AUA 2000: BACTERIA ASSOCIATED WITH MALE CPPS
Anonymous
Jay C. Lee, C. H. Muller, I. Rothman, D. Eschenbach, C. Agnew, J. N.
Krieger, J. Turner, M. Ciol, M. S. Frest, R. E. Berger Seattle, WA
INTRODUCTION AND OBJECTIVES: The presence of white blood cells (wbc)
in the expressed prostatic secretions (EPS) of men with category IIIa
Chronic Pelvic Pain Syndrome (CPPS) as well as previous reports of
bacteria in prostate biopsies have led investigators to seek an
infectious etiology for this syndrome. As well, the amount of
inflammation in the EPS has been used as a diagnostic criteria for
different types of CPPS. However, it is unknown whether bacteria exits
in prostates of men without CPPS, and whether there are differences in
the amount of white blood cells in the EPS of CPPS patients and normal
men.
METHODS: Study methods and design was approved by the University's
internal review board. Men with CPPS types IIIa and IIIb (N=84) and
controls [healthy volunteers (N=49)] underwent standard four glass
urine and transperineal, digitally guided prostate biopsies. Prostate
tissue was cultured for aerobes, anaerobes, trichomonas, chlamydia,
and Herpes Simples Viruses (HSV).
RESULTS: CPPS men and controls did not differ significantly in the
amount of wbc's in the EPS (p=0.74; Mann-Whitney U). Positive prostate
biopsy cultures were obtained in both patients and controls. Bacteria
were found in 39/84 (46%) CPPS patients and 14/49 (29%) controls
(p=0.04). One prostate biopsy culture from a CPPS patient grew HSV,
while one culture from a control grew Chlamydia trachomatis. CPPS
patients with >500 wbc/mm3 in EPS were more likely than those with
<500 to have positive cultures (65% vs. 25%; p<0.01). No association
between wbc in EPS and positive cultures was seen in the controls.
WBC's in EPS were also associated with positive coagulase negative
staphylococcus (p=0.03) and positive anaerobic cultures (p=0.04) in
CPPS patients but not in controls. The type of bacteria grown in
post-prostate massage urine was not related to that found in prostatic
biopsy cultures.
CONCLUSIONS: There does not appear to be any difference between CPPS
patients and controls with respect to inflammation in the EPS.
Bacteria are more common in the prostate biopsies of men with CPPS
than in controls. The types of bacteria found in post massage urine
did not correspond to that cultured from prostate biopsy cultures.
Patients with category IIIa CPPS were more likely to have bacteria in
prostate biopsy cultures than those with category IIIb. No
relationship was found between inflammation of EPS and bacteria in the
prostate biopsy cultures of controls Supported by: Paul G. Allen
Medical Foundation for Medical Research NIH
Anonymous
> BACTERIA ARE ASSOCIATED WITH MALE
> CHRONIC PELVIC PAIN SYNDROME.
>
>
> CONCLUSIONS:
>
> There does not appear to be any difference
> between CPPS patients and controls with
> respect to inflammation in the EPS.
This is more evidence that whatever the problem is that men with CPPS
have, it's apparently not inflammation. I find this a little
bewildering. Any comments?
> Bacteria are more common in the prostate
> biopsies of men with CPPS than in
> controls.
Yes, but less than half of the men with CPPS have bacteria, compared to
about 30% of "normal" men. The finding isn't exactly illuminating, to me
anyway.
> The types of bacteria found in post
> massage urine did not correspond to that
> cultured from prostate biopsy cultures.
Why? What does this imply?
> Patients with category IIIa CPPS were
> more likely to have bacteria in prostate
> biopsy cultures than those with category
> IIIb.
This is in line with Dr Shoskes' recent findings too, I think.
> No relationship was found between
> inflammation of EPS and bacteria in the
> prostate biopsy cultures of controls
Which makes controls different to CPPSers in this regard. So bacteria in
controls are not pathogenic, but cause injury in CPPS pts?
A confusing study?
Daniel Shoskes MD
Anonymous <nob...@noisebox.dhs.org> wrote:
> This is more evidence that whatever the problem is that men with CPPS
> have, it's apparently not inflammation. I find this a little
> bewildering. Any comments?
>
s
>
> Which makes controls different to CPPSers in this regard. So bacteria in
> controls are not pathogenic, but cause injury in CPPS pts?
>
> A confusing study?
First of all, it is very important to realize how difficult it is to
write a comprehensive abstract for papers and for meetings like this.
There are strict word and space limitations as well as requirements for
Introduction and Conclusion sections that limits the space for methods
and results to the point that much supportive data cannot be included.
More information gets presented at the meeting and far more in the
actual published paper (if one is written: fewer than 2/3 of papers
presented at meetings are ever published as peer reviewed papers).
The presence of bacteria in a body tissue or cavity does not mean
infection. The presence of WBC in tissue does not mean infection.
Infection is the presence of bacteria which produce local injury and to
which the body responds with an inflammatory reaction. 100% of normal,
healthy men have bacteria on the skin, probably 80-90% have bacteria in
the distal urethra, and as we seem to be learning about 30% have
bacteria in the prostate. Men with CPPS have a higher incidence of
bacteria in the EPS and prostate tissue. This may be because these
bacteria are causing the CPPS directly, indirectly (through auto-immune
stimulation) or because these bacteria have NOTHING to do with CPPS
other than serving as a marker for other processes going on. Perhaps an
"injured" prostate is more condusive to the growth of commensal
bacteria. Perhaps men with CPPS who have had courses of powerful
antibiotics have a change in the local flora of the prostate. Perhaps
nerve inflammation and muscle spasm produces substances that promote
bacterial growth. These are all testable hypotheses.
