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Session 2

Note to session notes: This document is intended and presented as "notes," and is not meant to be seen as a complete publication or medical document. There may be sentence fragments or gaps in this text. It is presented here so patients, doctors and other people interested in prostatitis can have some idea of how the meeting session went. After the meeting, notes were filled in from memory and occasional reference to tape recordings. Speakers were sent E-mails inviting them to revise and extend their remarks. Full identity and other contact information for speakers is available on the Attendees page. For "official" opinions and medical "facts," please refer elsewhere to medical journals, etc.

Session two, held on Thursday afternoon, Nov. 4, 1999, contained a series of condensed presentations, prepared on short notice. The presentations were designed to answer the questions: W hat is the state of the art in epidemiology, etiology and treatment? Attendees were free to come up to a microphone and make comments between the presentations. These are presented here without distinction. Remarks with the speaker icon next to the name of the speaker are available in the audio archives.

Epidemiology Panel

(An Epidemiologist with the Mayo Clinic in Rochester, MN, described what is known epidemiologically about prostatitis. Name witheld by request. The reason for this witholding is unrelated to this conference.)


    Epidemiology is the study of the distribution of diseases and occurrence of diseases.

    Considerably less is known about prostatitis than BPH and cancer. In the National Hospital Discharge Survey, based on 1992 data, there were 30,000 acute, 28,000 chronic, 19,000 unspecified cases of prostatitis that led to hospitalization.

    The National Ambulatory Medical Care survey in 1990-1994, studied by McNaughton-Collins et. al., found there are. 2 million office visits a year for prostatitis, 700,000 of them by men under 50, 900,000 over 50.

    In Mayo Clinic's Olmstead County (Minnesota) study, we questioned 2113 Men, ages 40 to 79. We gave them the questionnaire and then checked medical records. About 9 per cent, or one out of every eleven men reported prostatitis.. The incidence is about 3 per thousand person-years. If extrapolate this to theage distribution of the US, 310,000 men get a new diagnosis of prostatitis in a given year. In Olmstead, 75 per cent of the diagnosed prostatitis had no classification on the NIH scale. There were also some "uncertains." Although the new NIH classification may help us [understand the epidemiology of the disease], in routine clinical practice we still will have considerable challenges in diagnosing specific kinds of prostatitis. Risk factors [that can be seen from epidemiologic studies] include age, race, environmental factors, cytokines, and components of EPS, as well as genetic factors and autoimmune tendencies. For example, diagnosis of prostatitis is more common in the South.

Patient John Garst

    I don't know whether to wish there were fewer patients or more. If there were more, there would be more suffering, but it would be easier to get more money from Congress to study this. The genetic aspect seems important to me. Why, I wonder, are we more likely to get a diagnosis in the South?

Dr. Aare Mehik

    We studied whether prostatitis is more prevalent for Finns. Until recently the attitude in Finland was what is not killing patients is not important. We started a cross-sectional study in 1993 -1994, where we asked 102 questions. There were 2,500 randomly chosen respondents, of whom we got answers from1832. We then called non-respondents. We found a total of 261 chronic prostatitis patients. Of the respondents, the rate of prostatitis is 14 per cent. In our study, of these patients, 21.3 per cent suffer problems at least once a year. Fifty-eight per cent thought the main reason is cold climate and winter. They said they suffered in winter and not in the summer. [Maybe some respondents had BPH]

Dr. Tim Moon

    I'm willing to be the contrarian, and to doubt the common assumptions. Whatever prostatitis is, it seems to be becoming more prevalent. We've thought of it as affecting men 30-50, with confusion after 50 with BPH . We need to be cautious not become the age of false prophets. Less than 50 per cent of urologists really check prostate. Even fewer do the [Stamey-Meares] 4-jar test. Many [urologists] [have their patients] use antibiotics. [In the NIH definition] we have defined pain as a requirement. But at least 20 per cent of "prostatitis" patients don't have pain.

    We need to know, we're looking at the epidemiology of what? We need to clarify what we're looking at. There are overlapping symptoms. We don't consider treating cancer, BPH, or infection in the same way. These are clearly distinct entities, & We need to look at what the disease process is. It is not proven to be a disease of the prostate nor an inflammation.

Dr. Daniel Shoskes

    Have you got any idea of where the breakdown is? Is it in the rate of seeking care?


    It is possible you are not seeing patients but they are there.

Dr. Boris Gushchin

    I would see chronic prostatitis to be unlikely to cause a visit to the doctor.

Dr. Tim Moon

    {In the American medical system] Everybody has to leave with a diagnosis for the purpose of billing.

