Chronic prostatitis/chronic pelvic pain syndrome: Difference between revisions
revert vandalism |
Noodlebike (talk | contribs) |
||
Line 109: | Line 109: | ||
[[Transurethral needle ablation]] of the prostate ([[TUNA]]) has been shown to be ineffective in trials.<ref name="Leskinen-2002">{{Cite journal | last1 = Leskinen | first1 = MJ. | last2 = Kilponen | first2 = A. | last3 = Lukkarinen | first3 = O. | last4 = Tammela | first4 = TL. | title = Transurethral needle ablation for the treatment of chronic pelvic pain syndrome (category III prostatitis): a randomized, sham-controlled study. | journal = Urology | volume = 60 | issue = 2 | pages = 300–4 | month = Aug | year = 2002 | doi = 10.1016/S0090-4295(02)01704-1| pmid = 12137830 }}</ref> |
[[Transurethral needle ablation]] of the prostate ([[TUNA]]) has been shown to be ineffective in trials.<ref name="Leskinen-2002">{{Cite journal | last1 = Leskinen | first1 = MJ. | last2 = Kilponen | first2 = A. | last3 = Lukkarinen | first3 = O. | last4 = Tammela | first4 = TL. | title = Transurethral needle ablation for the treatment of chronic pelvic pain syndrome (category III prostatitis): a randomized, sham-controlled study. | journal = Urology | volume = 60 | issue = 2 | pages = 300–4 | month = Aug | year = 2002 | doi = 10.1016/S0090-4295(02)01704-1| pmid = 12137830 }}</ref> |
||
In an ongoing trial http://clinicaltrials.gov/ct2/show/NCT00775515 conducted by Arnon Krongrad, the pioneer of Laparascopic Radical Prostatectomy in the United States, a significant proportion of CP/CPPS patients are reporting large to complete reductions in their symptoms after LRP (an operation usually reserved for prostate cancer). This is a very last resort however, only to be considered after all other treatments have failed, due to the potentially serious side effects of the surgery. It does however, seem to indicate that the prostate and seminal vesicles may have a significant involvement in the symptoms of these men. |
|||
==Prognosis== |
==Prognosis== |
Revision as of 15:22, 18 August 2010
Chronic prostatitis/chronic pelvic pain syndrome | |
---|---|
Specialty | Urology ![]() |
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a pelvic pain condition in men, and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis. [1] This condition was previously known as chronic non-bacterial prostatitis, or prostatodynia (painful prostate).
Nomenclature
A distinction is sometimes made between "IIIa" (Inflammatory) and "IIIb" (Noninflammatory) forms of CP/CPPS,[2] depending on whether pus cells (WBCs) can be found in the expressed prostatic secretions (EPS) of the patient. Some researchers have questioned the usefulness of this categorisation, calling for the Meares-Stamey four-glass test to be abandoned.[3]
In 2007, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) began using the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS), for research purposes, to refer to pain syndromes associated with the bladder (i.e. interstitial cystitis/painful bladder syndrome, IC/PBS) and the prostate gland (i.e. chronic prostatitis/chronic pelvic pain syndrome, CP/CPPS).[4]
Older terms for this condition are "prostatodynia" (prostate pain) and non-bacterial chronic prostatitis.
Signs and symptoms
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterised by pelvic or perineal pain without evidence of urinary tract infection,[5] lasting longer than 3 months,[6] as the key symptom. Symptoms may wax and wane. Pain can range from mild discomfort to debilitating. Pain may radiate to back and rectum, making sitting difficult. Dysuria, arthralgia, myalgia, unexplained fatigue, abdominal pain, constant burning pain in the penis, and frequency may all be present. Frequent urination and increased urgency may suggest interstitial cystitis (inflammation centred in bladder rather than prostate). Post-ejaculatory pain, mediated by nerves and muscles, is a hallmark of the condition,[7] and serves to distinguish CP/CPPS patients from men with BPH or normal men. Some patients report low libido, sexual dysfunction and erectile difficulties.
