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Branching off of CP/CPPS[edit]

Looking for comments here on my proposal to reduce the CP/CPPS section to a single paragraph with a link to another page devoted to this complex subject, something like

Category III: CP/CPPS[edit]

This category, accounting for 90%-95% of prostatitis diagnoses,[1] is also known as chronic nonbacterial prostatitis. Men in this category have no known infection, but do have extensive pelvic pain lasting more than 3 months.[2] There are no standard diagnostic tests; diagnosis is by exclusion of other disease entities. Multimodal therapy is the most successful treatment option,[3] and includes α-blockers,[4] phytotherapy,[5][6] and protocols aimed at quieting the pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control.[7][8] Antibiotics are not recommended.[9][10]

  1. ^ Habermacher GM, Chason JT, Schaeffer AJ (2006). "Prostatitis/chronic pelvic pain syndrome". Annu. Rev. Med. 57: 195–206. doi:10.1146/ PMID 16409145. 
  2. ^ Luzzi GA (2002). "Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management". Journal of the European Academy of Dermatology and Venereology : JEADV 16 (3): 253–6. PMID 12195565. 
  3. ^ Potts JM (2005). "Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome". Current urology reports 6 (4): 313–7. PMID 15978236. 
  4. ^ Yang G, Wei Q, Li H, Yang Y, Zhang S, Dong Q (2006). "The effect of alpha-adrenergic antagonists in chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis of randomized controlled trials". J. Androl. 27 (6): 847–52. doi:10.2164/jandrol.106.000661. PMID 16870951. ...treatment duration should be long enough (more than 3 months) 
  5. ^ Shoskes DA, Zeitlin SI, Shahed A, Rajfer J (1999). "Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial". Urology 54 (6): 960–3. PMID 10604689. 
  6. ^ Elist J (2006). "Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized, double-blind, placebo-controlled study". Urology 67 (1): 60–3. doi:10.1016/j.urology.2005.07.035. PMID 16413333. 
  7. ^ Anderson RU, Wise D, Sawyer T, Chan C (2005). "Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men". J. Urol. 174 (1): 155–60. doi:10.1097/01.ju.0000161609.31185.d5. PMID 15947608. 
  8. ^ Anderson RU, Wise D, Sawyer T, Chan CA (2006). "Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training". J. Urol. 176 (4 Pt 1): 1534–8; discussion 1538–9. doi:10.1016/j.juro.2006.06.010. PMID 16952676. 
  9. ^ Alexander RB, Propert KJ, Schaeffer AJ, et al (2004). "Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial". Ann. Intern. Med. 141 (8): 581–9. PMID 15492337. 
  10. ^ Nickel JC, Downey J, Clark J, et al (2003). "Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial". Urology 62 (4): 614–7. PMID 14550427. 

Of course I'll cite each fact so that there is no opinion. Comments? DR?   Skopp   07:35, 5 November 2007 (UTC)