Dr. George Barbalias

    I think defining is a big predicament.

Dr. Richard Alexander

    Nobody 'created' the definition of [prostatitis based on] pain. In the Internet survey [done by Alexander and prostatitis patients] the number one thing mentioned by patients was pain. Curtis Nickel found pain the best discriminator of prostatitis in his symptom index validation. John Krieger also published a paper in Urology showing that pain is the principal complaint of patients with CP. We're not making that up. This is where we started because we had to start somewhere.

Dr. Curtis Nickel

    Now we must go and look for the symptoms, look at a population, that was my plea, based on last year's meeting. We decided to define what we're looking at based on the NIH 4 categories, so that where we do define prostatitis, there can be a way to compare what's happening in Greece, Finland, or anywhere. Now, [thanks to the NIH classification] we have a framework for discussing what we're dealing with.

Etiology Panel

Dr. Curtis Nickel

    [Describes prostatitis as an] "etiological enigma"

Dr. John Krieger

    What pathologist is talking about is based entirely on tissues. There are problems with this, because almost all of the tissue samples are taken either from BPH patients or cancer patients. Infection can be focal, [and tissue sample studies] don't correlate with doctors clinical findings.

    Many men have inflammation. We looked at more than 100 men within the NIH definition, and found minimal or no histological inflammation. Meanwhile the fertility literature uses different criteria, based on seminal analysis. And the urology literature is based on Meares and Stamey. However, there is no controversy in acute prostatitis.

    Careful cultures will show standard uropathogens. Problems with that are that only a minority of these patients fit in first two categories and cultures are not done in most practice settings. The assumptions are that patients with white cells might be infected, or that they might have non-infectious inflammatory disorder, or some organic pathology.

    But the group of patients without white cells might have pelvic floor problems, or a form of fibromyalgia, or psychological problems. The whole situation has patients and doctors clearly frustrated.

    The NIH Clinical definition has the advantage in that it is based on what patients suffer from. This is needed when we are grappling with no diagnostic physical finding, and no diagnostic physical test. That's why we worked on a definition based on symptoms.

    There may be a role for other bacterial causes, but such bacteria often can be cultured from patients with no symptoms. Is asymptomatic prostatitis worth pursuing?

    You could take a urodynamic approach. But it hasn't worked very well in patients, that I see.

    Other causes: as far as I can tell, we really don't have the answers. As for infection [as a cause of prostatitis], some patients do respond to antibiotic therapy, but in many cases this response is transient or incomplete. There are also very many other abnormalities that have been described. Many of these may be an effect, rather than a cause.

    We need to understand genetic , behavioral and industrial causes. It would be nice if we could prescribe responses based on what we can know. What causes chronic prostatitis? do we need to know the answer in order to improve the treatment? Don't know causes of cancer and BPH, but we have improved therapy [for those conditions].

    I'm convinced patients and their physicians will try anything. The real issue is monitoring the efficacy of this. There are very real problems in reporting efficacy. There is the real problem of long-term outcome seldom being reported in the literature.

    It would also be very nice if we could do primary prevention.

Dr. Hiromi Kumon

    We have been treating for Chlamydia, but it does not cause majority of abacterial prostatitis.

Dr. Rodney Anderson

    Etiology[of CPPS} is complex, but & there's good evidence for obstructive types of reflux. I have to take care of the patients. We are firmly in the belief there is a pelvic pain dysfunction, and we are working on it from a neuromuscular perspective. We have more success from the physical approach, until we can work out the molecular.

Dr. Durwood Neal

    I've always thought that it was bacterial. Until I began to study bacterial prostatitis. Now I think perhaps bacteria may not be involved, It may be the pelvic floor that we're dealing with, that may be the final common pathway. I don't think we can place all our patients into the same pigeonhole. "We are confronted with insurmountable opportunities."

David Bolles

    I am a5 year sufferer. I saw 5 urologists in Arizona. Urologists are frustrated. I have had many diagnoses. One suggested I see a psychiatrist. Each gave me a different treatment regime. Most consisted of some kind of antibiotic. It really lowers your confidence in the urologist, in their ability to diagnose, and lowers confidence in the entire medical field. There is so much confusion and frustration. So it is important to understand etiology. So that urologists can offer some form of standardized treatments.

Dr. Hiromi Kumon

    In one patient we were able to diagnose an inguinal hernia, in standing position

Dr. John Krieger

    Some men have inflammation in their EPS, and some don't. Some patients have objective inflammation in post-massage urine or ejaculate, even when they do not have any in their EPS.

Dr. Tim Moon

    What if [the root etiology of CPPS] is not prostatic.

