United Kingdom National guideline for the management of prostatitis

United Kingdom National guideline for the management
of prostatitis
Clinical Effectiveness Group
British Association of Sexual Health and HIV
Introduction and Methodology
Scope and Purpose: This guideline offers recommendations on the
management of acute and chronic prostatitis in the setting of
genitourinary medicine clinics. It applies primarily to men aged 18 years
or older presenting to health care professionals, working in departments
offering level 3 care in Sexual Health (see national strategy) within the
United Kingdom. However, the recommendations should prove useful in
other settings such as urology and primary care.
Stakeholder involvement: The authors are clinicians working in this field.
Members of BASHH have had the opportunity to comment on the
guideline, prior to publication.
Rigour of Development: Search Strategy – Medline Search 1996-2006
using keyword “prostatitis” “pelvic pain, male” and “chronic pelvic pain,
male”. Cochrane Database of Systematic reviews and the Cochrane
Controlled Trials Register up 2007 using keyword “prostatitis”. Additional
studies and review articles were identified through a manual search of
bibliographies of retrieved articles
Inclusion/exclusion of evidence criteria: Where available systematic
reviews were used. Studies were limited to humans and English language.
The previous guidelines (published in 2000) were used as a framework
that was revised and updated.
Classification
Prostatitis is classified into the following categories as recommended by
the US National Institutes for Health (NIH) [1]
I
II
III
IV
Acute bacterial prostatitis
Chronic bacterial prostatitis
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
A Inflammatory
B Non-inflammatory
(This division, based on the four-glass test, has not been
shown to be of any clinical or prognostic significance ([2])
Asymptomatic inflammatory prostatitis
(This is a histological diagnosis in patients undergoing a
prostate biopsy and is not discussed further in these
guidelines.)
Acute and chronic bacterial prostatitis account for <5% of all prostatitis
diagnoses; their precise incidence is unknown.
Acute Prostatitis
Aetiology
Acute prostatitis is caused by urinary tract pathogens [3]. These include:
• Gram negative organisms, most commonly Escherichia coli, Proteus
spp, Klebsiella spp and Pseudomonas spp
• Enterococci
• Staphylococcus aureus due to prolonged catheterisation
• Rarely anaerobes such as Bacteroides spp
Mode of Transmission
Infection may spread from the distal urethra/urethral meatus but can also
spread from the bladder, blood and lymphatic system. Acute prostatitis is
an uncommon complication of UTI.
Clinical features
Symptoms [4,5,6]
Acute prostatitis is an acute severe systemic illness.
Symptoms include:
• symptoms of a urinary tract infection: dysuria, frequency and
urgency
• symptoms of prostatitis: low back pain, perineal, penile and
sometimes rectal pain
• symptoms of bacteraemia: fever and rigors; arthralgia and myalgia
may occur
Signs [4,5,6]
Signs include:
• signs localised to the prostate: an extremely tender, swollen and
tense, smooth textured prostate gland which is warm to the touch
• signs of the bacteraemia: pyrexia and tachycardia
Complications
Patients with acute prostatitis may present with acute retention
secondary to prostatic oedema
Prostatic abscess, bacteraemia, epididymitis and pyelonephritis.
Diagnosis
• Mid-stream urine sample for dipstick testing, culture for bacteria and
antibiotic sensitivity
• Blood cultures for bacteria and antibiotic sensitivity
• Prostatic massage should not be performed on patients with acute
bacterial prostatitis. This may be painful, can precipitate bacteraemia,
and is likely to be of little benefit as pathogens are almost always
isolated from urine.
•
Management
General Advice
Adequate hydration should be maintained, rest encouraged and
analgesics such as non-steroidal anti-inflammatory drugs if required
•
•
•
•
•
Treatment
As acute prostatitis is a serious and severe illness empirical therapy
should be started immediately after blood and urine cultures have
been obtained.
Parenteral or oral treatment should be selected according to the
clinical condition of the patient. If there is deterioration or failure to
respond to oral therapy urgent admission and parenteral therapy
should be arranged.
Good antibiotic penetration into all areas of the prostate gland is
achieved because of the intense inflammation.
Antibiotics should be continued or changed according to sensitivity
results.
If acute retention occurs suprapubic catheterisation should be
performed to avoid damage to the swollen prostate [6].
Recommended Regimens
For patients requiring parenteral therapy antibiotics covering the likely
organisms should be used [7].
• A high dose broad spectrum cephalosporin (for example,
cefuroxime, cefotaxime or Ceftriaxone) plus gentamicin (level of
evidence IV, grade of recommendation C)
• When clinically improved the therapy can be switched to oral
treatment according to sensitivities.
For patients suitable for oral therapy, quinolones can be used [8,9]:
• Ciprofloxacin 500mg twice daily for 28 days (IV, C) [9]
or
• Ofloxacin 200mg twice daily for 28 days (IV, C) [10,11].
Allergy
For patients intolerant of, or allergic to, quinolones an alternative is:
• Trimethoprim 200mg twice daily for 28 days (IV, C).
Sexual partners
Treatment of sexual partners is not required.
Follow-up
• If the patient fails to respond fully to therapy the diagnosis of a
prostatic abscess should be considered [12]. This can be confirmed
by transrectal ultrasound scan or computed tomography scan of the
prostate. If present, perineal or transurethral drainage is necessary
[6].
• If acute prostatitis is managed correctly the prognosis is good. The
optimal duration of treatment is not known. 4 weeks of antibiotic
therapy is usually recommended to reduce the risk of developing
chronic bacterial prostatitis [4].
• Following recovery, the urinary tract should be investigated to
exclude a structural cause for urinary tract infection.
Chronic Bacterial Prostatitis (CBP)
This is chronic bacterial infection of the prostate with or without
symptoms of prostatitis, and with a history of recurrent urinary tract
infections caused by the same bacterial strain without any structural
abnormalities. It is rare in comparison to CP/CPPS.
Aetiology
The usual causative bacteria are those causing urinary tract infection,
most commonly E coli [13]. Some Gram positive organisms such as
Staphylococcus aureus and Enterococcus faecalis may cause CBP [14,15].
The role of other Gram positive organisms such as coagulase negative
staphylococci, non-group D streptococci and diptheroids remains
controversial and subject to debate [16].
Clinical Features
Symptoms
Typically there is a history of recurrent or relapsing urinary tract
infection, urethritis or epididymitis.
Patients frequently report genitourinary and pelvic pain / discomfort
during a flare-up and alleviation of symptoms after antibiotic
treatment.
They may be asymptomatic between acute episodes or have mild
pelvic pain or irritative voiding symptoms (frequency, urgency).
Signs
Apyrexial, no systemic signs.