Is this to replace the contents of the Signs and symptoms section at the start or to follow it? Silverye 09:25, 8 November 2007 (UTC)
To replace 5.x, IOW all details under section (5).   Skopp   09:48, 8 November 2007 (UTC)
Yes, I think this would work well - with the appropriate link to the second/follow-on page which covers the condition in more detail. Silverye 11:54, 8 November 2007 (UTC)
  • Note, current page is nearing the limit at 37 KB, where 32 KB is the suggested limit. I find that as I page through it with a new visitor's eye, the article is very confusing and repetitive, with numerous Diagnosis and Treatment sections. I think it would benefit from a split, especially since the word prostatitis is a bit of a misnomer for CPPS anyway.   Skopp   12:06, 5 November 2007 (UTC)
  • No objections, moving ahead.   Skopp   01:57, 8 November 2007 (UTC)
  • Object - suggest arguments over content get sorted out first, else will just end up being a fork for (possibly) different slant (ie POV) on topic. Whilst I'm sure each component would be important as far as individual patients, wikipedia is not written for patients (remember wikipedia does not give medical advice) but general interested readers. I'm not sure there really ought to be that much longer coverage on teh topic (from an encyclopaedic copyediting). So, suggest keep this on hold for now, but in principle one might similarly split off other classification categories with this then just umbrella simple introduction. David Ruben Talk 02:21, 8 November 2007 (UTC)
Ok, I'll hold off, but please note that the branching is suggested not for patients but for size and readability issues. Splitting off other classification categories is not warranted IMO because they are relatively small, straightforward and uncontroversial, medically and conceptually. Although I have nothing against it, in principle, and on second thoughts, it may be a good idea.   Skopp   02:48, 8 November 2007 (UTC)
I agree that currently the Category III: CP/CPPS section is getting hard to follow given the extra info it has in it. It would work better following the simple Signs and symptoms, Diagnosis, Treatment and Prognosis sections of the other ones (Category I & Category II) and keeping the text content minimal - with a seperate page giving the indepth content that the subject requires. Completely agree with David though in that we need to get the current arguments resolved prior to any split as the two current opposing Editors will just go to town on it. Silverye 09:25, 8 November 2007 (UTC)
  • To David Ruben — the page seems to be quiescent again. How do you feel about me moving forward on your suggestion about splitting off subtopics and leaving a small umbrella page? ► RATEL ◄ —Preceding comment was added at 00:09, 7 December 2007 (UTC)
  • To DGG - the page would best be changed and made more logical by leaving it as a short description of the NIH/NIDDK categorization of these 4 different disorders, and then link to separate pages on each of the four categories as shown above. This will also prevent people adding research from one area into another area (something that currently causes much friction). As it stands now, this page is like having a page called "Liver disorders" and then listing several quite different liver maladies, all on one page. It's not right, logically or medically. As it stands, the page is confusing and overlong, with numerous "symptoms" sections, etc ► RATEL ◄ 22:17, 27 March 2008 (UTC)

Page shortening and new pages[edit]

As discussed before, this hodgepodge of a page, which has becoming horribly confusing and overlong by WP standards, is now split into a few new pages. I found while doing this work that the infoboxes at the top of each page were completely different, so re-amalgamating the various pages would do a violence to logic and go against the desire to make wikipedia a proper and lucid resource. So don't do it. Hopefully we can now leave this page in a fairly static form. I've also worked on various redirects to make all forms of nomenclature work, including CPPS, CP/CPPS, Chronic nonbacterial prostatitis etc. ► RATEL ◄ 03:33, 2 May 2008 (UTC)


Ratel, what's the source? DGG (talk) 01:18, 13 July 2008 (UTC)

Various papers over the years showing incidence, the main one being PMID 16409145. Acute bacterial prostatitis is very rare according to all the papers on it, and CAT IV is an incidental finding on lab tests. ► RATEL ◄ 03:17, 13 July 2008 (UTC)
Whoa! Rechecking my figures for Cat IV, I found a new paper (PMID 18455767) putting incidence between 6 and 19%! I'll update the graph. Thanks for making me check this, very interesting finding that up to one in 5 normal men has pus cells in their semen! ► RATEL ◄ 03:32, 13 July 2008 (UTC)
And it gets more complex, because those figures (6-19%) do not relate to prostatitis diagnoses, but simply a cross section of men. So that cannot fit into the graph neatly since it measures a different population group. I'll give this a think. Maybe two graphs, one showing incidence for all types in the normal population, and one showing breakdown of prostatitis diagnoses? Ideas? ► RATEL ◄ 03:41, 13 July 2008 (UTC)

PCR studies[edit]

Please do not insert controversial text about CP/CPPS onto the page. PCR studies have shown both that both patients and controls have bacteria in their prostates. In an editorial in the February 2003 Journal of Urology, leading urologist and prostatitis researcher Dr Anthony Schaeffer wrote:

The Journal of Urology 2003; 169(2):597-598

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.

