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Diagnosis and Management of
Acute and Chronic Prostatitis
Daniel A. Shoskes
Floyd Katske
Sun Kim
P
rostatitis syndromes present an interesting contrast in incidence and
understanding. Acute and
chronic bacterial prostatitis are
relatively uncommon, but wellunderstood urinary tract infections caused by established
uropathogens. They are typically
responsive to appropriate antimicrobial therapy. By contrast, the
much more common nonbacterial prostatitis and prostatodynia
syndromes remain an enigma,
both in etiology, appropriate
workup, and therapy. The roughly 2 million annual outpatient
visits for chronic prostatitis in
the United States (Collins,
Stafford, O’Leary, & Barry, 1998)
usually lead to antimicrobial
therapy without an attempt to
document the presence of prostatic infection. This results in
very low durable response rates.
Despite this, non-antimicrobial
alternatives with documented
scientific benefit are limited,
often leading to a defeatist posture by both patient and doctor.
Some patients have persistent
Daniel A. Shoskes, MD, FRCS(c), is
Director for Renal Transplant,
Cleveland Clinic Florida, Fort
Lauderdale, FL.
Floyd Katske, MD, is Assistant
Clinical Professor, Department of
Urology, UCLA School of Medicine,
Torrance, CA.
Sun Kim, MD, is a Urology Resident,
Department of Urology, UCLA School
of Medicine, Torrance, CA.
Prostatitis syndromes are some of the most poorly understood yet
prevalent problems in urology. There is little controversy over acute
prostatitis, a urinary tract infection with systemic symptoms and
signs that typically responds to antimicrobial therapy. By contrast,
the chronic prostatitis syndromes have so far eluded attempts to
understand their pathophysiology and design effective therapies,
resulting in great frustration among patients and health care
providers. An accurate diagnosis and a multidisciplinary approach
are essential to assist men with this often debilitating condition.
Objectives
This educational activity is designed for nurses and other health
care professionals who care for and educate patients regarding acute
and chronic prostatitis. The multiple choice examination that follows
is designed to test your achievement of the following educational objectives. After studying this offering, you will be able to:
1. Define acute and chronic prostatitis.
2. Discuss the diagnosis of acute and chronic prostatitis.
3. Describe the therapeutic options for treating acute and chronic prostatitis.
symptoms for years to decades,
leading to depression, job loss,
and even suicide. By objective
measures the impact of chronic
prostatitis on quality of life is
similar to that of Crohn’s disease
(Wenninger, Heiman, Rothman,
Berghuis, & Berger, 1996).
Acute Prostatitis
Acute prostatitis is an acute
systemic illness usually caused by
uropathogenic bacteria in the
prostate leading to a febrile urinary tract infection. Patients complain of a sudden onset of fever,
chills, perineal pain, and lower
urinary tract symptoms such as
frequency, urgency, dysuria, nocturia, and even urinary retention.
Physical examination may reveal
UROLOGIC NURSING / August 2001 / Volume 21 Number 4
suprapubic tenderness and an
extremely tender prostate. It is
important to avoid vigorous palpation or intentional prostatic
massage in patients with presumed acute prostatitis, as it may
provoke bacteremia and septic
shock. Urinalysis usually reveals
elevated WBC and RBC counts
and urine culture will be representative of intra-prostatic organisms.
Blood analysis should include a
CBC and blood cultures, but not a
PSA, which will be elevated in
most patients due to the acute
inflammation.
For patients with signs of sepsis, therapy for acute prostatitis
begins with appropriate fluid
resuscitation and systemic antibiotics, such as ampicillin and an
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aminoglycoside, targeted at gramnegative pathogens. For patients
in urinary retention, a suprapubic
catheter is preferable to a urethral
Foley catheter, which may be difficult to place and produce
intense pain. Effective empirical
choices for oral antimicrobial
therapy (until culture with sensitivities are available) include
TMP-SMX (Septra®, Bactrim®) or
a
fluoroquinolone
(Cipro®,
®
®
Floxin , Levaquin ). These medications should be continued for
30 days. In patients not immediately responsive to these therapies or with a very fluctuant
prostate, prostatic abscess should
be considered and diagnosed by
CT scan or transrectal ultrasound.