Prevalence
The annual prevalence in the general population of chronic pelvic pain syndrome is 0.5%.[8] 38% of primary care providers, when presented with a vignette of a man with CPPS, indicate that they have never seen such a patient.[9] However, the overall prevalence of symptoms suggestive of CP/CPPS is 6.3%.[10] The role of the prostate was questioned in the etiology of CP/CPPS when both men and women in the general population were tested using the (1) National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI[11]) —with the female homolog of each male anatomical term use on questionnaires for female participants— (2) the International Prostate Symptom Score (IPSS), and (3) additional questions on pelvic pain. The prevalence of symptoms suggestive of CPPS in this selected population was 5.7% in women and 2.7% in men, placing in doubt the role of the prostate gland.[12] New evidence suggests that the prevalence of CP/CPPS is much higher in teenage males than once suspected.[13]
Theories of etiology
Nerves, stress and hormones
In 2008, a literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine, finding that the symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.[14]
Theories behind the disease include stress-driven hypothalamic-pituitary-adrenal axis dysfunction and adrenocortical hormone (endocrine) abnormalities,[15][16] neurogenic inflammation,[17][18][19] and myofascial pain syndrome.[20][21] In the latter two categories, dysregulation of the local nervous system due to past trauma, infection or an anxious disposition and chronic albeit unconscious pelvic tensing lead to inflammation that is mediated by substances released by nerve cells (such as substance P). The prostate (and other areas of the genitourinary tract: bladder, urethra, testicles) can become inflamed by the action of the chronically activated pelvic nerves on the mast cells at the end of the nerve pathways. Similar stress-induced genitourinary inflammation has been shown experimentally in other mammals.[22] However, there is no correlation between inflammation on histological examination of the prostate and the National Institutes of Health Chronic Prostatitis Symptom Index.[23]
The bacterial infection theory that for so long had held sway in this field was shown to be unimportant in a 2003 study from the University of Washington team led by Dr Lee and Professor Richard Berger. The study found that one third of both normal men and patients had equal counts of similar bacteria colonizing their prostates.[24] This view was endorsed by Dr Anthony Schaeffer, Professor and Chairman of the Department of Urology at Northwestern University, in a 2003 editorial of The Journal of Urology, in which he stated that "...these data suggest that bacteria do not have a significant role in the development of the chronic pelvic pain syndrome",[25] and a year later with his colleagues he published studies showing that antibiotics are essentially useless for CP/CPPS.[26][27] Since the publication of these studies, the research focus has shifted from infection to neuromuscular, behavioral, psychological, and genetic etiologies for UCPPS (CP/CPPS and IC/PBS), where the interplay between the lower urinary tract and other physiological systems is stressed.[28] UCPPS is now studied as a systemic disorder.[28] In support of this approach, a 2005 study showed that stress is correlated to Cat III prostatitis.[29]
Overlap with BPS/IC
Some researchers have suggested that CPPS is a form of bladder pain syndrome/interstitial cystitis (BPS/IC). In 2007 the NIDDK began to group IC/PBS and CP/CPPS under the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS). Therapies shown to be effective in treating IC/PBS, such as quercetin,[30] have also shown some efficacy in CP/CPPS.[31] Recent research has focused on genomic and proteomic aspects of the related conditions.[32]
Infection
Additional theories and observations include:
- Nanobacteria — In a preliminary 2005 open label study of 16 treatment-recalcitrant CPPS patients, controversial entities known as nanobacteria were proposed as a cause of prostatic calcification and symptoms found in CPPS.[33] Patients were treated with EDTA (to dissolve the calcifications) and 3 months of tetracycline (a calcium-leaching antibiotic with anti-inflammatory effects,[34] used here to kill the "pathogens"), and half had significant improvement in symptoms. Scientists have expressed strong doubts about whether nanobacteria are living organisms.[35][36] Research in 2008 showed that "nanobacteria" are merely tiny lumps of abiotic limestone.[37][38] Confirmation of the clinical efficacy of the treatment awaits placebo controlled studies.
- Viruses — The evidence supporting a viral cause of prostatitis and chronic pelvic pain syndrome is weak. Single case reports have implicated Herpes simplex virus (HSV) and Cytomegalovirus (CMV) but a study using PCR failed to demonstrate the presence of viral DNA in patients with chronic pelvic pain syndrome undergoing radical prostatectomy for localized prostate cancer.[39] The reports implicating CMV must be interpreted with caution because in all cases the patients were immunocompromised.[40][41][42] For HSV the evidence is weaker still and there is only one reported case and the causative role of the virus was not proven,[43] and there are no reports of successful treatments using antiviral drugs such as aciclovir.
Climate
The ambient temperature appears to play a role as cold is frequently reported as causing symptom aggravation and heat is often reported to be ameliorating.[44] It appears that cold is one of the factors that can trigger a process resulting in CP/CPPS.[45] Cold also causes aggravation of symptoms and can initiate a relapse.[45][46] A survey showed that the occurrence of prostatitis symptoms in men living in northern Finland —a cold climate—is higher than that reported in other parts of the world. This could be partly caused by the cold climate.[47]
Diagnosis
There are no definitive diagnostic tests for CP/CPPS. This is a poorly understood disorder, even though it accounts for 90%-95% of prostatitis diagnoses.[48] It is found in men of any age, with the peak incidence in men aged 35—45 years.[49] CP/CPPS may be inflammatory (Category IIIa) or non-inflammatory (Category IIIb), based on levels of pus cells in expressed prostatic secretions (EPS), but these subcategories are of limited use clinically. In the inflammatory form, urine, semen, and other fluids from the prostate contain pus cells (dead white blood cells or WBCs), whereas in the non-inflammatory form no pus cells are present. Recent studies have questioned the distinction between categories IIIa and IIIb, since both categories show evidence of inflammation if pus cells are ignored and other more subtle signs of inflammation, like cytokines, are measured.[50] In 2006, Chinese researchers found that men with categories IIIa and IIIb both had significantly and similarly raised levels of anti-inflammatory cytokine TGFβ1 and pro-inflammatory cytokine IFN-γ in their EPS when compared with controls; therefore measurement of these cytokines could be used to diagnose category III prostatitis.[51]
For CP/CPPS patients, analysis of urine and expressed prostatic secretions for leukocytes is debatable, especially due to the fact that the differentiation between patients with inflammatory and non-inflammatory subgroups of CP/CPPS is not useful.[52] Serum PSA tests, routine imaging of the prostate, and tests for Chlamydia trachomatis and Ureaplasma provide no benefit for the patient.[52]
Extraprostatic abdominal/pelvic tenderness is present in >50% of patients with chronic pelvic pain syndrome but only 7% of controls.[53] Healthy men have slightly more bacteria in their semen than men with CPPS.[54] The high prevalence of WBCs and positive bacterial cultures in the asymptomatic control population raises questions about the clinical usefulness of the standard 4-glass test as a diagnostic tool in men with CP/CPPS.[54] The use of the four-glass test by American urologists is now rare, with only 4% using it regularly.[55]
Men with CP/CPPS are more likely than the general population to suffer from Chronic Fatigue Syndrome (CFS),[56] and Irritable Bowel Syndrome (IBS).