Thanks for your input. ► RATEL ◄ 22:35, 18 April 2010 (UTC)

  • Arcadian, since you are a medical student, I appreciate your interest in this area, but you are not familiar with the complex issues and latest research. Please use the talk page to discuss your edits. ► RATEL ◄ 23:11, 18 April 2010 (UTC)
  1. The lead author on that study, Nadler, has published other studies funded by Bayer, holders of patents for some flouroquinolones.
  2. "The first therapeutic measure is often a 4- to 6-week course of a fluoroquinolone, which provides relief in 50% of men and is more efficacious if prescribed soon after symptoms begin. " There are NO studies supporting this statement, and high powered, high quality studies concluding the opposite,[1] which is why, per MEDRS, I am going for a review source.
  3. That study supports the use of the meares-stamey 4-glass method, found to be of questionable utility by larger studies, eg PMID 12913707
  4. That study supports use of TUNA, found to be of no use by other studies, eg PMID 12137830
  5. That study supports the use of alpha blockers, found to be no better than placebo in more recent studies, PMID 19092152
This is why I urge you not to use sources like this, as well as books on pediatric diseases (this is never a pediatric condition). I have the latest copy of Harrisons, and it is woefully behind the times on this condition, full of outdated and erroneous information. ► RATEL ◄ 23:45, 18 April 2010 (UTC)
  • You have now used a study (PMID 18289570 )of men with chronic prostatitis (ie chronic BACTERIAL prostatitis), not CP/CPPS, to justify the use of antibiotics in men with CP/CPPS. Please STOP or slow down, and take advice. You are introducing errors and bias onto the page. ► RATEL ◄ 00:01, 19 April 2010 (UTC)
The paper is comparing the benefit of levofloxacin or ciprofloxacin in two populations: those with traditional accepted uropathogens and nontraditional uropathogens. Patients with nontraditional uropathogens are considered nonbacterial. Why would this be inappropriate in appropriate in a discussion of the use of antibiotics with a CP/CPPS diagnosis? See PMID 17954024. --Arcadian (talk) 00:07, 19 April 2010 (UTC)
From your perspective, are patients with coagulase negative Staphylococcus species and Streptococcus species type II or type III? --Arcadian (talk) 00:16, 19 April 2010 (UTC)
The men in the study referenced cannot be Cat. III by definition ("mean symptom duration was 8.4 weeks (median 3.5)") because you only get classed as cat III after 3 months of pain. Staph is so common on testing (found routinely in the distal urethra in pts and controls) that it is not even noted by most labs, because it is seen as a contaminant. However, it is possible for a Cat. III patient to have intercurrent infection, or at least have bacteria localised to the gland (not necessarily an infection, because as we know, the same percentage of controls —in fact more— have bacteria in their prostates). Treating with antibiotics can provide relief, often temporary (and sometimes of longer duration of the anti-inflammatory effects help prevent allodynia and neural wind-up), to these patients (and also to patients without any positive cultures, strangely enough). Numerous sources now confirm that antibiotics have immunomodulatory and anti-inflammatory effects, so we have a clear basis for the phenomenon. As you may or may not know, antibiotic use in men with CP/CPPS is almost always on an empirical basis anyway.Just some background: the paper you reference is by J Curtis Nickel, someone with whom I have communicated, and someone known as "Mr Prostatitis" in the research world. ► RATEL ◄ 00:44, 19 April 2010 (UTC)
Per Harrison's, "Chronic bacterial prostatitis: The diagnosis is established by culture of E. coli, Klebsiella, Proteus, or other uropathogenic bacteria from the expressed prostatic secretion or postmassage urine in higher quantities than are found in first-void or midstream urine." So it's type III, so the comparison in PMID 18289570 applies. Also, per Harrison's: "CPPS. The effectiveness of antimicrobial agents is uncertain. Some patients with inflammatory subgroup disease benefit from a 4- to 6-week course of treatment with: Erythromycin or Doxycycline or TMP-SMX or Fluoroquinolone." I know from the above that you disagree with Harrison's, but it's hard to argue that it's not a reliable source. --Arcadian (talk) 00:28, 19 April 2010 (UTC)

Current problems with page[edit]

So, in summary, here are the problems with the current version of the page as I see them:

  1. Meares and Stamey are given pride of place on the page, mentioned first before the NIDDK classifications, and mentioned again in the table. You also link to sources that use this outmoded classification system, IOW sources that have not been updated in a decade. As someone who is highly familiar with this topic, I can attest that I never see mention of "prostatodynia" and nonbacterial prostatitis any longer, and nor is that nomenclature used in any of the quality journals. So that's the first thing that should change. The old classification system should be moved to a section at the end of the page and noted for historical interest only.
  2. Sources: there are inappropriate sources used on the page. We have a pediatrics book (!) and an outdated (see above) nephrology book. I suggest these are removed and if a book source is needed (rather than recent quality published research, which is my preference in this field because of the large advances in the previous decade), then we should turn to Campbell's Urology, the bible of urologists.
  3. A single, unreplicated study has been used to make the extraordinary claim that men with CP/CPPS, who also happen to have (probably contaminant) bacteria like Staph. in their cultures (as do a similar number of controls, other studies show) should be treated with antibiotics. If this study is used anywhere, it should be on the page dealing with CP/CPPS, not on this high-level switchboard page, where it is given far too much undue weight. I can produce numerous studies stating that men with CP/CPPS should NOT be treated with antibiotics. The greatest problem with current treatment of this disorder (UCPPS) in the medical world today is the routine overtreatment of this patient group with antimicrobials, and now we have text on the page that will perpetuate and exacerbate this.
  4. The last paragraph on the page needs a complete re-write. It is not only full of UNDUE problems and is out of place on this general page, but the phrasing is awkward, inexact and weasely, with "some" this and "some" that. It quotes a review that flies in the face of numerous studies (see above) and even other reviews (Cochrane).

That's a start. ► RATEL ◄ 23:53, 19 April 2010 (UTC)

External links[edit]

What was the problem with the external link for the Prostatitis Foundation? Terribleidea (talk) 01:14, 15 February 2011 (UTC)

Please study the rules on external links. This one breaches the rules on several counts (forum, advertising, not a unique resource, unverifiable research and theories eg. [2] [3] and many more.) That's not an exhaustive list. RxWatch (talk) 06:15, 15 February 2011 (UTC)

New review[edit]

[4] --Doc James (talk · contribs · email) 14:05, 12 November 2011 (UTC)

IgG4-related prostatitis[edit]

McLondon has added a paragraph about IgG4-related prostatitis to the page. I did some digging around and think it's better to remove the edit at this stage and perhaps add it back later in a modified form. My research showed that in one 2007 paper the prostatitis was described as Cat IV (" The present two cases complained of neither genitourinary nor pelvic symptoms and showed no granulocyte infiltration in the prostatic tissue samples. In this regard, they are classified as asymptomatic inflammatory prostatitis"). But in the study used as a source by McLondon, the symptoms are described so: "Patients almost exclusively presented with lower urinary tract symptoms such as dysuria, pollakisuria, urinary urgency, and a feeling of incomplete emptying". So these papers do not agree (although the second paper does use the first as a source!). These symptoms are not truly Cat IV, nor Cat I, II or III. This is an "other" form of prostatitis.

In addition, there are yet more conditions that cause prostate inflammation, such as reactive arthritis, Wegener's granulomatosis (PMID 22391468), sarcoidosis of the prostate (PMID 17347286), eosinophilic cystitis (which can affect the prostate), granulomatous prostatitis etc.

Possibly we should have a paragraph at the end of the page called "Other forms of prostatitis" that briefly describes these other forms of prostatitis? Ratel (talk) 09:21, 25 February 2015 (UTC)

