Αγαπητοί φίλοι τελικά κλείνω και εγώ 6μηνο τουλάχιστον χωρίς συμπτώματα. Εφάρμοσα τις παρακάτω οδηγίες που έχω δημοσιεύσει στον παρακάτω σύνδεσμο:
http://www.chronic-prostatitis.com/index.php?topic=244.0
μεγάλη βελτίωση είδα αρχικά από το Prosta-Q που το βρήκα στο amazon
http://www.chronic-prostatitis.com/index.php?topic=229.msg272#msg272
έλαβα λοιπόν για ένα μήνα vibramycin και ciproxin και xatral OD. To vibramycin το πήρα 2 μαζί μεσημέρι, αφού δεν άντεχε πια το στομάχι μου για ένα κάθε 12 ώρες όπως πρέπει. Διάβασα στο uptodate ότι είναι 24ωρο και έτσι το έλαβα έτσι. Είναι αντιβιοτικό για τα χλαμύδια, γιατί παρουσίασα πριν πάθω προστατίτιδα, πρώτα ουρηθρίτιδα και μια σταγόνα πράσινο υγρό. Έδωσα και στην γυναίκα τότε Ζithromax 2gr εφάπαξ σιρόπι που επίσης είναι για τα χλαμύδια. Μόνο άκουσα ότι το vibramycin δεν υπάρχει πια και στενοχωρήθηκα, μπορεί να είναι και φήμη δεν το ερεύνησα γιατί στενοχωριέμαι να ασχοληθώ ξανά με τα ίδια. Μάλιστα για να σας γράψω πέρασαν 3 μήνες.
Επίσης το ciproxin πήρα το 1000άρι το 24 ωρο για τον ίδιο λόγο
Αρχικά επίσης έλαβα το omnic tocas όπως λένε οι οδηγίες της Αμερικής, αλλά παρουσίασα παλίνδρομη εκσπερμάτιση και το άλλαξα με το xatral OD ένα πάλι την ημέρα και αυτή υποχώρησε. Φοβήθηκα μην κάνω νέα μόλυνση με το σπέρμα να μπαίνει αρχικά με την παλινδρόμηση μέσα στην ουροδόχο κύστη. Και τα δύο δεν πείραξαν καθόλου.
Για το στομάχι σας θα είναι προτιμότερο να λαμβάνετε peptonorm που είναι πάμφθηνο και δεν αυξάνει το μικροβιακό φόρτο στο γαστρεντερικό. Είναι βέβαια το φθηνότερο με διαφορά, θεραπεύει και γαστρορραγίες. Αλλά δεν έχουν αποδειχθεί ότι είναι καλύτερα να λαμβάνεται αυτό, έχει αποδειχθεί ισάξιο όμως με όλα τα άλλα, οπότε θα έλεγα καλύτερα γαϊδουρόδενε παρά γαϊδουρογύρευε...
Έπαιρνα και μια πολυβιταμίνη καθημερινά, όλα λοιπόν τα παραπάνω μαζί. Δεν επηρέαζαν την φαρμακοδυναμική των αντιβιοτικών φαρμάκων
Την αντιβίωση την πήρα εμπειρικά γιατί είμαι γιατρός και δυστυχώς δεν μπορούσα να κάνω καλλιέργεια προστατικού υγρού και μαλάξεις (το θεωρώ ανυπόφορο). Θα πρέπει πάντως να προσέξετε να μην τρώτε ερεθιστικές τροφές γιατί αλλιώς δεν θα δείτε βελτίωση και θα εγκαταλείψετε επιτυχημένη αντιβιοτική αγωγή. Σίγουρα σε όλους μας ξεκίνησε μικροβιακά η μόλυνση και μετά εάν καταφέρουμε να την καταπολεμήσουμε, πάμε στο χρόνιο πυελικό άλγος που έχουμε οι περισσότεροι από εμάς στο φόρουμ, που τόσο μας έχει βοηθήσει. Επίσης η αντιβίωση έχει και αντιφλεγμονώδη δράση και αυτό μπλέκει τα πράγματα. Μάλιστα στη δημοσίευση για το χρόνιο πυελικό άλγος το ξεκαθαρίζει αυτό. Εάν επιδεινώνεσαι αμέσως την άλλη μέρα από τη διακοπή της αντιβίωσης τότε η αντιβίωση έδρασε καθαρά ως αντιφλεγμονωδες! (προσoχή όμως μην φάτε ερεθιστικες τροφές)
Παρόλα αυτά την συστήνει τον πρώτο μήνα και ξέρω ότι αυτή δημοσίευση είναι σημαντική γιατί το uptodate το λαμβάνουν υπόψη τους οι ιατροί σε όλο τον κόσμο. Συνήθως γράφουν αυθεντίες σε αυτό, ενώ η συνδρομή του είναι ακριβή.