Experimental tests that could be useful in the future include tests to measure semen and prostate fluid cytokine levels. Various studies have shown increases in markers for inflammation such as elevated levels of cytokines,[57] myeloperoxidase,[58] and chemokines.[59][60]
Conditions with similar symptoms
Some conditions have similar symptoms to chronic prostatitis: Bladder neck hypertrophy and urethral stricture may both cause similar symptoms through urinary reflux (inter alia), and can be excluded through flexible cytoscopy and urodynamic tests.[61][62][63]
Treatment
A 2007 review article by Drs Potts and Payne in the Cleveland Clinic Journal of Medicine states:
"Indeed, chronic abacterial prostatitis (also known as chronic pelvic pain syndrome) is both the most prevalent form and also the least understood and the most challenging to evaluate and treat. This form of prostatitis may respond to non-prostate-centered treatment strategies such as physical therapy, myofascial trigger point release, and relaxation techniques."[64]
Nonpharmalogical/noninvasive
Physical and psychological therapy
Category III prostatitis may have no initial trigger other than anxiety, often with an element of OCD, panic disorder, or other anxiety-spectrum problem.[65][66][67] This is theorized to leave the pelvic area in a sensitized condition resulting in a loop of muscle tension and heightened neurological feedback (neural pain wind-up). Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress.
Aerobic exercise can help those sufferers who are not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms are not exacerbated by exercise.[68] Acupuncture has reportedly benefited some patients.[69]
For chronic nonbacterial prostatitis (Cat III), also known as CP/CPPS, which makes up the majority of men diagnosed with "prostatitis", a treatment called the "Wise-Anderson Protocol" (aka the "Stanford Protocol"),[20][21][70] has recently been published. This is a combination of:
- Medication (using tricyclic antidepressants and benzodiazepines)
- Psychological therapy (paradoxical relaxation, an advancement and adaptation, specifically for pelvic pain, of a type of progressive relaxation technique developed by Edmund Jacobson during the early 20th century)
- Physical therapy (trigger point release therapy on pelvic floor and abdominal muscles, and also yoga-type exercises with the aim of relaxing pelvic floor and abdominal muscles).[20][21]
Biofeedback
Biofeedback physical therapy to relearn how to control pelvic floor muscles may be useful.[71] [72] [73] [74] According to an article by Yuan Li biofeedback is satisfactory for treatment of chronic prostatitis (with mainly voiding problems) during puberty [75].
Food allergies
Anecdotal evidence suggests that food allergies and intolerances may have a role in exacerbating CP/CPPS, perhaps through mast cell mediated mechanisms. Specifically patients with gluten intolerance or celiac disease report severe symptom flares after sustained gluten ingestion.[76] Patients may therefore find an elimination diet helpful in lessening symptoms by identifying problem foods. Studies are lacking in this area.
Pharmacological treatment
There is now a substantial list of medications used to treat this disorder.[77] A brief mention of the more common drugs used to treat this condition is:
- Antibiotics: Antibiotics, the old mainstay of treatment, cannot be recommended for men with longstanding, previously treated CP/CPPS.[13] However, even though well-designed clinical trials have failed to demonstrate their efficacy, standard treatment often still consists of prolonged courses of antibiotics.[78] The utility of a trial of antimicrobial treatment is debatable in treatment-naive patients.[79] The use of antibiotics is generally discouraged.[27] Some state improvement on antibiotics is likely to be evanescent, and due to the anti-inflammatory effects of the antibiotic.[80]
- Heparinoids: A large multicenter prospective randomized controlled study showed that Elmiron was slightly better than placebo in treating the symptoms of CPPS, however the primary endpoint did not reach statistical significance.[81]
- Quercetin has shown effective in a randomized, placebo-controlled trial in chronic prostatitis using 500 mg twice a day for 4 weeks[82] Subsequent studies showed that quercetin, a mast cell inhibitor, reduces inflammation and oxidative stress in the prostate.[83][84]
- Pollen extract (Cernilton) has also been shown effective in randomized placebo controlled trials.[85][86]
- At least one study suggests that multi-modal therapy (aimed at different pathways such as inflammation and neuromuscular dysfunction simultaneously) is better long term than monotherapy.[87]
- Commonly used therapies that have not been properly evaluated in clinical trials although there is supportive anecdotal evidence gabapentin, benzodiazepines and amitriptyline.[88]
- Alpha blockers. The effectiveness of alpha blockers (tamsulosin, alfuzosin) is questionable in men with CPPS. A 2006 meta analysis found that they are moderately beneficial when the duration of therapy was at least 3 months.[89] However a 2004 trial found no benefit from alfuzosin during 6 weeks of treatment[26] and a 2008 clinical trial of alfuzosin found it was no better than placebo for treating CPPS in treatment naive recently diagnosed men.[90]
Surgery
Surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.[91]
Transurethral needle ablation of the prostate (TUNA) has been shown to be ineffective in trials.[92]
In an ongoing trial http://clinicaltrials.gov/ct2/show/NCT00775515 conducted by Arnon Krongrad, the pioneer of Laparascopic Radical Prostatectomy in the United States, a significant proportion of CP/CPPS patients are reporting large to complete reductions in their symptoms after LRP (an operation usually reserved for prostate cancer). This is a very last resort however, only to be considered after all other treatments have failed, due to the potentially serious side effects of the surgery. It does however, seem to indicate that the prostate and seminal vesicles may have a significant involvement in the symptoms of these men.
