Non-Bacterial Prostatitis

1. NIH Classification of Prostatitis
2. Microbiological Considerations
3. Issues Concerning the Seminal Vesicles
4. Issues Concerning Asymptomatic Inflammatory Prostatitis
5. Etiologies of Chronic Prostatitis
6. List of Remedies for Chronic Prostatitis

NIH Classification of Prostatitis

According to the latest NIH classification, prostatitis is grouped into four subcategories:

Category 1. Acute infection of the prostate gland.
Category 2. Chronic infection of the prostate gland.
Category 3. Chronic pelvic pain syndrome: chronic genito-urinary pain in the absence of uro-pathogenic bacteria localized in the prostate gland employing standard methodology.
  A. Inflammatory chronic pelvic pain syndrome
  B. Non inflammatory chronic pelvic pain syndrome
Category 4. Asymptomatic inflammatory prostatitis: In this group white blood cells and or bacteria are present in prostatic secretion, post prostatic massage urine sediment, semen, or histology specimens of the prostate  gland.

This classification allows antibiotic therapy only for those patients whose laboratory tests, following “standard methodology”, reveal “uro-pathogens”.  Accordingly, only Category 1 and a fraction of the patients in Category 2 would qualify to receive antibiotic therapy.

Microbiological Considerations

In our laboratory, a negative semen, urethral swab specimen or EPS culture is a very rare finding. Patients visiting us, in the great majority of cases, will bring along negative culture reports. The few positive microbiological findings encountered are without exception relatively fast growing aerobic bacteria. Isolation of anaerobic bacteria needs a minimum of ten days incubation, a length of  time not affordable for commercial laboratories. Without the participation of a dedicated laboratory in sample analysis, the true microbiology of chronic prostatitis remains a confusing, anecdotal chapter in medicine.  We also take issue with using PCR as the gold standard for testing for Chlamydia trachomatis. The Swedish experience has shown that Chlamydia is an exceptionally resourceful organism which is able to change its surface markers, thus enabling  it to elude detection by a system that is looking for one or two specific markers. That phenomenon would explain why a PCR test turns negative after a relatively short antibiotic course. Animals injected with a mixture of different strains of Chlamydia trachomatis will produce IgG type antibodies against a wide range of markers of the OMP (Outer Membrane Protein) of Chlamydia. This antibody is used in the IFA (Immune Fluorescent Antibody) system. Even if  the bacterium loses some of its surface markers during an antibiotic therapy course, there will be an ample number of markers left for the IFA antibody to adhere to and the attached fluorescent material will give away the presence of Chlamydia. Unfortunately, IFA testing is time consuming and needs trained eyes to read the slides.  In our experience IFA is far superior in following treatment response than the PCR test. IFA detects Chlamydia elementary bodies in a significant number in Category 2 and 3  patients. Chlamydia is detected in significant frequency. These cases have responded favorably to injection therapy. Issues Concerning the Seminal Vesicles.

If the inflammation involves the seminal vesicles or extends beyond the prostate capsule, adhesions could form between the prostate or seminal vesicles and the pelvic side wall. Due to their anatomic proximity and communicating duct systems, transrectal ultrasound examination of the prostate should be considered incomplete without careful examination of the seminal vesicles. Injection therapy always should involve both seminal vesicles even if typical sonographic signs of chronic seminal vesiculitis are missing. Deep pelvic discomfort, lower back pain, reduced ejaculatory volume with positive sonogram findings warrants extended therapy. These patients will benefit from additional physicotherapy following proper antibiotic courses. A significant number of patients with seminal vesiculitis belong to NIH Category 3.

Issues Concerning Asymptomatic Inflammatory Prostatitis

We appreciate the significance of NIH category 4, the asymptomatic male with bacteriospermia. Fertility issues are the dominating problems in this category. The culture studies are almost always positive and antibiotic therapy is used without exception for both husband and wife as the most significant remedy to restore fertility. Still, in a high number of cases, careful questioning reveals nuance changes in urine flow, increased post voiding dribbling, diminished ejaculatory volume, more frequent urination and nocturia all pointing toward chronic prostatitis with slowly progressing enlargement of the organ.  

Etiologies of Chronic Prostatitis

For the sake of completeness, I am listing here the academically accepted etiologies of chronic prostatitis, and a list of mostly empirical therapies that are widely offered.

Potential mechanisms for the development of non-bacterial chronic prostatitis include:

Altered Prostatic Host Defense

Risk factors that allow bacterial colonization or infection of the prostate with potentially pathogenic bacteria include intraprostatic ductal reflux,  phimosis,  unprotected penetrative anal rectal intercourse, UTIs,  acute epididymitis, indwelling urethral catheters and condom catheter drainage and transurethral surgery, especially in men who have untreated, infected urine.