@Ratel: I added the paragraph about IgG4-related prostatitis after reading a number of articles about it and IgG4-related disease (IgG4-RD). I do believe I summarised accurately the current knowledge surrounding IgG4-related prostatitis, backed by the couple of recent and valid references (from the past 14 months) that I provided.
IgG4-related prostatitis is not yet fully understood or widely known about so it remains under-recognised, but it is very much a confirmed cause of prostatitis, clearly fitting the Wiki definition of "histological (microscopic) inflammation of the tissue of the prostate gland". It can be associated with multi-organ involvement, just as in rheumatoid arthritis which is appropriately enough included on the arthritis wiki, and which is nowadays treated early and aggressively by rheumatologists... which eventually could conceivably occur with the steroid-responsive IgG4-RD.
I would think all validated causes of prostatitis (including sarcoidosis and other examples you mentioned above) merit inclusion somewhere on a Wiki page about prostatitis, irrespective of how and where they fit into a classification model designed for research more than 15 years ago. As you mentioned, causes (and I would include infections) should perhaps be included in a separate section on the Wiki. I personally wouldn't consider non-infective causes of prostatitis as 'other forms' though. They are just as much causes of prostatitis as infections are. Infections seem to be widely considered as the cause in only 5-10% of cases anyway.
Although exact symptoms of IgG4-related prostatitis might not be fully elucidated yet, in the paragraph I wrote I included those mentioned in a couple of recent studies as being particularly associated with it.
Regarding the 2007 paper you quoted above, this was obviously an early case study, just reporting on two 'histology' cases where positive IgG4 testing had been performed on prostate tissue samples. It was basically identifying more incidences of a newly recognised condition, not trying to characterise the condition. Despite what is mentioned in the paper's conclusion, neither case could reasonably be considered to be asymptomatic as both were diagnosed with benign prostatic hyperplasia, one requiring medication for the previous 24 years and the other one requiring surgery - the same surgery that provided the prostate tissue that got IgG4 tested 4 years later!
It was not really a study of prostatitis patients as such but did conclude, "From these points of view, we should carefully reevaluate patients with prostatitis and analyze clinical manifestations in a large number of patients with IgG4-related prostatitis."
Other studies into the condition include one from 2013 (Table 1 in the article includes a list of cases previously reported in other studies - mostly from Japan for reasons explained below) and one from Holland (database search which found 9 cases of prostatitis in 119 patients with established autoimmune pancreatitis).
As a background, IgG4-related disease was first recognised as a systemic condition in 2003 in Japan when extrapancreatic manifestations were identified in patients with autoimmune pancreatitis. As a result, a lot of the early research into IgG4-related disease was in Japan, and therefore the majority of cases reported seem to be among Asians with pancreatitis.
The first case of IgG4-related prostatitis was recognised around 2006 and has slowly become more recognised since. As most confirmed cases are identified from testing prostate tissue retrieved by prostate biopsy, TURP or prostatectomy, it follows that reported cases would be in men who tend to be the ones getting such procedures, i.e. older men. The naming as IgG4-related prostatitis was only recommended in 2012.
The NIDDK classification was described at the time (1999) by those involved in it as "research guidelines" "to address the confusion surrounding the diagnostic and treatment strategies in chronic prostatitis". It can still be used for classifying all prostatitis cases, whether cases are diagnosed as IgG4-related prostatitis or not, but it will fail to take pathology into consideration apart from infection and even then it doesn't address possible spread of infection to seminal vesicles or elsewhere in the reproductive tract which could be clinically relevant.
Classification is not necessarily making a diagnosis. Unlike Cat I, Cat IIIa is not in my view a clinical diagnosis, just a classification group. There's no reason why any Cat IIIa case would be immune to acquiring chronic bacterial prostatitis later on, then (if it's detected) get classified as Cat II instead, which would essentially hide the clinical reality that he would actually have a combination of at least two different conditions, one bacterial and one non-bacterial.
My understanding is that the NIDDK classification essentially subdivided symptomatic chronic prostatitis into 3 groups so that research could use "comparative evaluation" among somewhat similar groups of cases. At the time I doubt such research guidelines were intended to get used some 15 years later as a tool to ignore new discoveries about the condition(s) but were meant to aid make new discoveries.
Ultimately the Wiki page is not about the NIDDK classification though, even if it does currently dominate it. It's about a pathological condition (or conditions) with several causes, some known and others unknown. McLondon (talk) 10:41, 27 February 2015 (UTC)
I don't disagree with your points. The NIDDK classification system was never meant to cover all forms of prostatitis, just the commonest forms that are frequently confused. The other forms of prostatitis, which unlike the commonest forms are almost all subsidiary symptoms of systemic diseases, are relatively rare and covered under the articles on the diseases themselves (or if not, should be). My feeling is that this article needs to have a new section about other forms of prostatitis that occur as symptoms of other (wikilinked) diseases, such as IgG4-related pacreatitis. The section needs to mention the relative rarity as well, so as not to mislead or confuse readers. Have a go and let's see what you come up with. Ratel (talk) 13:44, 27 February 2015 (UTC)