Prognosis
In recent years the prognosis for CP/CPPS has improved greatly with the advent of multimodal treatment, phytotherapy, protocols aimed at quieting the pelvic nerves through myofascial trigger point release and anxiety control, and chronic pain therapy.[78][93][94]
Notable cases
- John Anderson — Deputy Prime Minister of Australia[95]
- John Cleese — British actor[96]
- Vincent Gallo — movie director[97]
- Glenn Gould — pianist[98]
- John F Kennedy — President of the United States of America[99]
- Howard Stern — radio personality[100][101]
- William Styron — author (Sophie's Choice)[102]
See also
- Bladder pain syndrome/interstitial cystitis — a related disease.
- Myofascial Pain Syndrome
- Myofascial Release
- Neuromuscular Therapy
- Trigger Points
- Pelvic myoneuropathy
External links
- The Urologic Chronic Pelvic Pain Syndrome Society
- Diagrams of the Pelvic Floor Muscles - pelvic musculature involved in causing CP/CPPS symptoms.
- Prostatitis at Curlie
References
- ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 12521576, please use {{cite journal}} with
|pmid=12521576
instead. - ^ "Prostatitis: Benign Prostate Disease: Merck Manual Professional". Retrieved 2010-04-17.
- ^ "Treatment of Chronic Prostatitis". www.medscape.com. Retrieved 2010-04-18.
- ^ "Multi-disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network". NIDDK. 2007. Retrieved 2008-01-11.
- ^ Schaeffer AJ (2007). "Epidemiology and evaluation of chronic pelvic pain syndrome in men". Int J Antimicrob Agents. 31: 108. doi:10.1016/j.ijantimicag.2007.08.027. PMID 18164597.
- ^ 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. doi:10.1046/j.1468-3083.2002.00481.x. PMID 12195565.
- ^ Shoskes DA, Landis JR, Wang Y, Nickel JC, Zeitlin SI, Nadler R (2004). "Impact of post-ejaculatory pain in men with category III chronic prostatitis/chronic pelvic pain syndrome". J. Urol. 172 (2): 542–7. doi:10.1097/01.ju.0000132798.48067.23. PMID 15247725.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Taylor BC, Noorbaloochi S, McNaughton-Collins M; et al. (2008). "Excessive antibiotic use in men with prostatitis". Am. J. Med. 121 (5): 444–9. doi:10.1016/j.amjmed.2008.01.043. PMC 2409146. PMID 18456041.
{{cite journal}}
: Explicit use of et al. in:|author=
(help); Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Phillp Hannno. "Defining The Urologic Chronic Pelvic Pain Syndromes: A New Beginning - An International Symposium". Urotoday. Retrieved 2008-07-22.
- ^ Daniels NA, Link CL, Barry MJ, McKinlay JB (2007). "Association between past urinary tract infections and current symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome". J Natl Med Assoc. 99 (5): 509–16. PMC 2576075. PMID 17534008.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ "NIH CPSI". www.ucpps.org. Retrieved 2009-11-10.
- ^ Marszalek M, Wehrberger C, Temml C, Ponholzer A, Berger I, Madersbacher S (2008). "Chronic Pelvic Pain and Lower Urinary Tract Symptoms in Both Sexes: Analysis of 2749 Participants of an Urban Health Screening Project". Eur. Urol. 55 (2): 499. doi:10.1016/j.eururo.2008.03.073. PMID 18395963.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b Nickel, JC.; Tripp, DA.; Chuai, S.; Litwin, MS.; McNaughton-Collins, M.; Landis, JR.; Alexander, RB.; Schaeffer, AJ.; O'Leary, MP. (2008). "Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome". BJU Int. 101 (1): 59–64. doi:10.1111/j.1464-410X.2007.07196.x. PMID 17924985.
