The Cleveland Clinic Foundation,
Department of Urology, Cleveland, OH
Introduction NIH Category IV
Prostatitis or asymptomatic inflammatory prostatitis is defined by inflammation, usually incidentally identified, in semen or in pathological prostate specimens. Prospective identification of this form of prostatitis
was systematically studied in a group of asymptomatic men with elevated PSA levels. These patients were treated with antibiotics before pursuing transrectal prostate biopsy and then followed to determine the efficacy
and safety of such an approach.
Methods During 1996 to 1998, 187 men with elevated PSA (> 4.0 ng/de) were referred for urological evaluation. Genitourinary examination included digital rectal examination and
prostate massage as well as microscopic evaluation of the mid-void and post prostate massage (VB3) specimens as well as the expressed prostatic secretions (EPS). Those with evidence of prostatitis were prescribed 4
weeks of antibiotics and repeat PSA blood test 2 to 4 weeks after completing antibiotics. In those men with persistently elevated PSA levels, transrectal prostate biopsy was carried out. The histological results were
then compared with those of men who did not have evidence of inflammation on EPS or VB3. Men from the prostatitis cohort were followed up to 24 months.
Results Of 122 evaluable patients (mean age = 62.9 years),
51 (43%) had clinical evidence of prostatitis. After antibiotic therapy, 22/51 (45%) had normal PSA levels; 29/51 underwent biopsy because of persistent PSA elevation. Prostatitis was identified histologically at a
significantly higher rate among men with clinical evidence of prostatitis when compared to those without prostatitis (15/29 [51%] vs. 13/71 [18%], p=0.001). Cancer was detected less often among those in the prostatitis
group (9/29 [31%] vs. 36/51 [51%], p=0.07). Mean PSA levels did not differ between these groups (8.90 ng/de vs. 9.04 ng/dL). None of the patients who had normalized PSA levels required subsequent biopsy. Of those who
had persistently elevated PSA levels, most remained stable or decreased.
Conclusions Until now, Category IV Prostatitis has not been prospectively studied in asymptomatic men. These results suggest that the
clinical exam is reliable in identifying Category IV Prostatitis in men with elevated PSA levels. Diagnosing this form of prostatitis may allow clinicians to consider antibiotic therapy and measurement of PSA decrement
before prostate biopsy. Long-term follow-up suggests that this treatment is safe, effective, and durable. The power of this study may be enhanced if men with normalized PSA levels had undergone prostate biopsy as well.