The patient may have a diffusely tender prostate during acute
episodes otherwise no objective clinical signs.
Diagnosis
This is usually based on history of recurrent urinary tract infections by the
same bacterial strain and the exclusion of other causes. In particular, no
structural reason for recurrent urinary tract infection is identified on
urinary tract imaging.
Investigations
1. Urine dipstick test (for evidence of urinary tract infection or other
abnormality that may require investigation e.g. haematuria).
2. MSU - urine cultures are sterile unless an acute urinary tract
infection is present - review past MSU results.
3. Urinary tract imaging (ultrasound or IVU) to exclude structural
abnormalities.
4. Lower urinary tract localisation study or “four-glass test” (see
appendix 1 for details of this). The reliability of this test is not
known because a gold standard for the diagnosis is not available.
The four-glass test is not widely used in clinical practice and may
not alter patient management [17]. Nonetheless, in suspected CBP
it may be considered and can confirm the diagnosis.
5. Urodynamics – may be considered, to exclude other conditions
predisposing to recurrent UTI.
Management
General advice
Patients should be given a detailed explanation of their condition – that
the prostate is a focus of infection which causes recurrent urinary tract
infection with particular emphasis on the long-term implications for their
health and the possibility of further episodes of urinary tract infection
unless the focus is eradicated by successful treatment. Clear and accurate
written information can help to reinforce this.
Treatment
Antibiotic treatment should be chosen according to bacterial cultures and
sensitivities.
Fluoroquinolones have become standard of care in CBP (Ib, A) – they
have good penetration of the prostate gland and broad spectrum activity
against both gram-negative and gram-positive organisms [18,19,20].
Most comparative studies have shown similar rates of clinical success
and/or bacteriological cure for the fluoroquinolones [20]. The
recommendations for other antibiotics are based on small studies plus
expert opinion.
Recommended regimens
For patients with CBP first-line treatment is with a quinolone such as [20]
•
or
•
or
•
or
•
Ciprofloxacin 500mg twice daily for 28 days (Ib, A) [15,21]
Levofloxacin 500mg od for 28 days (Ib,A) [15,22]
Ofloxacin 200mg twice daily for 28 days (III, B) [23.24]
Norfloxacin 400mg twice daily for 28 days (III, B) [25,26]
Side effects of quinolones – generally well tolerated but tendon damage
including rupture has occurred very rarely. Recent FDA recommendations
include advising the patient that at the first sign of tendon pain, swelling
or inflammation they should stop taking the drug, avoid exercise and use
of affected area and contact their doctor [27].
Allergy
For those allergic to quinolones or in patients recommended to avoid
quinolones (epilepsy or prone to seizures) treatment should be selected
according to antibiotic sensitivities of the bacterial isolate, and an
antibiotic with good penetration into the prostate should be chosen.
There is poor evidence for these alternative antibiotics.
Options include:
• Minocycline 100mg twice daily for 28 days [28] (III, B) (In practice
most experts would use doxycycline 100mg twice daily for 28 days
because of more toxicity with minocycline.)
or
• Trimethoprim 200mg twice daily for 28 days (IV,B)
If minocycline or doxycycline are used antibiotic sensitivity testing is
important, as many urinary pathogens are tetracycline resistant.
Alpha blockers – there is small amount of evidence that adding in alpha
blockers to antibiotics may improve symptoms of chronic bacterial
prostatitis and relapse rate but the study was difficult to analyse [29].
Some investigators have reported the use of submucosal injections of
antibiotics but this approach is not widely used [30].
Follow-up
Patients with CBP are at risk of relapse and should have a repeat MSU
after completing treatment.
For recurrent UTI after 28 days of treatment, further investigation for
predisposing conditions should be considered, antibiotic sensitivities
should be rechecked and the treatment repeated. Prolonged courses of
antibiotic (e.g. 3 months) may be tried but have not been studied
systematically.
Prostatic calculi have been suggested as a source for recurrent infection
[6]. They are very common radiographically [31,32]. Radical transurethral
prostatectomy or total prostatectomy have been reported to be effective
in a small number of patients if they are selected carefully and for very
specific indications, but usually this is not justified [33,34].
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
Introduction
This is a common chronic condition with estimates of between 2 and 14%
lifetime prevalence [35,36,37,38].
It cannot be rigidly defined but a suggested definition is the presence of
typical symptoms of discomfort or pain in the genital or pelvic region for
more than 3 months within the past 6 months [39].
Aetiology
Unknown aetiology, may be multifactorial.
Proposed mechanisms include:
• Infection (there is no evidence that CPPS is caused by an STI)
[13,40,41]
• Immunological [42,43,44,45,46]
• Autoimmunity [47,48]
• Neuromuscular spasm/pelvic floor muscle dysfunction [49,50]
• Intraprostatic urine reflux [51,52,53,54]
• Voiding dysfunction leading to increased intraprostatic pressure [54]
• Neurogenic inflammation [55]
• Functional somatic syndrome [56,57]
• Chronic pain syndrome [58,59]
Clinical features
Symptoms
Urological pain [1] including
• perineal pain
• lower abdominal pain
• penile pain (especially penile tip)
• testicular pain
• rectal and lower back pain
• ejaculatory pain
Patients also complain of variable irritative and obstructive symptoms
and/or ejaculatory disturbance [60].
The constellation of symptoms appear to be relatively similar and
consistent in men with CP/CPPS [61].
The symptoms usually remain constant although some men have large
fluctuations in the severity of symptoms over time [61].
Strictly, symptoms should have been present for at least 3 months to
diagnose CPPS [1] although in practice the diagnosis is often suspected
after a shorter duration of symptoms (see definition above).
There are several exclusion criteria for the diagnosis –
• Active urethritis, urogenital cancer, urinary tract disease, functionally
significant urethral stricture or neurological disease affecting the
bladder[1]
Assessment of symptoms
Symptom inventory or index (NIH CPSI) (see appendix 2)
This is a validated symptom questionnaire that scores on pain,
voiding dysfunction and quality of life [62]. It should not be used to
diagnose CP/CPPS but may be useful as an evaluative tool to assess
current symptoms and their impact. It is also useful in assessing
changes in symptom severity and impact during follow up, and as
an outcome measure following treatment [63].
Signs
There are few objective clinical signs and the prostate gland may, or may
not, be locally or diffusely tender to palpation.
Complications
Significant physical and psychological impact – cross-sectional studies
have shown sickness impact scores comparable to those with angina and
Crohn’s disease [64] and mental health scores worse than the most
severe subgroups of diabetes mellitus and chronic heart failure [65].
Diagnosis
There is no gold standard diagnostic test for this condition, therefore
CP/CPPS is a diagnosis of exclusion [66].