My Comments

I consider this group artificial. In phimosis, bacteria will multiply in an obstructed space, under the foreskin and eventually find their way to the prostate via the urethra. Rectal intercourse without protection will introduce rectal flora into the prostate through the milking of the urethra. UTIs cannot develop without bacteria entering through the urethra and passing through the prostate. All transurethral surgeries are performed on patients who had preexisting, infection related urinary tract problems( stricture, BPH, polyp, Cancer). The surgery will create traumatized tissues that is saturated with nourishing blood or lymph,  fertile ground for bacterial growth. There is always a real prostatitis component whether the patient is symptomatic or not. Epididymitis does not predispose to prostatitis. All bacteria that can cause epididymitis are present in EPS with or without subjective prostatitis symptoms in the patient.

Dysfunctional Voiding

Anatomic or neurophysiologic obstruction resulting in high-pressure dysfunctional flow patterns has been implicated in the pathogenesis of the prostatitis syndrome. Intraprostatic Ductal Reflux: Reflux of urine and possibly bacteria into the prostatic ducts has been postulated as one of the most important etiologic mechanisms involved in the pathogenesis of chronic bacterial and nonbacterial prostatic inflammation.

My Comments

Following a surgical procedure on the genito-urinary tract retrograde ejaculation is common. Diabetes is the most often encountered medical condition leading to neuroregulatory dysfunction in  the prostate.  It is known today that several subtypes of diabetes are caused by infection. The argument that infected urine and bacteria in the prostatic ducts will "reflux" into the prostate ignores the speread of these bacteria on their own.

Immunologic Alterations

The local prostatic immune system is activated by infection in bacterial prostatitis. Noninfectious inflammation might also be secondary to immunologically mediated inflammation due to some unknown antigen or perhaps even related to an autoimmune process.

My Comments

The least appreciated cause of chronic prostatitis, Chlamydia, has the highest antigenic potential. I suspect that a large number of cases with the diagnosis of non bacterial inflammation are due to the presence of Chlamydia trachomatis.

Chemically Induced Inflammation

Investigators have demonstrated that urine and its metabolites are present in the prostatic secretion of patients with chronic prostatitis. They have hypothesized that the prostatic inflammation and subsequent symptoms may be simply due to a chemically induced inflammation secondary to the noxious substances in the urine that have refluxed into the prostatic duct.

My Comments

I have not seen publications confirming this hypothesis. Without kidney or bladder infection, there should be no harmful, infection inducing substances in the bladder.

Neural Dysregulation/Pelvic Floor Musculature Abnormalities

Some investigators propose that the sensory and motor disturbances consistent with neural dysregulation of the lower urinary tract and may be a consequence of acquired abnormalities in the central nervous system.

My Comments

Without congenital defect, previous surgery, trauma, systemic disease or prior infection, there should not be any dysregulation of the lower urinary tract.

Interstitial Cystitis-like Cause

Interstitial cystitis is an ill-defined chronic pelvic pain syndrome occurring primarily in females, and a number of investigators have hypothesized that chronic nonbacterial prostatitis may have a similar cause.

My Comments

Interstitial cystitis is an infectious disease of the urinary tract with a significant immune component, often seen as a late sequel to Chlamydia infections. Even after proper antibiotic therapy, it can take many months before the immune system settles down.

Psychological Cause

Psychological factors have always been considered to play an important role in the development or exacerbation of the chronic prostatitis syndromes.

My Comments

In my experience psychological factors can  worsen the perception of prostatitis symptoms, but I have serious doubt that they are ever the sole cause.

An Interrelated, Pluricausal, Multifactorial Etiology

It is likely that the chronic prostatitis syndrome has a multifactorial etiology, either a spectrum of etiologic mechanisms or, more likely, a progression or cascade of events after some initiating factor.

My Comments

UNFORTUNATELY, THE INITIAL EPISODE OF PROSTATITIS IS SO OFTEN MISSED OR MISMANAGED THAT BY THE TIME IT BECOMES CLINICALLY CLASSIFIED AS CHRONIC PROSTATITIS, IT HAS BECOME\A MULTIFACETED, COMPLEX DISEASE. 

List of Therapeutic Remedies for Chronic Prostatitis

Medical

Antimicrobial Agents
Adrenergic Blocker Therapy
Anti-inflammatory Agents and Immune Modulators
Muscle Relaxants
Hormone Therapy
Phytotherapeutic Agents
Allopurinol

Physical Therapy

Prostatic Massage
Perineal or Pelvic Floor Massage and Myofascial Trigger Point Release.
Pudendal Nerve Entrapment Therapy
Biofeedback
Acupuncture
Psychological Support

Minimally Invasive Therapies

Balloon Dilatation
Minimally Invasive Surgery(transurethral needle ablation or TUNA)
Microwave Hyperthermia and Thermotherapy

Prostate Surgery

Surgery does not have an important role in the treatment of most  chronic prostatitis syndromes  unless a specific indication is discovered during the evaluation of the patient. I saw a few patients who had  undergone minimally invasive partial prostatic ablation. The follow up is too short to make any conclusion on the merit of the procedure.