Dr. John Krieger

    Patients could have similar complaints with different causes.

Dr. Durwood Neal

    We start with the prostate gland, but it's only one of the things we should look at.

Dr. David Wise

    [CPPS] is a headache in the pelvis, TMJ in pelvis, a chronic contraction in the pelvis.

Treatment Panel

Dr. Wolfgang Weidner

    We want to eradicate these bacteria, The question for me is after eradication of microorganisms, is there a normalization of the inflammatory parameters, and is there a normalization of symptoms. In Europe, we have a consensus to treat with modern quinolones. We feel we can eliminate the bacteria. We have heard of the idea of local injection [into the prostate gland of antibiotics], but the long term results are very bad. There is a renaissance of TURPs in Europe. All the treatment regimes need to be studied.

Dr. Andrew Doble

    Now that we have the NIH classification, need to re-evaluate all the treatments, we can't write of any treatment yet. It will help to know etiology, but it doesn't matter at the moment. Psuedomonas prostatitis is very difficult to eradicate. With what is called Type IIIa, we use anti-inflammatory agents. Microwave therapy, with improvements, should revisited. But since can't show prostate is the source, [of CPPS] we should limit physical actions.

Dr. Richard Berger

    It is very important to continue to study etiology. How many people get better on their own or with a single course of antibiotics? We don't really know. One can do single patient trials (by randomizing the drug or a placebo) and can choose how to study treatments better.

Dr. Boris Gushchin.

    In Russia, our options range all the way to very aggressive treatments, surgical treatments. For selected chronic prostatitis patients surgical management such as partial or complete TURP is utilized. Patients with obstructive symptoms are the ones who benefit the most from endoscopic surgery. Prostatitis patients with the prevalence of irritative symptoms do not demonstrate significant improvement from this kind of treatment. This reflects the fact that these patients do not form a single universal group, by any means. We need to find the etiology in each individual patient. Will be different in each patient.

[Name witheld]

    Clearly patients are at their wits' end. It is estimated that patients in the USA spend over a $1 billion on phytotherapy [herbal medications] for men's health. We have very little true clinical trial knowledge with these.

Patient John Garst

    What about treating for yeast?

Dr. Wolfgang Weidner

    We see yeast only in immunocompromised patients. TURPs [trans-urethral prostate surgery] are on increase in Germany, but there is no rationale for it.

Dr. Andrew Doble

    The problem is that aTURP doesn't get into the peripheral zone, which is where the inflammation of prostatitis is located.

Research Abstracts Session

    Notes on this portion: The content of the research abstracts is available on the Abstracts page. These notes only include remarks thought by your reporter to be significant, and make no claim of being inclusive

Dr. Curtis Nickel

    In planning the meeting, we orignally had booked time for 12 clinical papers, but we had 60 abstracts submitted. We will have presentations on 40.

Dr. Richard Berger

    We developed a "Tenderpoint score."

    What's tender in a physical exam, we took the scale from fibromyalgia and applied it to men with pelvic pain, had higher pelvic pain scores, all significantly higher. All 7 internal points were significantly higher. We found it is not just prostate pain syndrome, but pelvic pain syndrome. We found pain at all points in the perineum. Where this pain is located may differentiate men with CPPS, or it may be part of a more generalized pain disorder. Pain is not localized to pain in prostate, not correlated to bogginess.

Dr. Martin Ludwig

    [In studies of semen] we found no difference in sperm motility due to inflammation. CPPS may be negative a negative factor in fertility, but it cannot be detected by routine semen analysis.

Dr. Charles Muller

    This may be an old point, but the way we're going to measure white blood cells needs to be quantitative. We compared wet mount, stained smear and hemacytometer (grid for counting cells). [The white cell count found by using a] wet mount was highly dependent on the volume. The viscous prostatitic fluid creates more depth under the cover slide. Wet mount slides are not suitable for that purpose.

Dr. L. Eduardo Vega

    What if you have a lot of clumps?

Dr. Charles Muller

    Then the clumps will compromise your count no matter what you do.

Dr Jeanette Potts

    We studied 187 consultations for elevated PSA, and excluded those with symptoms. We find one can get a significant lowering of PSA score with treatment of prostatitis, and we feel that if this were universal, it would result in better use of PSA scores for detection of cancer. We also found that CPPS has a risk of infertility.

Dr. Jordan Dimitrakov

    What is the prevalence of fungal prostatitis? We found it in 13 percent of cases.

    We looked for Helicobacter pylori by PCR in prostates removed from patients. We found H. Pylori in 10 per cent of our patients. What we don't know is what would be the pathogenic role of H pylori in prostatitis, and how do people get infected?