My own conclusions so far? Some men with CPPS have true infections: I
find bacteria, I treat bacteria, I eliminate bacteria, symptoms
dissappear, and sometimes later bacteria and symptoms come back. Some
men with CPPS have bacteria that are commensals: I find bacteria, I
treat bacteria, I eliminate bacteria, symptoms are unchanged. One man
has radical prostatectomy + seminovesiculectomy and symptoms still
there. Another man goes on full immunosuppression following transplant
and symptoms dissappear (case report accepted for publication this year
in J Urol). Some men with CPPS have inflammation but no bacteria and
have failed therapy with antibiotics and antifungals but have complete
resolution of symptoms with anti-inflammatory therapy (cox-2
inhibitors, Prosta-Q). Some men with CPPS have nothing wrong with their
prostates. I find no bacteria. They insist they want to try
antibiotics+massage because of compelling but misguided hypotheses they
may have read on the internet. It doesn't help, anti-inflammatories
don't help. Physiotherapy, muscle relaxants (Flomax, Flexeril, Elavil)
break the muscle spasm and solve the problem. Finally some men respond
to none of these and other therapies and I have no idea what to do for
them, other than to continue with research that explores both the basic
science and clinical features of this (these??) disorders.
Daniel Shoskes MD
UCLA
http://www.ben2.ucla.edu/~dshoskes
Institute for Male Urology
http://www.urol.com
Anonymous
Daniel Shoskes MD wrote:
>
> In article <4364c40b3fc3ca77...@noisebox.dhs.org>,
> Anonymous <nob...@noisebox.dhs.org> wrote:
>
> > This is more evidence that whatever the problem is that men with CPPS
> > have, it's apparently not inflammation. I find this a little
> > bewildering. Any comments?
> >
> > Which makes controls different to CPPSers in this regard. So bacteria in
> > controls are not pathogenic, but cause injury in CPPS pts?
> >
> > A confusing study?
>
> First of all, it is very important to realize how difficult it is to
> write a comprehensive abstract for papers and for meetings like this.
> There are strict word and space limitations as well as requirements for
> Introduction and Conclusion sections that limits the space for methods
> and results to the point that much supportive data cannot be included.
> More information gets presented at the meeting and far more in the
> actual published paper (if one is written: fewer than 2/3 of papers
> presented at meetings are ever published as peer reviewed papers).
I did not realise that these papers will possibly not all be published
in peer reviewed journals. It'll be interesting to see which ones "make
it".
> The presence of bacteria in a body tissue or cavity does not mean
> infection. The presence of WBC in tissue does not mean infection.
> Infection is the presence of bacteria which produce local injury and to
> which the body responds with an inflammatory reaction. 100% of normal,
> healthy men have bacteria on the skin, probably 80-90% have bacteria in
> the distal urethra, and as we seem to be learning about 30% have
> bacteria in the prostate.
Yes, that was a surprising finding, but since it's based on biopsies of
normal men (and Wow! for how long have we all being saying how much we'd
like to see these biopsies done!), we have to believe it. Krieger and
Berger are reliable researchers. Let's see it replicated too. Any more
normal biopsy volunteers around?
> Men with CPPS have a higher incidence of
> bacteria in the EPS and prostate tissue. This may be because these
> bacteria are causing the CPPS directly, indirectly (through auto-immune
> stimulation) or because these bacteria have NOTHING to do with CPPS
> other than serving as a marker for other processes going on. Perhaps an
> "injured" prostate is more condusive to the growth of commensal
> bacteria. Perhaps men with CPPS who have had courses of powerful
> antibiotics have a change in the local flora of the prostate. Perhaps
> nerve inflammation and muscle spasm produces substances that promote
> bacterial growth. These are all testable hypotheses.
You've just outlined a whole world of future research, methinks.
> My own conclusions so far? Some men with CPPS have true infections: I
> find bacteria, I treat bacteria, I eliminate bacteria, symptoms
> dissappear, and sometimes later bacteria and symptoms come back. Some
> men with CPPS have bacteria that are commensals: I find bacteria, I
> treat bacteria, I eliminate bacteria, symptoms are unchanged. One man
> has radical prostatectomy + seminovesiculectomy and symptoms still
> there. Another man goes on full immunosuppression following transplant
> and symptoms dissappear (case report accepted for publication this year
> in J Urol).
Great! I've been looking forward to that case being published!
> Some men with CPPS have inflammation but no bacteria and
> have failed therapy with antibiotics and antifungals but have complete
> resolution of symptoms with anti-inflammatory therapy (cox-2
> inhibitors, Prosta-Q). Some men with CPPS have nothing wrong with their
> prostates. I find no bacteria. They insist they want to try
> antibiotics+massage because of compelling but misguided hypotheses they
> may have read on the internet. It doesn't help, anti-inflammatories
> don't help. Physiotherapy, muscle relaxants (Flomax, Flexeril, Elavil)
> break the muscle spasm and solve the problem. Finally some men respond
> to none of these and other therapies and I have no idea what to do for
> them, other than to continue with research that explores both the basic
> science and clinical features of this (these??) disorders.
>
> Daniel Shoskes MD, UCLA
What a god-awful riddle! Next step: let's get the geneticists to find
any genetic quirks CPPSers may have. There could be a breakthrough
lurking there ...