Diagnosis is usually made on a typical history and not on examination or
investigation findings.
The initial diagnostic evaluation of a patient presenting with pelvic pain
should consider the possibility of other underlying disease or disorder that
could cause the symptoms [67]. Atypical presentations may require
investigation to exclude other conditions before the diagnosis is made.
Initial screening should involve taking a complete history, examination
including digital rectal examination, urinalysis and MSU microscopy and
culture [66,67,68].
Test no longer recommended:
Lower urinary tract localisation study (four-glass test) (see appendix 1 for
details of this)
Recent studies have reported that localising leucocytes/bacteria to
the prostate cannot accurately differentiate between men with
CP/CPPS and men without symptoms [2] and results of the test do
not correlate with duration, frequency and severity of symptoms
[69]. The test procedure has not been standardised [70]. Some
argue that the test should be confined to research. It is not widely
used in clinical practice [17,71] and may not alter patient
management [72]. Therefore the test cannot be recommended in
the routine investigation of CP/CPPS.
Further tests that may be considered:
STI screen
Non-specific urethritis (NSU), chlamydia and gonorrhoea should be
excluded.
In selected patients:
Urine cytology – if the patient has microscopic haematuria with frequency,
urgency and dysuria urine cytology should be performed to help exclude
lower urinary tract malignancy [73]. Patients with unexplained
haematuria should be referred to an urologist.
PSA – PSA is recommended if indicated by abnormal prostate on digital
rectal examination [74]. Prostatic tenderness is not an indication. PSA can
be elevated during active inflammation of the prostate [75].
Simple urodynamics [76] – may identify bladder neck dysfunction,
bladder outflow obstruction and incomplete bladder emptying particularly
in those with urinary symptoms.
Transrectal ultrasound (TRUS) – is not useful in differentiating the various
forms of chronic prostatitis [77]. TRUS may identify prostatic calcification
but the significance of this is uncertain. Anecdotal reports indicate that
TRUS may rarely identify a treatable prostatic abscess or cyst, seminal
vesicle or ejaculatory duct abnormality [78](which may present with
ejaculatory pain), but its routine use in the investigation of suspected
CP/CPPS is not justified.
Patients with atypical presentations of CP/CPPS and unexplained
urological symptoms should be referred to a urologist.
Management
General advice
Patients should be given a detailed explanation of their condition with
reassurance, indicating that CP/CPPS is a non-malignant condition and not
a sexually transmitted infection that has a tendency to persist [79]. The
cause has not been determined with certainty but infection is unlikely.
Diagrams and written information (a leaflet) may be helpful. (further
information can be obtained from www.prostatitis.org)
Treatment
There are no reliably effective treatments for CP/CPPS [66,80,81]. Few
randomised, controlled trials are available and no large scale, welldesigned trials have been conducted. An observational report from a
specialised prostatitis clinic reported reasonable clinical results in only one
third of patients with monotherapy [82]. This may not reflect the
prognosis in newly diagnosed patients. Multimodal therapy (i.e. using
multiple treatment types simultaneously) has therefore been proposed
but this is not based on evidence from randomised trials [83].
Treatment should be individualised as CP/CPPS is not a standardised
disease or specific inflammatory process but rather a clinical syndrome.
Antibiotics (III,C)
There is no convincing evidence that antibiotics are effective in CP/CPPS.
Many clinicians try antibiotics initially, as there is evidence that some
patients benefit in uncontrolled clinical studies [84].
The effects of antibiotics could be a placebo effect as there appears to be
a large placebo effect in most RCTs in this condition [85,86,87] or related
to anti-inflammatory properties of some antibiotics such as doxycycline
and fluoroquinolones [88,89]; or antibiotics may eradicate bacteria that
are not routinely cultured or culturable.
Two recent RCTs have shown no benefit of antibiotics versus placebo but
both of these studies were in heavily pretreated patients [83,85]. The
value of antibiotic treatment in treatment naive men has not been
assessed.
The toxicity of antibiotics, particularly prolonged use of fluoroquinolones,
must also be considered. There is also concern that use of
fluoroquinolones may increase susceptibility to C. difficile infection [90].
Alpha-blockers (Ia,A)
There is modest evidence of their efficacy in CP/CPPS and a trial should
be considered in patients with troublesome persistent symptoms. A
systematic review showed a relative risk of improvement of 0.57
translating as number needed to treat of 6 [80]. The evidence suggests
prolonged treatment is needed (14-24 weeks) to show a clinically
significant effect and benefits appear greatest in those naïve to alphablockers.
RCTs where benefit was found included the following drugs and doses:
• Alfuzosin 5mg bd for 6 months [86]. Alfuzosin modified release 10
mg nocte may be used as an alternative but has not been evaluated;
• Tamsulosin 0.4mg for 6 weeks [91,92]
• Terazosin 1mg for 4 days , 2mg for 10 days then 5mg for 12 weeks
(14 weeks total) [87], or terazosin 5mg for 8 weeks [93] or terazosin
1-2mg tds for 6 months [94]
• Doxazosin 4mg daily for 6 months [95]
A further RCT [83] found no benefit with tamsulosin 0.4mg for 6
weeks; however patients were highly pretreated and probably not
naïve to alpha blockers.
Side effects of alpha blockers of significance – postural hypotension
and headache.
Other treatments
Limited evidence of effectiveness (from at least one RCT) has been
reported for the following investigational treatments (in alphabetical
order):
Finasteride (IbA) [96]
Fluoxetine (IbA)[97]
Mepartricin (IbA)[98]
Pelvic electromagnetic therapy (IbA) [99]
Prostat/poltit (pollen extract) (IbA)[100]
Quercetin (IbA) [101]
The following investigational treatments are of unknown
effectiveness, and cannot be recommended, because reported
studies are case series, uncontrolled trials or small RCTs showing no
statistical benefit:
Aerobic exercise [102]
Acupuncture [103]
Allopurinol [104]
Biofeedback, pelvic floor re-education and bladder training
[105,106]
Botulinum toxin A [107]
Capsaicin [108]
Cernilton (pollen extract)[109]
Cooled transurethral microwave therapy [110]
Corticosteroids [111]
Ibuprofen [112]
Myofascial trigger point release and paradoxical relaxation training
[113]
Prostatic massage [114]
Pelvic floor physical therapy [115]
Pentosan polysulphate [116]
Percutaneous tibial nerve stimulation [117]
Sacral magnetic stimulation [118]
Sertraline [119]
Terpene mixture (rowatinex) [112]
Transurethral needle ablation (TUNA)[120]
Urethroanal stimulation [121]
Zafirlukast [122]
Tricyclic antidepressants (eg amitriptyline) are sometimes tried in
CP/CPPS but there are no published trials to support their use. They
have been shown to be effective in some patients with other forms
of chronic pain [123].