{{cite journal}}
: Unknown parameter|month=
ignored (help) Cite error: The named reference "Nickel-2008" was defined multiple times with different content (see the help page). - ^ Pontari MA, Ruggieri MR (2008). "Mechanisms in prostatitis/chronic pelvic pain syndrome". J. Urol. 179 (5 Suppl): S61–7. doi:10.1016/j.juro.2008.03.139. PMID 18405756.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Anderson RU, Orenberg EK, Chan CA, Morey A, Flores V (2008). "Psychometric Profiles and Hypothalamic-Pituitary-Adrenal Axis Function in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome". J Urol. 179 (3): 956. doi:10.1016/j.juro.2007.10.084. PMC 2694575. PMID 18207189.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Dimitrakov J, Joffe HV, Soldin SJ, Bolus R, Buffington CA, Nickel JC (2008). "Adrenocortical Hormone Abnormalities in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome". Urology. 71 (2): 261–266. doi:10.1016/j.urology.2007.09.025. PMC 2390769. PMID 18308097.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Theoharides TC, Cochrane DE (2004). "Critical role of mast cells in inflammatory diseases and the effect of acute stress". J. Neuroimmunol. 146 (1–2): 1–12. doi:10.1016/j.jneuroim.2003.10.041. PMID 14698841.
- ^ Theoharides TC, Kalogeromitros D (2006). "The critical role of mast cells in allergy and inflammation". Ann. N. Y. Acad. Sci. 1088: 78–99. doi:10.1196/annals.1366.025. PMID 17192558.
- ^ Sant GR, Kempuraj D, Marchand JE, Theoharides TC (2007). "The mast cell in interstitial cystitis: role in pathophysiology and pathogenesis". Urology. 69 (4 Suppl): 34–40. doi:10.1016/j.urology.2006.08.1109. PMID 17462477.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ a b c 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.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ a b c 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.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Alexacos N, Pang X, Boucher W, Cochrane DE, Sant GR, Theoharides TC (1999). "Neurotensin mediates rat bladder mast cell degranulation triggered by acute psychological stress". Urology. 53 (5): 1035–40. doi:10.1016/S0090-4295(98)00627-X. PMID 10223502.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Nickel JC, Roehrborn CG, O'leary MP, Bostwick DG, Somerville MC, Rittmaster RS (2007). "Examination of the relationship between symptoms of prostatitis and histological inflammation: baseline data from the REDUCE chemoprevention trial". J. Urol. 178 (3 Pt 1): 896–900, discussion 900–1. doi:10.1016/j.juro.2007.05.041. PMID 17632164.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Lee JC, Muller CH, Rothman I; et al. (2003). "Prostate biopsy culture findings of men with chronic pelvic pain syndrome do not differ from those of healthy controls". J. Urol. 169 (2): 584–7, discussion 587–8. doi:10.1097/01.ju.0000045673.02542.7a. PMID 12544312.
{{cite journal}}
: Explicit use of et al. in:|author=
(help); Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Schaeffer AJ (2003). "Editorial: Emerging concepts in the management of prostatitis/chronic pelvic pain syndrome". J Urol. 169 (2): 597–598. doi:10.1016/S0022-5347(05)63961-4. PMID 12544315.
{{cite journal}}
: Unknown parameter|DUPLICATE DATA: pages=
ignored (help) - ^ a b 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.
{{cite journal}}
: Explicit use of et al. in:|author=
(help)CS1 maint: multiple names: authors list (link) - ^ a b 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. doi:10.1016/S0090-4295(03)00583-1. PMID 14550427.
{{cite journal}}
: Explicit use of et al. in:|author=
(help)CS1 maint: multiple names: authors list (link) - ^ a b "Multi-disciplinary Approach to the Study of Chronic Pelvic Pain". NIDDK - Department of Health and Human Services. 2007. Retrieved 2008-02-12.
- ^ Ullrich PM, Turner JA, Ciol M, Berger R (2005). "Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain". Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 30 (2): 112–8. doi:10.1207/s15324796abm3002_3. PMID 16173907.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Theoharides, TC.; Whitmore, K.; Stanford, E.; Moldwin, R.; O'Leary, MP. (2008). "Interstitial cystitis: bladder pain and beyond". Expert Opin Pharmacother. 9 (17): 2979–94. doi:10.1517/14656560802519845. PMID 19006474.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Murphy, AB.; Macejko, A.; Taylor, A.; Nadler, RB. (2009). "Chronic prostatitis: management strategies". Drugs. 69 (1): 71–84. doi:10.2165/00003495-200969010-00005. PMID 19192937.
{{cite journal}}
: Cite has empty unknown parameter:|month=
(help) - ^ Dimitrakov, J.; Dimitrakova, E. (2009). "Urologic chronic pelvic pain syndrome--looking back and looking forward". Folia Med (Plovdiv). 51 (3): 42–4. PMID 19957562.
{{cite journal}}
: Cite has empty unknown parameter:|month=
(help) - ^ Shoskes DA, Thomas KD, Gomez E (2005). "Anti-nanobacterial therapy for men with chronic prostatitis/chronic pelvic pain syndrome and prostatic stones: preliminary experience". J. Urol. 173 (2): 474–7. doi:10.1097/01.ju.0000150062.60633.b2. PMID 15643213.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Rempe S, Hayden JM, Robbins RA, Hoyt JC (2007). "Tetracyclines and pulmonary inflammation". Endocr Metab Immune Disord Drug Targets. 7 (4): 232–6. doi:10.2174/187153007782794344. PMID 18220943.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Urbano P, Urbano F (2007). "Nanobacteria: facts or fancies?". PLoS Pathogens. 3 (5): e55. doi:10.1371/journal.ppat.0030055. PMC 1876495. PMID 17530922.
{{cite journal}}
: CS1 maint: unflagged free DOI (link) - ^ Urbano P, Urbano F (2007). "Nanobacteria: Facts or Fancies?". PLoS Pathogens. Retrieved 2008-01-15.
