Table Of ContentW. Weidner P.O. Madsen H.G. Schiefer {Eds.}
Prostatitis
Etiopathology, Diagnosis and Therapy
With 58 Figures and 52 Tables
Springer-Verlag
Berlin Heidelberg New York London Paris
Tokyo Hong Kong Barcelona Budapest
Prof. Dr. Wolfgang Weidner
U rologische Klinik
Klinikum der lustus-Liebig-Universitat
Klinikstr. 29
35392 Giessen, Germany
Prof. Dr. PaulO. Madsen
Veterans Administration Medical Center
and Department of Surgery
University of Wisconsin School of Medicine
2500 Overlook Terrace
Madison, Wisconsin 53705, USA
Prof. Dr. Hans Gerd Schiefer
Institut fiir Medizinische Mikrobiologie
Klinikum der lustus-Liebig-Universitat
Schubertstr. 1
35392 Giessen, Germany
ISBN-13:978-3-642-78183-4 e-ISBN-13:978-3-642-78181-0
DOl: 10.1007/978-3-642-78181-0
Library of Congress Cataloging-in-Publication Data. Prostatitis: etiopathology, diagnosis and therapy /
W. Weidner, P.O. Madsen, H.G. Schiefer (eds.) p. em. Includes bibliographical references and index.
ISBN-13:978-3-642-78183-4 1. Prostatitis. I. Weidner, W. (Wolfgang)
II. Madsen, PaulO., 1927- III. Schiefer, H.G. (Hans Gerd). RC899.P77 1994 616.6'5 - dc20 93-29539
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Contributors
Ameye, F.
Department of Urology, University Hospitals Leuven, UZ. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Baert, L.
Department of Urology, University Hospitals Leuven, UZ. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Blacklock, N.J.
42 Western Way, Alverstoke, Gosport, Hampshire POl2 2NQ, UK
Brahler, E.
Klinik und Poliklinik fUr Psychotherapie und Psychosomatische Medizin
der Universitat, Karl-Tauchnitz-Str. 25, 04107 Leipzig, Germany
Ceri, H
Department of Biological Sciences, University of Calgary, Calgary,
Alberta T2N 1N4, Canada
Clements, R.
Department of Clinical Radiology, Royal Gwent Hospital, Newport,
Gwent NP9 2UB, UK
De Ridder, D.
Department of Urology, University Hospitals Leuven, UZ. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Doble, A.
Department of Urology, Addenbrooke's Hospital, Hills Road,
Cambridge CB2 2QQ, UK
Drescher, P.
Veterans Administration Medical Center and Department of Surgery,
University of Wisconsin School of Medicine, 2500 Overlook Terrace,
Madison, Wisconsin 53705, USA
VI Contributors
Frick,1.
Landeskrankenanstalten, Urologische Abteilung, Mullner Hauptstr. 48,
5020 Salzburg, Austria
e.
Gasser, T.
Urologische UniversiHitsklinik, Department fUr Chirurgie der Universitat
Basel, Kantonsspital, 4031 Basel, Switzerland
Griffiths, G.1.
Department of Clinical Radiology, Royal Gwent Hospital, Newport,
Gwent NP9 2UB, UK
Herremans, D.
Department of Urology, University Hospitals Leuven, U.Z. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Hofstetter, A.G.
Urologische Klinik und Poliklinik der Universitat, Klinikum GroBhadern,
Marchioninistr. 15,81377 Munchen, Germany
Kawamura, N.
Department of Urology, Tokai University School of Medicine, Boseidai,
Isehara, Kanagawa 259-11, Japan
Krause, W.
Abteilung fUr Dermatologie mit Schwerpunkt Andrologie, Medizinisches
Zentrum fUr Hautkrankheiten der Universitat, Deutschhaussstr. 9,
35037 Marburg, Germany
Ludwig, M.
Klinik und Poliklinik fur Urologie der Universitat, Robert-Koch-Str. 40,
37075 Gottingen, Germany
Madsen, P.O.
Veterans Administration Medical Center and Department of Surgery,
University of Wisconsin School of Medicine, 2500 Overlook Terrace,
Madison, Wisconsin 53705, USA
Naber, K.G.
Urologische Klinik, Elisabeth Krankenhaus, Schulgasse 20, 94315 Straubing,
Germany
Nickel, J.e.
Department of Urology, Queen's University, Kingston General Hospital,
Kingston, Ontario K7L 2V7, Canada
Contributors VII
Olson, M.E.
Department of Biological Sciences, University of Calgary, Calgary,
Alberta T2N IN4, Canada
Peeling, WB.