Sexual partners
Partner notification and empirical treatment of sexual partners are not
required unless a specific sexually transmitted pathogen is found at initial
screening. Management should be according to the guidelines for that
specific infection.
Follow-up
Chronic prostatitis is a difficult to manage, relapsing condition with
fluctuating symptoms and patients are typically followed up for long
periods of time.
No specific follow-up recommendations can be made.
The NIH chronic prostatitis symptom index can be used as an outcome
measure following treatment [62].
Prognosis
There is no evidence that CP/CPPS patients have a decreased survival
over 2 years [61]. Most of men initially diagnosed with CP/CPPS
experience symptom improvement over the following 6 months [124] In
one study approximately 33% of patients had no further symptoms one
year later [125]. In the largest prospective longitudinal evaluation of the
natural history of CP/CPPS, one-third of men showed moderate to marked
improvement over two years [61]. The prognosis appears to be worse in
those with previous episodes, more symptoms, depressive symptoms and
ejaculatory pain. [61,124, 125,126].
Qualifying statement
The recommendations in this guideline may not be appropriate for use in
all clinical situations. Decisions to follow these recommendations must be
based on the professional judgement of the clinician and consideration of
individual patient circumstances and available resources.
All possible care has been undertaken to ensure the publication of the
correct dosage of medication and route of administration. However, it
remains the responsibility of the prescribing physician to ensure the
accuracy and appropriateness of the medication they prescribe.
Auditable Outcome Measures
• Initial assessment of men with suspected CP/CPPS to include
documented history, examination including digital rectal examination,
urinalysis and MSU microscopy and culture (target 95%).
• Initial investigation of men (who have been sexually active) with
CP/CPPS to include STI screen (target 95%).
Acknowledgements
Authors and Centre
Emma Street, Janet Wilson, Department of Genitourinary Medicine, The
General Infirmary at Leeds. Graz Luzzi, Department of Genitourinary
Medicine, Wycombe Hospital, High Wycombe.
Membership of the CEG
Clinical Effectiveness Group: chairman, Keith Radcliffe; Imtyaz AhmedJushuf; David Daniels; Mark Fitzgerald; Neil Lazaro; Gillian McCarthy; Guy
Rooney.
Editorial Independence
This guideline was commissioned and edited by the CEG of the BASHH,
without external funding being sought or obtained.
No conflict of interest by any authors or group members.
References
1.Kreiger JN,Nyberg Jr, L and Nickel JC. NIH Consensus Definition and
Classification of Prostatitis. NEJM 1999;81(3):236-237.
2. Nickel JC, Alexander RB, Schaeffer AJ, et al. Leukocytes and bacteria in
men with chronic prostatitis/ chronic pelvic pain syndrome compared to
asymptomatic controls. J Urol 2003;170:818-822
3. Millan-Rodriguez F, Orsola de los Santos A, Veyreda-Martija JM, et al.
Management of acute prostatitis: experience with 84 patients (Spanish).
Arch Esp de Urol 1995;48:129-36 (abstract).
4. Pewitt EB, Schaeffer AJ. Urinary tract infection in urology, including
acute and chronic prostatitis. Infect Dis Clin N Am 1997;11:623-46.
5.Leigh DA. Prostatitis - an increasing clinical problem for diagnosis and
management. J Antimicrob Chemo 1993;32(suppl A):1-9.
6.Meares EM Jr. Acute and chronic prostatitis: Diagnosis and treatment.
Infect Dis Clin N Am 1987;1:855-873.
7.Katoh N, Ono Y, Ohshima S, et al. Diffusion of cefmenoxime and
latamoxef into prostatic fluid in patients with acute bacterial prostatitis.
Urologia Int 1992;48:191-4.
8.Arakawda S, Kamidono S, Hirose T, et al. Re-examination of the criteria
for clinical evaluation on bacterial prostatitis - analysis of the data of the
clinical study of tenafloxacin (Japanese). Hinyokika Kiyo - Acta Urologica
Japonica 1994;40:455-66 (abstract)
9.Andriole VT. Use of quinolones in treatment of prostatitis and lower
urinary tract infections. Eur J Clin Microbiol Infect Dis 1991;10:342-50
10. Suzuki K, Tamai H, Naide Y, et al. Laboratory and clinical study of
ofloxacin in the treatment of bacterial prostatitis (Japanese). Hinyokika
Kiyo - Acta Urologica Japonica 1984;30:1505-18 (abstract)
11 Remy G, Rouger C, Chavanet P, et al. Use of ofloxacin for prostatitis.
Rev Infect Dis 1988;10(suppl 1):173-4.
12. Meares EM Jr. Prostatic abscess. J Urol 1986;136:1281-2.
13. Weidner HG, Schiefer HG, Krauss H, et al. Chronic prostatitis: a
thorough search for etiologically involved micro-organisms in 1461
patients. Infection 1991;19 (suppl 3):S119-125.
14.Nickel JC and Moon T. Chronic Bacterial Prostatitis; An Evolving Clinical
Enigma. Urology 2005; 66(1): 2-8.
15. Bundrick W, Heron SP, Ray P,et al. Levofloxacin versus ciprofloxacin
in the Treatment of Chronic Bacterial Prostatitis: A Randomised Doubleblind Multicenter Study. Urology 2003;62(3):537-541.
16. Gorelick JI, Senterfit LB, Vaughan ED Jr. Quantitative bacterial tissue
culture from 209 prostatectomy specimens: findings and implications. J
Urol 1988;139:57-60.
17. McNaughton Collins M, Fowler FJ, Elliott DB, et al. Diagnosing and
Treating Chronic Prostatitis; do urologists use the four-glass test? Urology
2000;55(3);403-407.
18. Bjerklund Johansen TE, Gruneberg RN, Guibert J, et al. The role of
antibiotics in the treatment of chronic prostatitis: a consensus statement.
Eur Urol 1998; 34(6): 457-466.
19. Wagenlehner FME and Naber KG. Prostatitis: the role of antibiotic
treatment. World J Urol 2003;21:105-108.
20. Naber KG. Antibiotic treatment of chronic bacterial prostatitis in Nickel
JC (Ed) Textbook of Prostatitis 1999, 285-292.
21. Naber KG, the European Lomefloxacin Prostatitis Study Group.
Lomefloxacin versus ciprofloxacin in the treatment of chronic bacterial
prostatitis. Int J Antimic Agents 2002;20:18-27.