- ^ Michael Hopkin (2008). "Nanobacteria theory takes a hit". Nature. Retrieved 2008-04-29.
- ^ Martel J, Young JD (2008). "Purported nanobacteria in human blood as calcium carbonate nanoparticles". Proc. Natl. Acad. Sci. U.S.A. 105 (14): 5549–54. doi:10.1073/pnas.0711744105. PMC 2291092. PMID 18385376.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Leskinen MJ, Vainionp R, Syrjnen S; et al. (2003). "Herpes simplex virus, cytomegalovirus, and papillomavirus DNA are not found in patients with chronic pelvic pain syndrome undergoing radical prostatectomy for localized prostate cancer". Urology. 61 (2): 397–401. doi:10.1016/S0090-4295(02)02166-0. PMID 12597955.
{{cite journal}}
: Explicit use of et al. in:|author=
(help)CS1 maint: multiple names: authors list (link) - ^ Benson PJ, Smith CS (1992). "Cytomegalovirus prostatitis". Urology. 40 (2): 165–7. doi:10.1016/0090-4295(92)90520-7. PMID 1323895.
- ^ Mastroianni A, Coronado O, Manfredi R, Chiodo F, Scarani P (1996). "Acute cytomegalovirus prostatitis in AIDS". Genitourinary medicine. 72 (6): 447–8. PMC 1195741. PMID 9038649.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ McKay TC, Albala DM, Sendelbach K, Gattuso P (1994). "Cytomegalovirus prostatitis. Case report and review of the literature". International urology and nephrology. 26 (5): 535–40. PMID 7860201.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Doble A, Harris JR, Taylor-Robinson D (1991). "Prostatodynia and herpes simplex virus infection". Urology. 38 (3): 247–8. doi:10.1016/S0090-4295(91)80355-B. PMID 1653479.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Hedelin H, Jonsson K (2007). "Chronic prostatitis/chronic pelvic pain syndrome: symptoms are aggravated by cold and become less distressing with age and time". Scand. J. Urol. Nephrol. 41 (6): 516–20. doi:10.1080/00365590701428517. PMID 17853027.
- ^ a b Hedelin H, Jonsson K (2007). "Chronic abacterial prostatitis and cold exposure: an explorative study". Scand. J. Urol. Nephrol. 41 (5): 430–5. doi:10.1080/00365590701365123. PMID 17853032.
- ^ Gao DJ, Guo YS, Yu HY, Wang YJ, Cui WG (2007). "[Prevalence and related factors of prostatitis-like symptoms in young men]". Zhonghua Nan Ke Xue (in Chinese). 13 (12): 1087–90. PMID 18284056.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Mehik A, Hellström P, Lukkarinen O, Sarpola A, Järvelin M (2000). "Epidemiology of prostatitis in Finnish men: a population-based cross-sectional study". BJU Int. 86 (4): 443–8. doi:10.1046/j.1464-410X.2000.00836.x. PMID 10971269.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Habermacher GM, Chason JT, Schaeffer AJ (2006). "Prostatitis/chronic pelvic pain syndrome". Annu. Rev. Med. 57: 195–206. doi:10.1146/annurev.med.57.011205.135654. PMID 16409145.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Daniel Shoskes (2008). Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Humana Press. p. 171. ISBN 1934115274.
- ^ A Pontari, M. (2002). "Inflammation and anti-inflammatory therapy in chronic prostatitis". Urology. 60 (6 Suppl): 29–33, discussion 33–4. doi:10.1016/S0090-4295(02)02381-6. PMID 12521589.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Ding XG, Li SW, Zheng XM, Hu LQ (2006). "[IFN-gamma and TGF-beta1, levels in the EPS of patients with chronic abacterial prostatitis]". Zhonghua Nan Ke Xue (in Chinese). 12 (11): 982–4. PMID 17146921.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ a b Weidner W, Anderson RU (2007). "Evaluation of acute and chronic bacterial prostatitis and diagnostic management of chronic prostatitis/chronic pelvic pain syndrome with special reference to infection/inflammation". Int J Antimicrob Agents. 31: 91. doi:10.1016/j.ijantimicag.2007.07.044. PMID 18162376.
- ^ Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S (2008). "Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study". J. Urol. 179 (2): 556–60. doi:10.1016/j.juro.2007.09.088. PMC 2664648. PMID 18082223.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ a b Nickel JC, Alexander RB, Schaeffer AJ, Landis JR, Knauss JS, Propert KJ (2003). "Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls". J. Urol. 170 (3): 818–22. doi:10.1097/01.ju.0000082252.49374.e9. PMID 12913707.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ McNaughton Collins, M.; Fowler, FJ.; Elliott, DB.; Albertsen, PC.; Barry, MJ. (2000). "Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?". Urology. 55 (3): 403–7. doi:10.1016/S0090-4295(99)00536-1. PMID 10699621.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Leslie A Aaron; et al. (2001). "Comorbid Clinical Conditions in Chronic Fatigue, A Co-Twin Control Study". J Gen Intern Med. 16 (1): 24–31. doi:10.1111/j.1525-1497.2001.03419.x. PMC 1495162. PMID 11251747.