Τροφές ερεθιστικές είναι η καφεΐνη, οπότε κομμένο τσάι-καφές. Ακόμα και τώρα που είμαι καλά, αν αρχίσω με τον ίδιο ρυθμό με το παρελθόν την καφεΐνη, αμέσως πονάω λίγο αρχικά και πιστεύω αν συνεχίσω, θα φτάσω στα ίδια με πριν!
Φυσικά καυτερά το ξέρετε όλοι. Επίσης και οι γλυκές πιπεριές μου έκαναν τότε κακό και μου φαίνεται είχα διαβάσει και για αυτό. Τώρα πια φυσικά τρώω πιπεριες μη καυτερες. Επίσης στις ερεθιστικές τροφές είναι και το αλκοόλ (όσο πιο πολύ οινόπνευμα, τόσο πιο ερεθιστικό το ποτό, πάειι και αυτό τον καιρό της ασθένειας), ενώ και η σοκολάτα και κακάο επειδή περιέχουν καφεΐνη, θα πρέπει με μέτρο. Τα γλυκά επίσης μου κάναν κακό και το διάβασα στο ιντερνετ, οπότε τον καιρό της προστατίτιδας τα έκοψα όσο μπορούσα και αυτά.
Καλό μου έκανε και ο βελονισμος (τον έκανα ταυτοχρονα με την θεραπεια) και το λέει και αυτό στην δημοσίευση. Μάλιστα δεν πρέπει να ντρέπεστε γιατί δεν ξεγυμνώνεσαι, αλλά τα νεύρα ξεκινάνε από ψηλά, οπότε οι βελόνες μπαίνουν ψηλά στο εφηβαίο μπροστά και πίσω στην ιεροκοκκυγική μοίρα. Άρα απλώς χαμηλώνεις μόνο το εσώρουχο
Πάρα πολύ με βοήθησε η πλατφόρμα παλμικών δονήσεων της telemarketing για πιο φθηνά. Μοιάζει με το power plate και κάνει τα ίδια σε πιο φθηνή τιμή. Καθόμουν πάνω για δυο 20λεπτά την ημέρα και έσκυβα μάλιστα και προς τα μπρος για να ακουμπήσει πιο καλά ο προστάτης. Με τις δονήσεις έμπαινε μες στις κύστες του προστάτη η αντιβίωση καθώς και ήταν αποτελεσματική η άμυνα του οργανισμού μέσα σε αυτές. Πιστεύω ότι αυτή με έσωσε. Όπου την βρείτε φθηνότερη πάρτε την και πιστεύω ότι θα δείτε καλό. Εάν τελικά γίνεται καλά με αυτήν, παρακαλώ ενημερώστε με να κάνω εργασία, να το μάθει παγκοσμίως ο ιατρικός κόσμος. Προσοχή δεν είμαι ουρολόγος και δεν μπορώ να παρακολουθώ ασθενείς. Όταν σταμάτησα την αντιβίωση διέκοψα και τις δονήσεις.
Τέλος με βοήθησε εξαιρετικά το φόρουμ και έμαθα πολλά μυστικά και ξεφοβήθηκα με την παλίνδρομη εκσπερμάτιση, έμαθα και την κρουοσετίνη, έμαθα να μην αγχώνομαι, έμαθα για τις ασήμαντες επιδεινώσεις όταν κρατούσα τα ούρα και όταν αγχωνόμουν, που με τίποτε δεν σημαίνουν ότι αρρώστησες ξανά. Επίσης έμαθα να χαλαρώνω την περιοχή οπότε ο πόνος υποχωρεί!
Απλώς να ξέρετε όσο καλά και να είσαι πάντα μικροπροβλήματα θα έχετε, αλλά θα είναι ασήμαντα και δεν θα είναι πόνος, άλλωστε το λέτε και στο φόρουμ. Ουσιαστικά όλα όσα σας είπα τα ξέρατε, με τη διαφορά να είναι οι παλμικές δονήσεις, ο βελονισμός και ο συνδυασμός αυτών.
Να είστε καλά, όσα ήξερα σας τα είπα και θα μπορέσετε και εσείς να τα καταφέρετε!

Infectious causes of dysuria in adult men
Authors
Heidi Swygard, MD, MPH
Myron S Cohen, MD
Arlene C Seña, MD, MPH
Section Editor
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor
Barbara H McGovern, MD
Literature review current through: Jun 2012. |This topic last updated:Ιαν 14, 2011.
INTRODUCTION — Dysuria in men (described as pain, tingling, or burning during or just after urination) may be localized to the urethral meatus, the distal portion of the penis, or anywhere along the penile shaft. Dysuria in men may be a presenting complaint of urethritis, prostatitis, epididymitis, or urinary tract infections.
Urethritis is more commonly seen in young sexually active men, whereas urinary tract infections occur in older men with prostatic hypertrophy or history of prior catheterization. Dysuria is also reported in the majority of men with symptomatic gonorrhea and over half of patients with nongonococcal urethritis (NGU).