22.Giannorini G, Mogorovich A, Valent F ,et al. Prulifloxacin versus
levofloxacin in the treatment of chronic bacterial prostatitis: a prospective
randomized double-blind trial. J Chemother 2007;19(3):304-308.
23. Remy G, Rouger C, Chavanet P, et al. Use of ofloxacin for prostatitis.
Rev Infect Dis 1988;10(suppl1):173-4.
24 Koff W. Clinical trial comparing lemofloxacin and ofloxacin in the
treatment of chronic bacterial prostatitis. (Brasil) Revista-Brasileira-deMedicina 1996;53:88-91 (abstract).
25. Sabbaj J, Hoagland VL, Cook T. Norfloxacin verses cotrimoxazole in
the treatment of recurring urinary tract infections in men. Scand J Infect
Dis 1986;48(suppl):48-53.
26. Schaeffer AJ, Darras FS. The efficacy of norfloxacin in the treatment
of chronic bacterial prostatitis refractory to trimethoprimsulfamethoxazole and/or carbenicillin J Urol 1990;144:690-3.
27.FDA (Food and Drugs Adminstration), July 2008.
www.fda.gov/drug/InfoSheets/HCP/fluoroquinolonesHCP.htm. (last
accessed 9th September 2008).
28. Paulson DF, White RD. Trimethoprim-sulfamethoxazole and
minocycline-hydrochloride in the treatment of culture proven bacterial
prostatitis. J Urol 1978;120:184-5.
29.Barbalias GA, Nikiforidis G and Liatsikos EN. Alpha-blockers for the
treatment of chronic prostatitis in combination with antibiotics. J Urol
1998;159(3):883-887.
30.Wei-Lie HU,Zhong S-Z and Xe H-X. Treatment of chronic bacterial
prostatitis with amikacin through submucosal injection. Asian J Androl
2002;4:163-167..
31. Ludwig M, Weidner W, Schroeder-Printzen I, et al. Transrectal
prostatic sonography as a useful diagnostic means for patients with
chronic prostatitis or prostatodynia. Br J Urol 1994;73:664-8.
32. Peeling WB, Griffiths GJ. Imaging of the prostate by ultrasound. J Urol
1984;132:217-24.
33. Barnes RW, Hadley HL, O’Donoghue EP. Transurethral resection of the
prostate for chronic bacterial prostatitis. Prostate 1982;3:215-9.
34. Smart CJ, Jenkins JD, Lloyd RS. The painful prostate. Br J Urol
1975;47:861-9
35. Roberts RO, Jacobson DJ, Girman CJ, et al. Prevalence of Prostatitislike symptoms in a Community based cohort of older men. J Urol
2002;168;2467-2471.
36.Nickel JC, Downey J, Hunter D and Clark J. Prevalence of prostatitislike symptoms in a population based study using the National Institutes of
Health Chronic Prostatitis Symptom Index. J Urol 2001;165:842-845.
37.Mehik A, Hellstrom P, Lukkarinen O et al. Epidemiology of prostatitis in
Finnish men: a population-based cross-sectional study. BJU Int
2000;86:443-448.
38. Clemens JQ, Meenan RT, O’Keeffe-Rosetti MC, et al. Prevalence of
Prostatitis-Like Symptoms in a Managed Care Population. J Urol
2006;176(2):593-596
39. Schaeffer AJ, Datta NS, Fowler JE, et al. Overview Summary
Statement. Urology 2002 60(Suppl 6A):1-4.
40. Pontari MA and Ruggieri MR. Mechanisms in prostatitis/chronic pelvic
pain syndrome J Urol 2004;172(3):839-845.
41.Lee JC, Muller CH, Rothman I, et al. Prostate biopsy culture findings of
men with chronic pelvic pain syndrome do not differ from those of health
controls. J Urol 2003;169:584-588.
42. Khadra A, Fletcher P, Luzzi G, Shattock R and Hay P. Interleukin-8
levels in seminal plasma in chronic prostatitis/chronic pelvic pain
syndrome and nonspecific urethritis. BJU Int 2006;97:1043-1046.
43.Alexander RB, Ponniah S, Hasday J and Hebel JR. Elevated levels of
proinflammatory cytokines in the semen of patients with chronic
prostatitis/chronic pelvic pain syndrome Urology 1998;52:744-748.
44.Miller LJ, Fischer KA, Goralnick SJ, et al Interleukin-10 levels in
seminal plasma: implications for chronic prostatitis-chronic pelvic pain
syndrome. J Urol 2002;167:753-756.
45.Hochreiter WW, Nadler RB, Koch AE, et al. Evaluation of the cytokines
interleukin 8 and epithelial neutrophil-activating peptide 78 as indicators
of inflammation in prostatic secretions. Urology 2000;56:1025-1029.
46.Shoskes DA, Albakri Q, Thomas K and Cook D. Cytokine
polymorphisms in men with chronic prostatitis/chronic pelvic pain
syndrome: association with diagnosis and treatment response. J Urol
2002;168:331-335.
47. John H, Maake C, Barghorn A, et al. Immunological alterations in the
ejaculate of chronic prostatitis patients: clues for autoimmunity.
Andrologica 2003;35:294-299.
48. Batstone GR, Doble A and Gaston JS. Autoimmune T cell responses to
seminal plasma in chronic pelvic pain syndrome (CPPS). Clin Exp Immunol
2002;128:302.
49. Hetrick DC, Glazer H, Liu Y-W, et al. Pelvic floor electromyography in
men with chronic pelvic pain syndrome: a case-control study. Neurourol
and Neurodynamics.;25:46-49.
50. Zermann, D-H, Ishigooka M, Doggweiler R and Schmidt R.
Neurourological insights into the etiology of gentiourinary pain in men. J
Urol 161;903-908.
51. Doble A, Walker MM, Harris JRW, et al. Intraprostatic antibody
deposition in chronic abacterial prostatitis. Br J Urol 1990;65:598-605.
52. Persson BE and Ronquist G. Evidence for a mechanistic association
between non-bacterial prostatitis and levels of urate and creatinine in
expressed prostatic secretions. J Urol 1996;155:958-60.
53. Kirby RS, Lowe D, Bultitude MI, et al. Intra-prostatic urinary reflux:
an aetiological factor in abacterial prostatitis. Br J Urol 1982;54:729-31.
54. Barbalias GA, Meares EM Jr, Sant GR. Prostadynia: clinical and
urodynamic characteristics.. J Urol 1983;130:514-517.
55. Miller LJ, Fischer KJ, Goralnick SJ, et al. Nerve growth factor and
chronic prostatitis/chronic pelvic pain syndrome. Urology 2002;59:603608.
56. Ku JH, Kim SW and Paick J-S. Quality of life and psychological factors
in chronic prostatitis/chronic pelvic pain syndrome. Urology 2005;66:693701.