{{cite journal}}
: Explicit use of et al. in:|author=
(help) - ^ He, L.; Wang, Y.; Long, Z.; Jiang, C. (2009). "Clinical Significance of IL-2, IL-10, and TNF-alpha in Prostatic Secretion of Patients With Chronic Prostatitis". Urology. 75 (3): 654–7. doi:10.1016/j.urology.2009.09.061. PMID 19963254.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Pasqualotto, FF.; Sharma, RK.; Potts, JM.; Nelson, DR.; Thomas, AJ.; Agarwal, A. (2000). "Seminal oxidative stress in patients with chronic prostatitis". Urology. 55 (6): 881–5. doi:10.1016/S0090-4295(99)00613-5. PMID 10840100.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Penna, G.; Mondaini, N.; Amuchastegui, S.; Degli Innocenti, S.; Carini, M.; Giubilei, G.; Fibbi, B.; Colli, E.; Maggi, M. (2007). "Seminal plasma cytokines and chemokines in prostate inflammation: interleukin 8 as a predictive biomarker in chronic prostatitis/chronic pelvic pain syndrome and benign prostatic hyperplasia". Eur Urol. 51 (2): 524–33, discussion 533. doi:10.1016/j.eururo.2006.07.016. PMID 16905241.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Khadra, A.; Fletcher, P.; Luzzi, G.; Shattock, R.; Hay, P. (2006). "Interleukin-8 levels in seminal plasma in chronic prostatitis/chronic pelvic pain syndrome and nonspecific urethritis". BJU Int. 97 (5): 1043–6. doi:10.1111/j.1464-410X.2006.06133.x. PMID 16643489.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Chiari R (1983). "Urethral obstruction and prostatitis". Int Urol Nephrol. 15 (3): 245–55. doi:10.1007/BF02083011. PMID 6654631.
- ^ Hruz P, Danuser H, Studer UE, Hochreiter WW (2003). "Non-inflammatory chronic pelvic pain syndrome can be caused by bladder neck hypertrophy". Eur. Urol. 44 (1): 106–10, discussion 110. doi:10.1016/S0302-2838(03)00203-3. PMID 12814683.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Romero Pérez P, Mira Llinares A (1996). "[Complications of the lower urinary tract secondary to urethral stenosis]". Actas Urol Esp (in Spanish; Castilian). 20 (9): 786–93. PMID 9065088.
{{cite journal}}
: CS1 maint: unrecognized language (link) - ^ Potts J, Payne RE (2007). "Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key". Cleveland Clinic journal of medicine. 74 (Suppl 3): S63–71. doi:10.3949/ccjm.74.Suppl_3.S63. PMID 17549825.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Anderson, RU.; Orenberg, EK.; Morey, A.; Chavez, N.; Chan, CA. (2009). "Stress induced hypothalamus-pituitary-adrenal axis responses and disturbances in psychological profiles in men with chronic prostatitis/chronic pelvic pain syndrome". J Urol. 182 (5): 2319–24. doi:10.1016/j.juro.2009.07.042. PMID 19762053.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Li, HC.; Wang, ZL.; Li, HL.; Zhang, N.; Chen, HW.; Zhang, P.; Gan, WM.; Chong, T.; Wang, ZM. (2008). "[Correlation of the prognosis of chronic prostatitis/chronic pelvic pain syndrome with psychological and other factors: a Cox regression analysis]". Zhonghua Nan Ke Xue. 14 (8): 723–7. PMID 18817346.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Clemens, JQ.; Brown, SO.; Calhoun, EA. (2008). "Mental health diagnoses in patients with interstitial cystitis/painful bladder syndrome and chronic prostatitis/chronic pelvic pain syndrome: a case/control study". J Urol. 180 (4): 1378–82. doi:10.1016/j.juro.2008.06.032. PMC 2569829. PMID 18707716.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Giubilei G, Mondaini N, Minervini A; et al. (2007). "Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments--could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study". J. Urol. 177 (1): 159–65. doi:10.1016/j.juro.2006.08.107. PMID 17162029.
{{cite journal}}
: Explicit use of et al. in:|author=
(help)CS1 maint: multiple names: authors list (link) - ^ Rosted P (2007). "Chronic prostatitis/chronic pelvic pain syndrome and acupuncture - a case report". Acupunct Med. 25 (4): 198–9. doi:10.1136/aim.25.4.198. PMID 18160930.
- ^ "The Stanford Protocol". 2005. Retrieved 2006-12-09. Video
- ^ Cornel EB, van Haarst EP, Schaarsberg RW, Geels J (2005). "The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III". Eur. Urol. 47 (5): 607–11. doi:10.1016/j.eururo.2004.12.014. PMID 15826751.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 11113739, please use {{cite journal}} with
|pmid=11113739
instead. - ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 9146624, please use {{cite journal}} with
|pmid=9146624
instead. - ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 19751259, please use {{cite journal}} with
|pmid=19751259
instead. - ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 16978277, please use {{cite journal}} with
|pmid=16978277
instead. - ^ "Prostatitis and Wheat". www.chronicprostatitis.com. Retrieved 2009-11-05.
- ^ "Pharmacological treatment options for prostatitis/chronic pelvic pain syndrome". 2006. Retrieved 2006-12-11.