While the standard therapy for
prostatic abscess has been
drainage via transurethral resection, recent reports suggest transperineal or transrectal drainage
under guidance of transrectal
ultrasound is equally effective
and avoids a surgical procedure.
Immunocompromised patients
and diabetics are particularly at
risk for prostatic abscess caused
by atypical organisms including
gram-positive bacteria and fungi.
Once therapy is completed and
the acute prostatitis resolved,
patients should be reassessed for
risk factors such as significant
prostatic hypertrophy or inefficient voiding with high residual
urines.
Chronic Prostatitis
The chronic prostatitis syndromes are characterized by urogenital pain, often associated
with voiding symptoms and erectile dysfunction. These symptoms may be continuous, intermittent, or relapsing. Pain may
be felt in the perineum, penis,
scrotum, lower abdomen, back,
or groin. Hematuria is rare, but
hematospermia is more common.
Patients may feel relief after ejaculation, or have severe post-ejaculatory pain as their primary
symptom. Age of onset begins in
late adolescence, with a median
256
age of presentation in the mid
40s. Onset may be gradual or
sudden, but few patients give a
history of prior acute prostatitis.
History of urethral discharge or
penile lesions may indicate urethritis or other sexually transmitted disease (STD). Patients often
have a strong belief that they
have identified the instigating
cause, usually related to a sexual
encounter or significant increase
in stress. Symptoms may either
be severe, leading to immediate
medical consultation, or so mild
that the patient waits months
before seeking care.
A thorough physical examination focusing on the abdomen
and pelvis is essential, particularly to rule out other pathology that
may produce urogenital pain (for
example, inguinal hernia, varicocele). The rectal examination is
performed with the patient standing and leaning over the examining table and supporting his
weight on one elbow, a position
which aids in relaxation of the
buttock and leg muscles. At the
start of the rectal examination, the
surrounding pelvic muscles
should first be palpated to search
for painful muscle spasm. The
prostate in chronic prostatitis may
be small or enlarged, boggy or
firm, and mildly uncomfortable to
excruciatingly painful. Enlarged
seminal vesicles may be palpable
as well, particularly in small and
thin patients. Prostate massage is
accomplished with a rolling
motion of the examining finger
from lateral to medial and then
from superior to inferior. Expressed fluid is collected into a
sterile container held by the
patient under the penis. A glass
slide is touched to the penis to
collect the last drop for
microscopy.
For the past 30 years, the
classification system devised by
Meares and Stamey has been the
standard used (see Table 1).
However, this system has never
been validated or shown to differentiate patients on the basis of
prognosis or response to therapy.
Indeed, fewer than 50% of urologists or primary care physicians
surveyed even examine expressed prostatic secretions let
alone perform the entire protocol
(Moon, 1997). The classification
system is based upon the culture
and examination of first voided
urine (VB1), mid-stream urine
(VB2), expressed prostatic secretions (EPS), and post-prostatic
massage urine (VB3). Patients
with positive bacterial cultures
that localize to the EPS and/or
VB3 samples are classified as
chronic bacterial prostatitis
(CBP).
Standard teaching requires
that the cultured organisms be
established uropathogens and
that patients have recurrent urinary tract infections with these
prostatic organisms, although the
rationale for these latter requirements has never been scientifically validated. By this definition, probably fewer than 5% of
chronic prostatitis patients have
CBP.
In patients without positive
localizing cultures, further classification is based on the number
of WBCs per high-power field
(40x objective) in a wet mount of
EPS. Patients with an excessive
number of WBCs are classified as
having nonbacterial prostatitis
(NBP) and those without classified as having prostatodynia.
While many authors use 10 WBC
per hpf as their upper limit of
normal for EPS, this number has
not been firmly established.
Clearly many patients with chronic prostatitis fluctuate between
low and high WBC counts over
time (Wright, Chmiel, Grayhack,
& Schaeffer, 1994), and many
asymptomatic patients have
counts in the abnormal range.
Realizing that the full “4
glass” test is rarely performed
and seldom guides treatment, it
is still important to thoroughly
rule out infection in these
patients, at least at the initial
consultation. At a minimum
UROLOGIC NURSING / August 2001 / Volume 21 Number 4
Table 1.