57.Tripp DA, Nickel JC, Wang Y, et al. Catastrophizing and paincontingent rest predict patient adjustment in men with chronic
prostatitis/chronic pelvic pain syndrome. J Pain 7(10):697-705.
58. Yang CC, Lee JC, Kromm BG, Ciol MA and Berger RE. Pain
sensitization in male chronic pelvic pain syndrome: why are symptoms so
difficult to treat? J Urol 2003:170:823-827.
59.Lee JC, Yang CC, Kromm BG and Berger RE. Neurophysiologic testing
in chronic pelvic pain syndrome: a pilot study. Urology 2001;58:246-250.
60. Krieger JN, Egan KJ, Ross SO, et al. Chronic pelvic pains represent the
most prominent urogenital symptom of ‘chronic prostatitis’. Urology
1996;48:715-722.
61. Propert KJ, McNaughton Collins M, Leiby BE, O’Leary MP, Kusek JW
and Litwin MS. A prospective study of symptoms and quality of life in men
with chronic prostatitis/ chronic pelvic pain syndrome: the National
Institutes of Health chronic prostatitis cohort study. J Urol 2006;175:619623
62. Litwin MS, McNaughton Collins M, Fowler FJ Jr, et al. The National
Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI):
Development and validation of a new outcome measure. J Urol
1999;162:369-375.
63. Turner JA, Ciol MA, Korff MV, Berger R. Validity and responsiveness of
National Institutes of Health Chronic Prostatitis Symptom Index. J Urol
2003;169(2):580-583
64. McNaughton Collins M, Pontari MA, O’Leary MP, et al. Quality of life is
impaired in men with chronic prostatitis; the Chronic Prostatitis
Collaborative Research Network. J Gen Intern Med 2001;16(10):656-662.
65. Wenninger K, Heiman JR, Rothman I, Berghuis JP and Berger RE.
Sickness impact on chronic nonbacterial prostatitis and its correlates. J
Urol 1996;155(3):965-968.
66. McNaughton Collins M, MacDonald R and Wilt TJ. Diagnosis and
Treatment of chronic abacterial prostatitis: a systematic review. Ann
Intern Med 2000;133:367-381
67. Nickel JC Clinical Evaluation of the patient presenting with prostatitis.
Eur Urol 2003. (Suppl) 68;1-4.
68. Nickel JC. Clinical Evaluation of the Man with Chronic
Prostatitis/chronic pelvic pain syndrome. Urol 2002;60(suppl 6A):20-23.
69. Schaeffer AJ, Knauss JS, Landis JR, et al. Leukocyte and bacterial
counts do not correlate with severity of symptoms in men with chronic
prostatitis: the National Institutes of Health chronic prostatitis cohort
study. J Urol 2002;168:1048-1053.
70. Muller CH, Berger R, Mohr LE and Kreiger J. Comparison of
microscopic methods for detecting inflammation in expressed prostatitis
secretions. J Urol 2001;166:2518-2524
71. Luzzi GA, Bignell C, Mendel D and Maw RD. Chronic Prostatitis/Chronic
Pelvic Pain Syndrome: a national survey of genito-urinary medicine
clinics. Int J STD AIDS 2002;13(6):416-419.
72.Thin RN. Diagnosis of chronic prostatitis: overview and update. Int J
STD & AIDS 1997;8(8):475-81.
73. Nickel JC, Adern D and Downey J. Cytologic Evaluation if Urine is
Important in Evaluation of Chronic Prostatitis. Urology 2002;60(2):225227
74. Referral guidelines for suspected cancer in adults and children:
guidelines for suspected urological cancer. Reference CG27.
www.nice.org.uk
75. Nadler RB, Schaeffer AJ, Knauss JS, et al. Total Prostate specific
Antigen is elevated and statistically, but not clinically significant, in
patients with chronic pelvic pain syndrome/ prostatitis (abstract) 2003;J
Urol 169(suppl 4):27.
76.Kohn IJ, Te AE, Kaplan SA. The role of urodynamics in evaluating
patients with chronic prostatitis. In; Nickel JC (Ed) Textbook of Prostatitis.
ISIS Medical Media, Oxford, pp 227-232.
77. Ludwig M, Weidner W, Schroeder-Printzen I, Zimmerman O and
Ringert RH. Transrectal prostatic sonography as a useful diagnostic means
for patients with chronic prostatitis or prostatodynia. Br J Urol
1994;73(6):664-8.
78. De La Rosette JJ, Karthaus HF, Debruyne FM. Ultrasonographic
findings in patients with non-bacterial prostatitis. Urol Int 1992;48:323326.
79. Turner JA, Ciol MA, Von Korff M and Berger R. Health Concerns of
patients with nonbacterial prostatitis/pelvic pain. Arch Intern Med
2005;165:1054-1059.
80. Dimitrakov JD, Kaplan SA, Kroenke K, Jackson JL and Freeman MR.
Management of Chronic Prostatitis/ Chronic Pelvic Pain Syndrome: An
Evidence-Based Approach. Urology 2006;67(5):881-888.
81. Jang T and Schaeffer A. (2005) Chronic prostatitis. Clinical Evidence.
Volume 13. www.clinicalevidence.com
82. Nickel JC, Downey J, Ardern D, Clark J and Nickel K. Failure of a
monotherapy strategy for difficult chronic prostatitis/chronic pelvic pain
syndrome. J Urol 2004;172:551-554.
83. Alexander RB, Propert KJ, Scaheffer AJ, et al. Ciprofloxacin or
tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a
randomised, double-blind trial. Ann Intern Med 2004;141:581-9.
84. Nickel JC, Downey J, Johnston B and Clark J. Predictors of patient
response to antibiotic therapy for chronic prostatitis/chronic pelvic pain
syndrome: a prospective mulitcenter clinical study. J Urol
2001;165:1539-1544.
85. Nickel JC, Downey J, Clark J, et al. Levofloxacin for chronic
prostatitis/chronic pelvic pain syndrome in men: a randomised placebocontrolled mulitcenter trial. Urology 2003;62:614-617.
86. Mehik A, Alas P, Nickel JC, Sarpola A and Helstrom PJ. Alfuzosin
treatment for chronic prostatitis/chronic pelvic pain syndrome: a
prospective randomised, double-blind, placebo-controlled, pilot study.
Urology 2003;62:425-429.
87. Cheah PY, Liong ML, Yen KH, et al. Terazosin therapy for chronic
prostatitis/chronic pelvic pain syndrome: a randomized, placebocontrolled trial. J Urol 2003;169:492-596
88. Dalhoff A, Shalit I. Immunomodulatory effects of quinolones. Lancet
Infect Dis 2003;3(6):359-371.