St. Woolos Hospital, South Gwent Health Unit, 131 Stow Hill, Newport,
Gwent NP9 4SZ, UK
Petrovich, Z.
Department of Urology, University Hospitals Leuven, U.Z. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Pfau, A.
Department of Urology, Hebrew University - Hadassah Medical Center,
P.O. Box 12000, 91120 Jerusalem, Israel
Schaeffer, A.J.
Department of Urology, Northwestern University Medical School,
303 E. Chicago Avenue, Chicago, Illinois 60611, USA
Schiefer, H.G.
Institut fiir Medizinische Mikrobiologie der Universitat, Schubertstr. 1,
35392 Giessen, Germany
Taylor-Robinson, D.
Division of Sexually Transmitted Diseases, Clinical Research Centre,
Watford Road, Harrow, Middlesex HAl 3UJ, UK
Thin, R.NT.
Department of Genitourinary Medicine, St. Thomas' Hospital,
London SE1 7EH, UK
Vahlensieck, W Jr.
Urologische Klinik und Poliklinik der Universitat, Klinikum GroBhadern,
Marchioninistr. 15, 81377 Miinchen, Germany
Van Poppel, H.
Department of Urology, University Hospitals Leuven, HZ. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Van Th illo , E.
Department of Urology, University Hospitals Leuven, U.Z. Sint-Pieter,
Brusselsestraat 69, 3000 Leuven, Belgium
Weidner, W
Urologische Universitatsklinik, Klinikstr. 29, 35392 Giessen, Germany
Preface
Prostatitis syndromes continue to be a major problem in urology. About every
second man will experience symptoms of prostatitis during his lifetime. A study
by the U.S. National Center for Health Statistics showed that approximately
25% of the men seen for urogenital problems suffer from prostatitis.
What is the intention of this book? Although investigations in recent years,
including microbiologic and immunologic ones, have focused on the correct
diagnosis of prostatitis, much confusion still remains regarding its correct
classification, its etiology, and the evaluation of diagnostic results. Many
clinicians, therefore, tend to lump together several diseases of variable type and
sequela as prostatitis.
The term "prostatitis" implies an inflammatory disease, but true bacterial
infection is detected in only 5 %-1 0% of patients. In fact, most patients reveal no
significant bacterial counts in the prostatic fluid. Nonetheless, 40%-60% of
these patients suffer from non bacterial prostatitis, as shown by the fact that the
prostatic fluid contains elevated leukocyte counts while common uropathogens
are not detected.
Essentially, three clinical types of real inflammatory prostatitis are widely
accepted: acute and chronic bacterial and nonbacterial prostatitis. There re
mains a condition denoted as prostatodynia, covering patients in whom signs of
neither inflammation nor infection are found. Multiple extraprostatic disorders
are suspected causes of these complaints, e.g., bladder outlet disorders, detrusor
hyperreflexia, pelvic floor tension myalgia, interstitial cystitis, urolithiasis, ostitis
pubis, and anogenital disorders. Proven data concerning these special problems
are rare, and their association to prostatodynia is unclear. The intention of this
book is to provide the reader with a clarification of the etiopathogenesis of
prostatitis and the competence to exclude the patient with complaints and
symptoms of prostatitis but without true prostatic inflammation, i.e., to identify
the man suffering from prostatodynia, thus preventing multiple and useless
antibiotic trials. Instead, if the diagnosis prostatodynia is clarified, there may
be an indication for, among other things, psychodynamic investigation and
therapy.
This book concentrates on clinical prostatitis strictu sensu and does not treat
the various types of histologically detected inflammation of the prostate, e.g.,
"prostatitis" associated with benign prostatic hypertrophy. Very rarely, prost
atectomy specimens of younger patients or autopsy samples of prostates
x Preface
without evidence of hyperplasia demonstrate inflammatory infiltrates. In men
up to the age of 40, prostatitis is mainly located in the peripheral gland, not in
the transition zone. Demographic data demonstrate that prostatitis symptoms
mostly occur in men over 40 years of age, with decreasing frequency in men
beyond the age of 50, in whom chronic recurrent prostatitis is almost exclusively
seen in biopsies of hyperplastic prostatic glands. Since inflammatory infiltrates
of the prostate must be considered noncharacteristic, we have decided not to
include chapters on histology or cytology in consideration of the fact that
prostatic biopsies for the morphological diagnosis of prostatitis syndromes are
indicated only in cases of clinical suspicion of carcinoma.