Classification Systems for Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Meares-Stamey
Classification
NIH Classification
+
Acute prostatitis
Category I
Urine culture sufficient to
diagnose.
+
+ or -
Chronic bacterial
Category II
Some require recurrent UTI
with uropathogens.
No
-
+
Nonbacterial
Category IIIa
WBC elevation may be
intermittent.
No
-
-
Prostatodynia
Category IIIb
Must rule out other pelvic
pathology.
No
+ or -
+ or -
None
Category IV
Asymtomatic
EPS/VB3
Culture
Elevated WBC in
EPS or VB3?
Yes
+
No
Acute
UTI?
Comments
UTI: Urinary tract infection
EPS: Expressed prostatic secretions
VB3: Post prostatic massage urine
patients should have pre and
post prostatic massage urine
samples cultured, with a preference for EPS microscopy and culture. A urethral swab for culture
of bacteria and STDs and a
semen culture are indicated,
especially for patients with post
ejaculatory pain that may point
to an infection of the seminal
vesicles. A serum PSA is essential for men over 45 years of age
and in any man with a palpable
abnormality of prostatic contour.
It is important to realize that
inflammation and infection of
the prostate can significantly elevate serum PSA and yield a low
free:total PSA ratio (unlike the
high ratio found more commonly
in BPH). Men with elevated
screening PSA values who admit
to symptoms of prostatitis are
often best served by repeating the
test after a course of antibiotics,
which may return the PSA to a
normal level, avoiding an unnecessary biopsy.
Cystoscopy is seldom necessary, and should only be used if
other pathology such as urethral
stricture or carcinoma in situ is
strongly suspected. Men with
significant voiding dysfunction
should undergo urodynamics to
rule out bladder/bladder neck
pathology. Finally, in men with
chronic bacterial prostatitis and
those with symptoms suggesting
seminal vesicle or testicular
involvement, a transrectal ultrasound can demonstrate central
prostatic stones or evidence of
ejaculatory duct obstruction.
A recent NIH consensus conference was held on the subject of
chronic
prostatitis
(Nickel,
Nyberg, & Hennenfent, 1999) and
a new classification system proposed (see Table 1). Acute prostatitis is replaced by category I,
chronic bacterial prostatitis
replaced by category II, nonbacterial prostatitis replaced by category IIIa, and prostatodynia replaced by category IIIb. Category
III patients collectively are now
referred to as having chronic
pelvic pain syndrome (CPPS), a
change that reflects the predominance of pain in these patients
and the uncertainty of the role of
the prostate in producing the
symptoms. A new category IV
designates asymptomatic patients
who have evidence for prostatic
inflammation, either in the EPS or
in prostate tissue biopsies.
UROLOGIC NURSING / August 2001 / Volume 21 Number 4
Management
The mainstay of therapy for
men with category II (chronic
bacterial) prostatitis is antibiotics, using agents with high penetration into the prostatic fluid as
well as a spectrum of activity to
include the most common organisms. Features that allow prostatic penetration include lipid solubility and a high pKa. Commonly
used agents that fulfill these criteria include the sulfas (for
example, Septra), the fluroquinolones (for example, Cipro,
Levaquin), the erythromycins (for
example, Zithromax®, Biaxin®),
and the tetracyclines (for example, Minocin®). Therapy is commonly continued for at least 6
weeks and the patient then recultured. Some men, particularly
those with enlarged boggy prostates with large volumes of EPS,
may benefit from regular prostatic
massage combined with the
antibiotics (Nickel, Alexander et
al., 1999).
In patients with relapsing
infections, a transrectal ultrasound may reveal prostatic calcification. While diffuse calcification along the surgical capsule of
the prostate is a common finding
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Table 2.
