Multidisciplinary Approach to Prostatitis - Beyond the Abstract

By strict definition, “prostatitis” is the inflammation of the prostate gland where inflammation is defined as the reaction of the tissue to injury or infection. The suffix -itis is a word-forming element from ancient Greek that added to the name of an anatomical part, denotes the presence of a disease characterized by inflammation of that part of the body. A very extensive definition that can include many different pathological conditions. In fact, under the large umbrella of the definition of prostatitis, different pathological features have been included which manifest similar symptoms and signs but probably originate from several different or concomitant etiologic factors.   The tendency to consider the whole of these disorders as a single disease is probably the cause of the great difficulty of treatment and the consequent frustration of physicians and patients.

Since the sixties of the last century, it has been attempted to group patients with prostatitis into more homogeneous subgroups for symptomatology and etiology. In the Introduction of this paper Prof. Kurt Naber, who has devoted most of his successful scientific career to the study of urinary tract infections and prostatitis, nicely described the evolution of scientific studies and clinical practice in the diagnosis and treatment of prostatitis in the last 50 years. His tale started with the description of the work of Meares and Stamey, which was summarized by Stamey himself about 27 years ago.

These Authors established the basic principles we are still using, by developing the segmented culture technique for localizing the infections in the males to the urethra, the bladder, or the prostate.1,2 The results of the segmented culture test together with the presence of clinical symptoms allowed to: acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), nonbacterial prostatitis, and prostatodynia. The same categories with slight modifications were the basis of the still used NIH classification: acute bacterial prostatitis; chronic bacterial prostatitis; chronic pelvic pain syndrome (CPPS) type 3a (inflammatory) and 3b (noninflammatory) and asymptomatic prostatitis. These categories were intended to create different categories of the disease on the basis of their etiology. Although the NIH classification is still of great use and constitutes the basis for the choice of treatment, it presents some weak points, as it is based on a complex and costly and not always reproducible diagnostics. On the other hand, it is not uncommon that the same patient is classified in different categories when observed in different periods of time. It can happen that in some periods of time the presence of infection may not be demonstrable because of an insufficient collection of the specimen, which is not always representative of the secretions of the whole gland, or because it is confined to biofilms on prostatic calcifications.

On the other hand, clinical experience shows that monotherapy with antibiotic or other drugs is often insufficient for the control of symptomatology. For this reason, more recently patients are classified not only by the results of microbiological tests but also by clinical features to differentiate different phenotypes requiring different therapeutic approaches. The original UPOINT algorithm proposed by Skoskes takes into account urinary (U), psycho-social (P), organ-specific (O), infection (I), neurological (N), muscle tension and tenderness (T) domain. A further domain related to sexuality (S) was recently added in consideration of the high impact of quality of life of prostatitis-related sexual dysfunctions (erectile, ejaculatory, libido loss). This multifaceted presentation of the disease requires a multimodal therapeutic approach addressing the individual clinical phenotypic profile. Antibiotics, alpha-blockers, anti-inflammatory drugs, anticholinergics, antidepressants, 5-ARI inhibitors, phytotherapy (quercitin, pollen extracts, Serenoa), PDE-5 inhibitors, gabapentinoids and miorelaxants can be considered in various combinations for a multimodal therapeutic regimen in conjunction with pelvic floor physiotherapy and psychological counseling. A peculiarity of this review was also considering the role of adjacent organs as causes of persistence of infection and prostatic inflammation.

The association of prostatitis with intestinal disorders has been described with the attention focused on the intestinal microbiota. Bacterial intestinal flora and its interaction with foods can influence the metabolic, immune and inflammatory response of the organism. The qualitative and quantitative alteration of the bacterial intestinal flora is called “dysbiosis” which, by altering the probiotic functions, causes invasive intestinal diseases and correlates with numerous systemic diseases. The causes of dysbiosis in adults are determined by drugs, stress, wrong diet, bad lifestyle, infections, and food intolerances. Low-grade inflammation increased intestinal permeability, and trans-parietal migration may be involved in the pathogenesis of acute and chronic prostatitis. The role of sexually transmitted infections should also be carefully considered with the systematic search for Chlamydia, Mycoplasmas, and Trichomonas in the patient's prostatic fluids of the patients and in swabs of sexual partners.

The approach to patients with prostatitis must, therefore, be multidisciplinary with the involvement of urologists, microbiologists, infectious disease specialists, gastroenterologists, physiotherapists, and psychologists in order to tailor the best possible treatment for each individual patient.

Written by: Alberto Trinchieri, MD, Lecturer at Urology School, University of Milan, Milan, Italy

References
1. Stamey TA. Prostatitis. J Royal Soc Med. 1981; 74:22-40.
2. Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol. 1968; 5:492-518.
3. Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009; 73:538-42.
4. Magri V, Wagenlehner F, Perletti G, et al. Use of the UPOINT chronic prostatitis/chronic pelvic pain syndrome classification in European patient cohorts: sexual function domain improves correlations. J Urol. 2010; 184:2339-45.

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