89.Kuzin II, Snyder JE, Uqine GD, et al. Tetracyclines inhibit activated B
cell function. Int Immunol 2001;13(7):921-931.
90. Delaney JAC, Dial S, Barkun A and Suissa S.Antimicrobial drugs and
community-acquired Clostridium difficle-associated disease, UK. Emerg
Infect Dis [serial on the internet] 2007 May [9th September 2008]
Available from http://www.cdc.gov/EID/content/13/5/761/htm.
91.Nickel JC, Narayan P, McKay J and Doyle C. Treatment of chronic
prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomised
double blind trial. J Urol 2004;171:1594-1597.
92.Batstone RD, Lynch J and Doble A. A randomized-placebo controlled
pilot study of tamsulosin, naproxen and combination in category IIIA/IIIB
chronic prostatitis/chronic pelvic pain syndrome(abstract). J Urol 2005
(suppl 4); 173:30.
93.Sivkov A, Oshepkov V, Egorov A and Pataki K. Terazosin in patients
with chronic prostatitis(abstract). BJU Int 2004;94 (suppl 2):5.
94. Cho I, Kim J, Lee K, Lee K and Chang Y. The effect of terazosin on
symptom recurrence in men with chronic prostatitis/chronic pelvic pain
syndrome(abstract). Urology 2006;68(Suppl 15A):55.
95. Tugcu V, Tasci AI, Fazlioglu A, et al. A Placebo-Controlled Comparison
of the efficiency of triple- and monotherapy in category IIIB chronic pelvic
pain syndrome (CPPS). Eur Urol 2007:51:1113-1118.
96 Kaplan MA, Volpe MA, Te AE. A prospective 1 year trial using saw
palmetto versus finasteride in the treatment of category III
prostatitis/chronic pelvic pain syndrome. J Urol 2004;171(1):284-288.
97.Pavlopoulos PM, Xanthopoulou G, Kakouri P, et al. Fluoxetine in the
management of men with chronic prostatitis/chronic pelvic pain syndrome
(abstract).Urology 2006;68(Suppl 5A):53-54.
98. De Rose, AF, Gallo F, Giglio M and Carmignani G. Role of mepartricin
in category III chronic nonbacterial prostatitis/ chronic pelvic pain
syndrome: a randomized prospective placebo-controlled trial. Urology
2004;63(1):13-16.
99.Rowe E, Smith C, Laverick L, et al. A prospective randomized, placebocontrolled double-blind study of pelvic electromagnetic therapy for the
treatment of chronic pelvic pain syndrome with 1 year of follow-up. J Urol
2005;173:2044-2047
100. Elist J. 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 2006;67(1):60-63.
101. Shoskes DA, Zeitlin SI, Shahed A and Rajfer J. Querectin in men
with category III chronic prostatitis: a preliminary prospective, doubleblind, placebo control trial. Urology 1999;54:960-963.
102. Giubilei G, Mondaini N, Minervini A, et al . 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
2007;177:159-165.
103. Chen R and Nickel JC. Acupuncture ameliorates symptoms in men
with chronic prostatitis/chronic pelvic pain snydrome. Urology
2003;61:1156-1159.
104.Persson B, Rondquist G, Ekblom M. Ameliorative effect of allopurinol
on non-bacterial prostatitis: a parallel double-blind controlled study. J
Urol 1996;155:961-964.
105.Ye Z-Q, Cai D, Lan R-Z, et al. Biofeedback therapy for chronic pelvic
pain syndrome. Asian J Androl 2003;5:155-158.
106.Clemens JQ, Nadler RB, Schaeffer AJ, Belani J, Albaugh J and
Bushman W. Biofeedback, pelvic floor re-education, and bladder training
for male chronic pain syndrome. Urology 2000;56:951-955.
107.Chuang JC and Chancellor MB. The application of botulinum toxin in
the prostate. J Urol 2006;176(6):2375-2382.
108. Turini D, Beneforti P, Spinelli M, Malagutti S and Lazzeri M.
Heat/burning sensation induced by topical application of capsaicin on
perineal cutaneous area: new approach in diagnosis and treatment of
chronic prostatitis/chronic pelvic pain syndrome? Urology
2006;67(5):910-913.
109.Rugendorf EW, Weidner W, Ebeling, et al. Results of treatment with
pollen extract ( cernilton N) in chronic prostatitis and prostatdynia. Br J
Urol 1993:71:433-438.
110. Kastner C, Hochreiter W, Huidobro, et al. Cooled transurethral
microwave thermotherapy for intractable chronic prostatitis- results of a
pilot study after 1 year. Urology 2004;64(6):1149-1154.
111.Bates SM, Hill VA, Anderson JB, et al. A prospective ,randomized
double-blind trial to evaluate the role of a short reducing course of oral
corticosteroid therapy in the treatment of chronic prostatitis/chronic pelvic
pain syndrome. BJU Int 2007;99:355-359.
112. Lee CB, Ha U-S, Lee SJ, et al. Preliminary experience with a terpene
mixture versus ibuprofen for treatment of category III chronic
prostatitis/chronic pelvic pain syndrome. World J Urol 2006;24(1):55
113.Anderson RA, Wise D, Sawyer T and Chan C. Integration of
myofascial trigger point release and paradoxical relaxation training
treatment of chronic pelvic pain in men. J Urol 2005;174:155-160.
114. Shoskes DA and Zeitlin SI. Use of prostatic massage in combination
with antibiotics in the treatment of chronic prostatitis. Prostate Cancer
Prostatic Dis 1999;2:159-162.
115. Potts JM, O’Dougherty E. Pelvic floor physical therapy for patient
with prostatitis. Curr Urol Rep 2000;1(2):155-158.
116. Nickel JC, Forrest JB, Tomera K, et al. Pentosan polysulfate Sodium
therapy for men with chronic pelvic pain syndrome: a mulitcenter,
randomized, placebo-controlled study. J Urol 2005;173:1252-1255.
117. Van Balken MR, Vandoninck V, Messelink BJ. Percutaneous tibial
nerve stimulation as neuromodulative treatment of chronic pelvic pain.
Eur Urol 2003;43:158-163.
118. Leippold T, Strebel RT, Huwyler M, et al. Sacral magnetic stimulation
in non-inflammatory chronic pelvic pain syndrome. BJU Int 2005;95:838841
119. Lee RA, West RM and Wilson JD. The response to sertraline in men
with chronic pelvic pain syndrome. Sex Transm Inf 2005;81:147-149.
120.Leskinen MJ, Kilponen A, Lukkarinin O and Tammela TLJ.