Therapeutic Options in Nonbacterial Prostatitis
(NIH Category IIIa)
First Line
❏ Empiric antibiotic therapy (quinolone, erythromycin, or tetracycline
class)
❏ Prostatic massage +/- antibiotic therapy
❏ Alpha blocker (for example, tamsulosin) +/- antibiotic therapy
❏ Bioflavonoid phytotherapy (for example, quercetin, Prosta-Q®)
❏ Finasteride
❏ Supportive measures (see Table 4)
Second Line (anecdotal data)
❏ Intraprostatic injection of antibiotics
❏ Allopurinol
❏ Antifungal therapy and diet modifications
❏ Cytoreductive prostatic therapy (for example, transurethral
microwave therapy)
Table 3.
Therapeutic Options in Prostatodynia
(NIH Category IIIb)
❏
❏
❏
❏
❏
Pelvic muscle physiotherapy
Bioflavonoid phytotherapy (for example, quercetin, Prosta-Q®)
Alpha blocker (for example, tamsulosin)
Neuromuscular pain agents (for example, gabapentin, tricyclic antidepressants)
Very important to rule out other causes of pain unrelated to prostate
(for example, hernia, interstitial cystitis, urinary tract stone)
in men with and without prostatitis and requires no therapy,
larger stones located more centrally could represent a bacterial
focus and these patients may
benefit from transurethral resection of these stones. For men
without an anatomic focus who
recur despite antibiotics with or
without
prostatic
massage,
longer courses of suppressive
antibiotics may be necessary. For
men on prolonged antibiotic
therapy, it is important to be vigilant for complications that can
occur with each class of agents
and monitor for their occurrence
(for example, tendon inflammation with quinolones, photosensitivity with tetracyclines).
It is patients with CPPS (cat-
258
egory IIIa and IIIb; nonbacterial
prostatitis and prostatodynia)
who remain the true therapeutic
challenge (see Tables 2 & 3).
Suggested etiologies for these
disorders include occult infection, neurogenic bladder, an
autoimmune or other inflammatory reaction, neuromuscular
pelvic muscle spasm, or sterile
urinary reflux into the prostate.
Due to the similarities in symptoms with bacterial prostatitis, an
occult infection with difficult-toculture or entrapped microorganisms has been suspected.
The evidence for involvement of Mycoplasma, Ureaplasma, and Chlamydia is inconclusive; nevertheless most urologists will treat category IIIa
patients with a trial of an erythromycin or tetracycline to rule
out the possibility. Careful cultures of EPS will often show
growth of gram-positive organisms such as Staphyloccocus epidermidis or Corynebacterium.
Transperineal biopsies will often
grow bacteria not found by other
means (Berger, Krieger, Rothman,
Muller, & Hillier, 1997). It may be
that these bacteria escape detection and conventional treatment
because they are protected within biofilms in the prostatic tissue
(Nickel, Costerton, McLean, &
Olson, 1994).
Ribosomal RNA techniques
(16S), used to detect bacterial signal in the prostatic fluid of men
with negative cultures, demonstrated that the presence of bacterial signal by this technique predicted response to empiric
antibiotic
therapy
(Tanner,
Shoskes, Shahed, & Pace, 1999).
We have identified novel bacterial sequences which map closest
to the Corynebacteria which we
have not found in any control or
BPH patients. While it is not yet
possible to identify which bacteria present in an EPS sample are
acting as true pathogens and
which may be commensals or
contaminants, it is our philosophy to first treat and eradicate
these bacteria and assess the
impact on symptoms. This
approach is effective in about
one-third of patients (Shoskes &
Zeitlin, 1999).
An autoimmune or inflammatory reaction is suggested by the
elevation of seminal cytokines in
these patients and by our own
observation that markers of oxidant stress are significantly elevated in patients with CPPS
(submitted manuscript). Some patients do report benefit with nonsteroidal anti-inflammatories; however, long-term use is limited by
the toxicity of these agents.
Whether the newer cox-2 inhibitors will be of added benefit is
currently under study. Brief trials
of corticosteroids have also been
UROLOGIC NURSING / August 2001 / Volume 21 Number 4
tried with mixed results.
