prostatitis
• 40 men, Cipro for 4 weeks
• EPS sterilized in:
– 92% at 3 months
– 70% at 12 months
– 80% at 24 months
• failures not associated with calculi
• no symptom outcome measure
• Weidner et al,Drugs 58:103, 1999
Adjuvants to Antibiotics in Category II
Prostatitis
• Combination with alpha blockers
– Barbalias GA et al J Urol 1998; 159 (3): 883.
• Combination with prostatic massage
– Shoskes DA, Zeitlin SI. Prostate Cancer and Prostate
Diseases 1999; 2 (3): 159
• Long term-low dose suppressive therapy
Quinolones: New vs Old
• moxifloxacin (Avelox),
gatifloxacin (Tequin)
• superior for:
–
–
–
–
Gram positive
enterococcus
anaerobes
possibly chlamydia,
mycoplasma
• ciprofloxacin (Cipro),
ofloxacin (Floxin)
• superior for:
- E. coli
- Proteus
- Pseudomonas
Antibiotics for CPPS
• Most common therapy for chronic
prostatitis despite no randomized, placebo
controlled studies
• Belief that all prostatitis is due to infection
– difficult to culture bacteria
– biofilm
16S rRNA in CPPS
• Krieger (1996) - signal seen in 77% of biopsies from
men with CPPS
• Keay (1999) - signal seen in 88% of biopsies from
men with CaP
• Hochreiter (2000) - 0/28 cadaveric organ donors had
bacterial signal
• Tanner (1999) - signal seen in 65% of EPS samples
from men with CPPS
– Predominance of Corynebacterial forms including newly
discovered bacteria
Role of Antibiotics in CP/CPPS
• Multicenter study of 102 patients with
prostatitis (II, IIIa and IIIb)
• Recent UTI excluded
• 12 weeks of ofloxacin
• regardless of category, 57% felt moderate to
marked improvement
• no difference in response by category,
antibody status or WBC count
• No help if no improvement by 4 weeks
Why Might Antibiotics Help CPPS?
• All prostatitis is bacterial
– why most patients fail?
– why no improvement after RP
– why immunosuppression helps?
• Antibiotics have direct anti-inflammatory effects
– quinolones, macrolides and tetracyclines block IL-6 and IL-8
• Intracellular pathogens not detected
– chlamydia, E. coli
• Placebo effect
Conclusions
• Antibiotics have definite role for category II
chronic prostatitis
• Many patients with category III will respond
but mechanism unclear
• Compelling evidence that some with nonuropathogens have infection but many don't
• Bacteriologic cure not equivalent to cure
• Prospective randomized placebo controlled
trial should help settle in 2002
CCF Diagnostic Protocol
• Off antibiotics for at least 2 weeks
• History, Physical, NIH-CPSI
• Uroflow, ultrasound bladder residual
• Urethral swab, EPS +/- semen
• Bacterial cultures for 5 days
• Post ejaculatory pain or recurrent category II ->
TRUS
• Cysto for hematuria or suspected stricture
• Hydrodistension if suspect IC
CCF Treatment Protocol
• Category II
– antibiotics +/- massage +/- tamsulosin
• Category III
– antibiotics +/- massage
– antifungal if hyphae or prolonged Ab
– tamsulosin for voiding symptoms
– Prosta-Q 2-3x per day for 1 month
– empiric Proscar or Elmiron
– physiotherapy, Elavil, Neurontin, Zanaflex