- ^ a b Duclos, AJ.; Lee, CT.; Shoskes, DA. (2007). "Current treatment options in the management of chronic prostatitis". Ther Clin Risk Manag. 3 (4): 507–12. PMC 2374945. PMID 18472971.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Wagenlehner, FM.; Naber, KG.; Bschleipfer, T.; Brähler, E.; Weidner, W. (2009). "Prostatitis and male pelvic pain syndrome: diagnosis and treatment". Dtsch Arztebl Int. 106 (11): 175–83. doi:10.3238/arztebl.2009.0175. PMC 2695374. PMID 19568373.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Hua VN, Williams DH, Schaeffer AJ (2005). "Role of bacteria in chronic prostatitis/chronic pelvic pain syndrome". Curr Urol Rep. 6 (4): 300–6. doi:10.1007/s11934-005-0028-z. PMID 15978234.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Nickel JC, Forrest JB, Tomera K; et al. (2005). "Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicenter, randomized, placebo controlled study". J. Urol. 173 (4): 1252–5. doi:10.1097/01.ju.0000159198.83103.01. PMID 15758763.
{{cite journal}}
: Explicit use of et al. in:|author=
(help); Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ 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. doi:10.1016/S0090-4295(99)00358-1. PMID 10604689.
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Shahed, AR.; Shoskes, DA. (2000). "Oxidative stress in prostatic fluid of patients with chronic pelvic pain syndrome: correlation with gram positive bacterial growth and treatment response". J Androl. 21 (5): 669–75. PMID 10975414.
{{cite journal}}
: Cite has empty unknown parameter:|month=
(help) - ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 12050565 , please use {{cite journal}} with
|pmid=12050565
instead. - ^ Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brähler E, Weidner W (2009). "A Pollen Extract (Cernilton) in Patients with Inflammatory Chronic Prostatitis-Chronic Pelvic Pain Syndrome: A Multicentre, Randomised, Prospective, Double-Blind, Placebo-Controlled Phase 3 Study". Eur. Urol. 56 (3): 544–51. doi:10.1016/j.eururo.2009.05.046. PMID 19524353.
{{cite journal}}
: Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ 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.
- ^ Potts JM (2005). "Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome". Current urology reports. 6 (4): 313–7. doi:10.1007/s11934-005-0030-5. PMID 15978236.
- ^ "Management of Men Diagnosed With Chronic Prostatitis/Chronic Pelvic Pain Syndrome Who Have Failed Traditional Management". www.ncbi.nlm.nih.gov. Retrieved 2009-12-13.
- ^ 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)
{{cite journal}}
: CS1 maint: multiple names: authors list (link) - ^ Nickel JC, Krieger JN, McNaughton-Collins M; et al. (2008). "Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome". N. Engl. J. Med. 359 (25): 2663–73. doi:10.1056/NEJMoa0803240. PMC 2815340. PMID 19092152.
{{cite journal}}
: Explicit use of et al. in:|author=
(help); Unknown parameter|month=
ignored (help)CS1 maint: multiple names: authors list (link) - ^ Nickel JC (2007). "Treatment of chronic prostatitis/chronic pelvic pain syndrome". Int J Antimicrob Agents. 31: 112. doi:10.1016/j.ijantimicag.2007.07.028. PMC 2245867. PMID 17954024.
- ^ Leskinen, MJ.; Kilponen, A.; Lukkarinen, O.; Tammela, TL. (2002). "Transurethral needle ablation for the treatment of chronic pelvic pain syndrome (category III prostatitis): a randomized, sham-controlled study". Urology. 60 (2): 300–4. doi:10.1016/S0090-4295(02)01704-1. PMID 12137830.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Shoskes, DA.; Katz, E. (2005). "Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome". Curr Urol Rep. 6 (4): 296–9. doi:10.1007/s11934-005-0027-0. PMID 15978233.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Bergman, J.; Zeitlin, SI. (2007). "Prostatitis and chronic prostatitis/chronic pelvic pain syndrome". Expert Rev Neurother. 7 (3): 301–7. doi:10.1586/14737175.7.3.301. PMID 17341178.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ "Anderson goes". Australian Broadcasting Corporation Transcript. Retrieved 2008-05-12.
- ^ Allison Reitz (2009). "John Cleese tour pays the 'Alimony' with West Coast comedy shows". tickenews.com. Archived from the original on 2009-07-28. Retrieved 2009-07-28.
The star of Monty Python and "A Fish Called Wanda" has been diagnosed with prostatitis, the inflammation of the prostate gland and is undergoing treatment.
{{cite web}}
: Unknown parameter|month=
ignored (help) - ^ Roger Ebert. "The whole truth from Vincent Gallour Flies". Chicago Sun Times. Retrieved 2008-05-30.
- ^ "Glenn Gould as Patient". Retrieved 2008-05-12.
- ^ Dallek, Robert (2003). An Unfinished Life: John F. Kennedy 1917-1963. Boston: Little, Brown. p. 123. ISBN 0316172383.
- ^ "The Howard Stern Show for September 4, 2007". Howard Stern. Retrieved 2008-05-12.
- ^ "The Howard Stern Show for September 5, 2007, PULLING OUT A PLUM". Howard Stern. Retrieved 2008-05-12.
- ^ Leavitt, David (2008-05-11). "Styron's Choices". NY Times. Retrieved 2008-05-12.