Anecdotally, we have a patient
with a renal transplant who suffered recurrent CPPS pre-transplant but who has been asymptomatic since his transplant on full
cyclosporine-based immunosuppression. Clearly, the long-term
complications associated with
immunosuppression effectively
contraindicates its use. Phytotherapy with quercetin, which is a
plant-derived polyphenolic compound with anti-inflammatory
and anti-oxidant properties, has
been shown to significantly
improve symptoms of men with
CPPS (Shoskes, 1998). In a randomized, prospective, placebo
controlled trial, 82% of men with
CPPS treated with quercetin (in
the form of the supplement
Prosta-Q®) had a significant
improvement in symptom score,
as compared with 20% of men
treated with placebo (Shoskes,
Zeitlin, Shahed, & Rajfer, 1999).
In men whose CPPS is associated with voiding dysfunction,
urodynamics may show bladder
outflow obstruction from pseudodyssynergia (Kaplan et al.,
1997). Whether this abnormal
voiding pattern is secondary to
initial infection or inflammation
or whether it is a primary disorder is not known. Nevertheless,
therapy with an alpha blocker,
either alone or in combination
with antibiotics (Barbalias,
Nikiforidis, & Liatsikos, 1998) or
bladder retraining with biofeedback (Kaplan et al., 1997) are
effective. In the younger men
typical of CPPS patients, tamsulosin is the most easily tolerated
of the alpha blockers because it
lacks anti-hypertensive effects.
Preliminary studies suggest that
finasteride may also benefit men
with CPPS, but whether this is
due to shrinkage of the prostate or
another unrelated mechanism is
not known (Leskinen, Lukkarinen,
& Marttila, 1999). Men with
prominent dysuria or voiding dysfunction associated with their
pain may have interstitial cystitis,
Table 4.
Supportive Measures for Patients with Chronic Prostatitis
(NIH Categories II and III )
❏
❏
❏
❏
❏
❏
Hot baths
Nonsteroidal anti-inflammatory agents
Avoid alcohol, spicy foods, and caffeine
Avoid repetitive perineal trauma (for example, mountain bike riding)
Inflatable donut to sit on for prolonged periods of sitting
Stress reduction counseling
Table 5.
Internet Resources
❏
❏
❏
❏
❏
Prostatitis Foundation: http://www.prostatitis.org
Interstitial Cystitis Collaborative Network: http://www.icn.org
Cleveland Clinic Florida Prostatitis Clinic: http://www.dshoskes.com
Institute for Male Urology: http://www.urol.com
Prostatitis Newsgroup: sci.med.prostate.prostatitis
which can be diagnosed by classical findings on cystoscopy
under anesthesia. Other secondline therapies with anecdotal evidence of efficacy are listed in
Table 2.
In patients with no evidence
of infection or inflammation (category IIIb), CPPS may be related
to pelvic floor myalgia. This may
be appreciated on physical examination as previously described,
or inferred from lack of response
to antimicrobial or anti-inflammatory therapy. Therapeutic
options are outlined in Table 3.
Supportive measures, which may
improve symptoms in all
patients with chronic prostatitis/CPPS, include pelvic physiotherapy, local heat, and avoiding
alcohol, spicy foods, and caffeine
(see Table 4). Systemic neuromuscular relaxants may also be
of help, although side effects
often limit their use. Anecdotal
evidence suggests that gabapentin (Neurontin®), often combined with a low-dose tricyclic
antidepressant, may be of value
in these patients.
Chronic prostatitis can have
a major psychological impact on
UROLOGIC NURSING / August 2001 / Volume 21 Number 4
men’s lives leading to stress,
depression, and even suicide.
Some have suggested a subset of
these men have a primary psychologic disorder with somatization of symptoms to the lower
urinary tract. Indeed, men with
chronic genital pain have a significant incidence of emotional
loss at onset of symptoms and
many lack social supports
(Schover, 1990). As with all
chronic pain disorders, it can be
very difficult to isolate cause and
effect when dealing with psychologic problems. Nevertheless, it
is important to understand the
impact on quality of life that
these men may suffer and to offer
appropriate referral to counseling, even as an adjunct to other
therapies (see Table 5).
Summary
Prostatitis syndromes remain
a diagnostic and therapeutic challenge. Infection should always be
searched for first and eradicated.