Transurethral Needle Ablation for the treatment of chronic pelvic pain
syndrome (category III prostatitis): a randomized, sham-controlled study.
Urology 2002;60:300-304.
121. John H, Ruedi C, Kotting S, Schmid DM, Fatzer M and Hauri D. A new
high frequency electrostimulation device to treat chronic prostatitis. J Urol
2003;170:1275-1277.
122. Goldmeier D, Madden P, McKenna M and Tamm N. Treatment of
category IIIA prostatitis with zafirlukast: a randomized controlled
feasibliity study. Int J STD and AIDS 2005;16(3):196-200.
123. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane
Database Syst Rev 2007;(4):CD005454.
124. Turner JA, Ciol MA, Von Korff M and Berger R. Prognosis of Patients
with New Prostatitis/Pelvic Pain Syndrome Episodes. J Urol
2004;172:538-541
125. Nickel JC, Downey JA, Nickel KR and Clark JM. Prostatitis-like
symptoms; one year later. BJU Int 2002;90:678-681.
126.Shoskes DA, Landis JR, Wang Y, et al. Impact of ejaculatory pain in
men with category III chronic prostatitis/chronic pelvic pain syndrome. J
Urol 2004;172:542-547.
127. Meares EM Jr, Stamey TA. Bacterial localisation patterns in bacterial
prostatitis and urethritis. Invest Urol 1968;5:492-518.
Appendix 1
Four-glass test (lower urinary tract localisation procedure; MearesStamey test) [127]
Preparation
• No antibiotics should have been taken for one month.
• The patient should not have ejaculated for two days.
• The patient should have a full but not distended bladder.
Prostatic massage should not be performed if there is evidence of
urethritis or urinary tract infection. If either of these is present they
should first be treated to prevent prostatic secretion contamination.
Prostatic massage
• The foreskin should be fully retracted and the penis well cleaned to
prevent contamination.
• A 5-10 ml sample of first-void urethral urine (VB1) should be collected.
• The patient should pass a further 100-200 ml urine and then a further
5-10 ml sample of mid-stream bladder urine (VB2) should be collected.
• By digital rectal examination a vigorous massage of the prostate gland
should be performed for 1 minute, from periphery towards the midline
with a sterile container held over the glans to collect any expressed
prostatic secretions (EPS).
• A wet preparation microscopic examination of a sample of EPS should
be made to determine the number of polymorphonuclear leucocytes
(PMNL) per high power field (x 400).
• Immediately after the massage another 5-10 ml post-massage urine
(VB3) should be collected.
• All three urine samples should have microscopy and quantitative
culture.
A dry prostatic massage is reasonably common
Interpretation of results
• To assign an organism to the prostate, the colony count in the EPS and
VB3 is required to be at least 10 times greater than in VB1-2.
• For prostatic inflammation ≥10 PMNL/high power field (hpf) is
considered diagnostic. In cases of a dry expressate a PMNL count of
10/hpf greater in VB3 than VB1 and VB2 is diagnostic of prostatitis.
• The presence of clumps of PMNL (5+) and oval fat bodies
(macrophages containing fat droplets) in the EPS support the diagnosis
of inflammatory CP/CPPS.
If there is significant bacteruria in both VB2 and VB3, 3 days of
nitrofurantoin 50mg four times daily, which is not prostate penetrating,
should be given and the procedure then repeated.
Appendix 2 NIH- Chronic Prostatitis Symptom Index (NIH-CPSI)
NIH Chronic Prostatitis Symptom Index
Developed by the NIDDK-funded Chronic Prostatitis Collaborative Research Network
Read an abstract about the NIH symptom index
Pain or discomfort
1. In the last week, have you experienced any pain or discomfort in the following
Yes
areas?
Area between rectum and testicles (perineum)
No
1
0
Testicles
1
0
Tip of the penis (not related to urination)
1
0
Below your waist, in your pubic or bladder area
1
0
Yes
No
1
0
1
0
2. In the last week, have you experienced:
Pain or burning during urination?
Pain or discomfort during or after sexual climax (ejaculation)?
3. How often have you had pain or discomfort in any of these areas over the last
week?
Never
0
Rarely
1
Sometimes
2
Often
3
Usually
4
Allways
5
4. Which number best describes your AVERAGE pain or discomfort on the days
that you had it over the last week?
0
no pain
1
2
3
4
5
6
7
8
9
10
Pain bad as you can imagine
Urination
5. How often have you had a sensation of not emptying your bladder completely
after you finished urinating during the last week?
Not at all
0
Less than 1 time in 5
1
Less than half time
2
About half time
3
More than half time
4
Almost always
5
Modified with permission from Litwin MS, McNaughton-Collins M ' Fowler FJ, et al. The NIH Chronic Prostatitis
Symptom index (NIH-CPSI). Development and validation of a new outcomes measure. J Urol. In press.
6. How often have you had to urinate again less than 2 hours after you finished
urinating, over the last week?
Not at all
0
Less than 1 time in 5
1
Less than half time
2
About half time
3
More than half time
4
Almost always
5
Impact of symptoms
7. How much have your symptoms kept you from doing the kinds of things you
would usually do, over the last week?
None
0
Only a little
1
Some
2
A lot
3
8. How much did you think about your symptoms during the last week?
None
0
Only a little
1
Some
2
A lot
3
Quality of life
9. If you were to spend the rest of your life with your symptoms just the way they
have been during the last week, how would you feel about that?
Delighted
0
Pleased
1
Mostly satisfied
2
Mixed (about equally satisfied and dissatisfied)
3
Mostly dissatisfied
4
Unhappy
5
Terrible
6
Scoring the Symptom Index Domains
Pain:Total of items 1 a, 1 b, 1 c, 1 d, 2a, 2b, 3, and 4
Urinary symptoms:Total of items 5 and 6
Quality of life impact:Total of items 7, 8, and 9
Pain and urinary score:Total of item 1 to 6
Total score:
(1) Calculate and report 3 separate scores (pain, urinary symptoms, and quality of life)
(2) Calculate and report a pain and urinary score (range 0-31), referred to as the "symptom scale score."
•
Mild =0-9,
•
moderate=10-18
•
severe=19-31.
(3) Calculate and report total score (range 0-43), referred to as the "total score." Assess patients at baseline
and follow them over time using each patient as his own control. Can also use to compare to "norms"
established and published.
This information is forwarded to you by the Prostatitis Foundation. We do not provide
medical advice. We distribute literature and information relevant to prostatitis. While we
encourage all research we do not endorse any doctor, medicine or treatment protocol.
Consult with your own physician.
© 2002 The Prostatitis Foundation
Further Contact:(click on words or mailbox)
This page was created by Ideasmith®.
Add to this site