The book contains some introductory chapters on basic data, e.g., patho
physiology, host-parasite interactions, anatomy of prostatic infection, and also
general considerations of disease-related complaint complexes, psychosomatics,
diagnostic management, ultrasonography, and ejaculate analysis. Additionally,
the basic conditions of therapy are discussed not only from a pharmacokinetic
angle but also considering the development of acceptable animal models,
allowing standardized therapeutic trials.
Clinical management of acute and chronic bacterial prostatitis has now been
established, following a widely accepted schedule of therapy with a good
prognosis for cure. Obviously, the new fluoroquinolones are a significant
improvement in therapy, but the urgent question is how to treat patients in
whom antibiotic therapy fails. Baert et al. have analyzed this problem, contrib
uting their experience with local therapy and transurethral and open surgery of
infected prostatic glands.
Our book also deals with non bacterial prostatitis. It is our opinion that this
complex entity is a major problem as regards its still unknown etiology and
missing rational therapy in most cases. In patients with nonbacterial prostatitis,
diagnostic efforts should not only concentrate on chlamydial and/or mycoplas
mal infections, but on unconventional pathogens, too, in view of the increasing
incidence of AIDS and the reestablished significance of parasites as treatable
causes of urogenital infections in sexually active men. For practical use, the
procedures suggested by Thin seem to us to be a feasible schedule for daily work.
The editors would feel satisfied if this monograph could assist the practicing
physician to provide optimal diagnosis and treatment to every patient suffering
from prostatitis syndromes.
Finally, the editors gratefully acknowledge the continuous efforts and
assistance of Mrs. Karoline Karrer in the production of this book.
Giessen, Germany W Weidner
Madison, Wisconsin, USA P.O. Madsen
Giessen, Germany H.G. Schiefer
January 1994
Contents
I Introduction
Classification, Etiology, and Diagnosis of Prostatitis
P.O. Madsen, P. Drescher, and T.e. Gasser. With 1 Figure 3
II Prostatitis: Basic Data
Physiology and Pathophysiology of Prostate Infection
J. Frick. With 3 Figures ................. . 11
Host -Parasite Interactions in Prostatitis
H.G. Schiefer. . . . . . . . . . . . . . . . . 23
The Anatomy of the Prostate:
Relationship with Prostatic Infection
N.J. Blacklock. With 6 Figures . . . 32
Complaint Complexes and Psychosomatic Aspects
E. Briihler. . . . . . . . . . . . . . . . . . . . . .. 40
Diagnostic Management in Chronic Prostatitis
W Weidner and M. Ludwig. With 7 Figures 49
Ultrasonographic Features of Prostatitis
R. Clements, G.J. Griffiths, and WE. Peeling. With 18 Figures. . . . 66
Prostatitis and Male Infertility
W Krause. With 7 Figures .. 91
Basis for Antibacterial Treatment of Prostatitis:
Experimental and Clinical Pharmacokinetic Studies and
Models
P.O. Madsen, P. Drescher, and T.e. Gasser. With 6 Figures. 110
Experimental Prostatitis
J.e. Nickel, M.E. Olson, and H. Ceri. 123
XII Contents
III Acute Bacterial Prostatitis
Acute Prostatitis and Prostatic Abscess
W. Vahlensieck, Jr., and A.G. Hofstetter. 133
IV Chronic Bacterial Prostatitis
Etiology, Pathogenesis, and Inflammatory Reactions in Chronic
Bacterial Prostatitis
A.J. Schaeffer. With 1 Figure . . . . . . . . . . . . . . . . . . . . . 151
The Treatment of Chronic Bacterial Prostatitis:
Principles and Management
A. Pfau ........................ . 158
The Role of Quinolones in the Treatment of Chronic Bacterial
Prostatitis
K.G. Naber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
In Loco Antibiotics in Chronic Bacterial Prostatitis
L. Baert and D. De Ridder. With 3 Figures. . . . . 191
Radical Transurethral Prostatectomy for Chronic Bacterial
Prostatitis
L. Baert and D. H erremans. . . . . . . . . . . . . . . . . . . 197
Radical Prostatectomy for Chronic Bacterial Prostatitis
L. Baert and H. Van Poppel. . . . . . . . . . . . . . . ... 206
Immunotherapy and Prostatitis
L. Baert and E. Van Thil/o . ... 210
V Nonbacterial Prostatitis
The Diagnosis, Aetiology and Pathogenesis of Chronic
Abacterial Prostatitis
A. Doble and D. Taylor-Robinson. With 2 Figures. . . 215
Prostatic Infection by Unconventional, Fastidious Pathogens
H.G. Schiefer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Trichomonas vaginalis
N. Kawamura. With 2 Figures. 245