If symptoms persist, therapies targeted to inflammation, such as
NSAIDs or quercetin, should be
tried. Pelvic-muscle spasm and
voiding dysfunction will often
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improve with alpha blockers,
physiotherapy, systemic muscle
relaxants, and other supportive
therapy. Perseverance and creativity in therapy can lead to
durable improvement in the
majority of men with this debilitating condition. New therapies
must be evaluated scientifically
using validated instruments for
symptom severity and quality of
life improvement. •
References
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Barbalias, G.A., Nikiforidis, G., &
Liatsikos, E.N. (1998). Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. Journal of Urology, 159(3),
883-887.
Berger, R.E., Krieger, N., Rothman, I.,
Muller, C.H., & Hillier, S.L. (1997).
Bacteria in the prostate tissue of men
with idiopathic prostatic inflammation. Journal of Urology, 157(3), 863865.
Collins, M.M., Stafford, R.S., O’Leary,
M.P., & Barry, M.J. (1998). How common is prostatitis? A national survey
of physician visits. Journal of
Urology, 159(4), 1224-1228.
Kaplan, S.A., Santarosa, R.P., D’Alisera,
P.M., Fay, B.J., Ikeguchi, E.F.,
Hendricks, J., Klein, L., & Te, A.E.
(1997). Pseudodyssynergia (contraction of the external sphincter during
voiding) misdiagnosed as chronic
nonbacterial prostatitis and the role
of biofeedback as a therapeutic
option. Journal of Urology, 157(6),
2234- 2237.
Leskinen, M., Lukkarinen, O., & Marttila,
T. (1999). Effects of finasteride in
patients with inflammatory chronic
pelvic pain syndrome: A double-
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blind, placebo-controlled, pilot
study. Urology, 53(3), 502-505.
Moon, T.D. (1997). Questionnaire survey
of urologists and primary care physicians’ diagnostic and treatment practices for prostatitis. Urology, 50(4),
543-547.
Nickel, J.C., Alexander, R., Anderson, R.,
Krieger, J., Moon, T., Neal, D.,
Schaeffer, A., & Shoskes, D. (1999).
Prostatitis unplugged? Prostatic
massage revisited. Tech Urology,
5(1), 1-7.
Nickel, J.C., Costerton, J.W., McLean, R.J.C.,
& Olson, M. (1994). Bacterial biofilms:
Influence on the pathogenesis, diagnosis, and treatment of urinary tract
infections. Journal of Antimicrobial
Chemotherapy, 33(Suppl. A), 31-41.
Nickel, J.C., Nyberg, L.M., & Hennenfent,
M. (1999). Research guidelines for
chronic prostatitis: Consensus report
from the first National Institutes of
Health International Prostatitis
Collaborative Network. Urology,
54(2), 229-233.
Schover, L.R. (1990). Psychological factors
in men with genital pain. Cleveland
Clinic Journal of Medicine, 57(8),
697-700.
Shoskes, D.A. (1998). Effect of the
bioflavonoids quercetin and curcumin on ischemic renal injury: A
new class of renoprotective agents.
Transplantation, 66(2), 147-152.
Shoskes, D.A., & Zeitlin, S.I. (1999). Use
of prostatic massage in combination
with antibiotics in the treatment of
chronic prostatitis. Prostate Cancer
and Prostate Diseases, 2(3), 159-162.
Shoskes, D.A., Zeitlin, S.I., Shahed, A., &
Raifer, J. (1999). Quercetin in men
with category III chronic prostatitis:
A preliminary prospective, doubleblind, placebo-controlled trial.
Urology, 54(6), 960-963.
Tanner, M.A., Shoskes, D., Shahed, A., &
Pace, N.R. (1999). Prevalence of
Corynebacterial 16S rRNA sequences
in patients with bacterial and “nonbacterial” prostatitis. Journal of
Clinical Microbiology, 37(6), 18631870.
Wenninger, K.J., Heiman, R., Rothman,
A., Berghuis, J.P., & Berger, R.E.
(1996). Sickness impact of chronic
nonbacterial prostatitis and its correlates. Journal of Urology, 155(3),
965-968.
Wright, E.T., Chmiel, J.S., Grayhack, J.T.,
& Schaeffer, A.J. (1994). Prostatic
fluid inflammation in prostatitis.
Journal of Urology, 152(6, Pt. II),
2300-2303.
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