How Urologists Deal With Chronic Prostatitis? The Preliminary Results of a Mediterranean Survey - Beyond the Abstract

Chronic prostatitis (CP) is a relatively common spectrum of disorders that impacts a significant number of younger males. It mainly consists of chronic suprapubic, abdominal, penile, perineal, or scrotal pain accompanied or not by lower urinary tract symptoms and/or sexual or erectile dysfunction. It is considered to have a generally indolent course however the burden of the symptoms varies from patient to patient. For a considerable number of patients, symptoms are persistent and insupportable.


In Greece, the perception of CP varies among urologists. In general, there are three main categories: the prostatitis believers, the prostatitis refuters, and the remaining urologists. The first group diagnoses prostatitis upon presentation, they usually don’t need any documentation and prescribe empirically long-term antibiotic treatment. The second group seriously doubts patients’ mental or psychical status and mainly prescribes less relevant diagnostic tests. The last group acknowledges that chronic prostatitis is the most frustrating and difficult clinical problem to manage within urology. This happens likely because the etiopathology of prostatitis is uncertain, other diseases of the urogenital system share common symptoms with prostatitis, the diagnostic work-up of prostatitis is not completely standardized, the microbiological diagnosis is partly inadequate and there are restrictions in the prescription of some clinical and laboratory tests in several countries.

According to our study, the preferred diagnostic methods (89.6 and 84.4% of Greek and 98.12% and 96.62% of Italian urologists) are medical history and physical examination alone or combined with the IPSS questionnaire. Therefore is possible that many urologists know little about CP and consider CP as the benign prostatic hyperplasia (BPH) of younger men. In fact, symptom assessment by the NIH-CPSI is rarely used in both Greece and Italy (17.29 and 19.4% of respondents, respectively). Moreover, as shown in our study, a variety of diagnostic tests are performed in patients with a suspected diagnosis of CP. These include imaging, endoscopy, urodynamics and prostate-specific antigen (PSA) testing. None of them is specifically recommended in the evaluation of patients with prostatitis.

Even though the Meares and Stamey (MS) “4-glass” test is the gold standard test for the CP diagnosis, most urologists rule out bacterial infection by ordering semen culture. Few Italian and Greek respondents perform the MS test (20.3% and 11.6% respectively) for unknown reasons. To our knowledge, time and geographical trends in the use of this test may exist. In conclusion, recognizing chronic bacterial prostatitis (CBP) is actually difficult, as the history and examination are highly variable. However, almost all patients note some degree of genitourinary pain or discomfort. Several patients are presenting with recurrent febrile urinary tract infections. For this reason, a detailed history is needed in order to pose suspicion of CP. The SM test is imperative in order not only to rule out bacterial infection but also to localize the infection. However, ultrasonography and uroflowmetry are non-invasive, low-cost tests for a rapid study of the anatomy of the urinary system and for a general estimation of the urinary function; hence they could be adopted in CP diagnostic workup.

Written by: Konstantinos Stamatiou, MD, PhD, and Evangelia Samara, MD, PhD, MSc, Urology Department, Tzaneion Hospital, Piraeus, Greece

References:

  1. Krieger, John N., Susan O. Ross, Ajit P. Limaye, and Donald E. Riley. "Inconsistent localization of gram-positive bacteria to prostate-specific specimens from patients with chronic prostatitis." Urology 66, no. 4 (2005): 721-725.
  2. Stamatiou, Konstantinos, Vittorio Magri, Gianpaolo Perletti, Vaia Papadouli, Nectaria Recleiti, Vassiliki Mamali, and Olympia Zarkotou. "Chronic prostatic infection: Microbiological findings in two Mediterranean populations." Archivio Italiano di Urologia e Andrologia 91, no. 3 (2019).
  3. Ku, Ja Hyeon, JAE‐SEUNG PAICK, and Soo Woong Kim. "Factors influencing practices for chronic prostatitis: A nationwide survey of urologists in South Korea." International journal of urology 12, no. 11 (2005): 976-983.
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