Both acute and chronic prostatitis can occur in young and middle-aged men. Chronic prostatitis can occur as a complication of acute prostatitis or without any recognized initial infection. Urethral instrumentation and prostatic surgery are known causes of prostatitis, but many patients have no history of a precipitating event.
Isolated acute cystitis does not commonly occur in men. The much lower incidence of cystitis is men, compared to women, has been attributed to less frequent colonization around the urethra due to the drier periurethral environment, increased length of the urethra, and antibacterial substances in prostatic fluid. Most men with acute cystitis have a functional or anatomic abnormality. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
Acute bacterial epididymitis is a relatively rare disease, but can cause serious illness. It can be seen in conjunction with acute prostatitis, particularly in older men who may have underlying prostatic obstruction or recent instrumentation as a risk factor. Acute epididymitis can also be due to a sexually acquired infection.
HISTORY — A thorough sexual history should be obtained from all patients with dysuria. (See "Screening for sexually transmitted diseases", section on 'Taking a sexual history'.)
Painful urination is usually the chief complaint in men with urethritis. They may also complain of pruritis or discharge at the urethral meatus. Discharge may be present throughout the day or may be scanty and only present on the first morning void.
Some general principles can suggest different etiologies of urethritis secondary to sexually transmitted diseases:
   Since the incubation period for gonorrhea is shorter (less than two weeks) than for chlamydia (which has a variable onset of 2 to 35 days), a urethral discharge that is described as acute and frankly purulent is suggestive of gonorrhea.
   Patients with dysuria alone are more likely to have chlamydial infection.
   Dysuria that is accompanied by painful genital ulcers is probably due to genital HSV; patients with primary HSV infection may also complain of fever, tender local inguinal lymphadenopathy, and headache.
Detailed information regarding these infections is available elsewhere. (See "Genital Chlamydia trachomatis infections in men" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Diagnosis of gonococcal infections" and "Treatment of urogenital gonococcal infections".)
The typical signs and symptoms of acute bacterial prostatitis are similar to upper urinary tract infection and include fever, chills, malaise, myalgia, dysuria, and cloudy urine. In addition, swelling of the acutely inflamed prostate can cause obstructive symptoms, ranging from dribbling and hesitancy to anuria.
Patients with chronic prostatitis may have complaints of typical cystitis such as frequency, dysuria, and urgency. However, other subtle symptoms may include perineal discomfort, discomfort during ejaculation, deep pelvic pain, or pain radiating to the back. The diagnosis of prostatitis should be considered in men who have a history of recurrent UTIs in the absence of risk factors, such as bladder catheterization. (See "Acute and chronic bacterial prostatitis".)
Patients with acute epididymitis often complain of irritative voiding symptoms (dysuria, frequency, urgency) and pain in one testicle. These localizing symptoms are often accompanied by a history of high fever and rigors.
Acute cystitis is indicated by dysuria and other complaints of urinary frequency, urgency, suprapubic pain, and cloudy or bloody urine. The presence of upper tract infection is suggested by systemic symptoms such as fever, chills, and malaise. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
PHYSICAL EXAMINATION — The physical examination should include measurement of temperature and assessment of the general well-being of the patient. Specific attention should be given to a full genital and rectal examination and assessment of tenderness in the costovertebral region.
The physical examination should include lymph node palpation and inspection and palpation of the testicles and penis. The skin of the entire pubic area, scrotum, groin, and penis should be examined for lesions or genital ulcers. The testes, epididymides, and spermatic cords should be palpated for masses or tenderness. The foreskin should be completely retracted and the urethral meatus should be inspected for crusting, redness, or discharge.
In patients with suspected urethritis, penile discharge may be mucoid, mucopurulent, or purulent in appearance. If there is no apparent urethral discharge noted on physical examination, the urethra should be milked from the base to the meatus by placing the gloved thumb along the ventral surface of the base of the penis and the forefinger on the dorsum and applying gentle pressure. The hand is moved slowly toward the meatus to expel any discharge for specimen collection [1]. (See "Genital Chlamydia trachomatis infections in men" and "Diagnosis of gonococcal infections".)
The typical signs of acute prostatitis notable upon examination include high fevers and chills. The finding of an edematous and tender prostate on physical examination should lead to a presumptive diagnosis of acute prostatitis. The digital rectal examination should be performed in a gentle fashion when acute prostatitis is suspected since vigorous examination can induce bacteremia. (See "Acute and chronic bacterial prostatitis".) The physical exam in patients with chronic prostatitis may be unremarkable.
In patients with epididymitis, physical examination is usually notable for induration and swelling of the involved epididymis in association with exquisite tenderness. Urologic consultation for possible torsion might be necessary if the onset of pain was sudden and severe [2]. (See "Evaluation of the acute scrotum in adults".)
Patients with an upper urinary tract infection are often febrile and uncomfortable in appearance; in severe cases, physical examination may be notable for hypotension and flank pain. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
MICROBIOLOGY
Urethritis — Gonorrhea is a common cause of urethritis in the United States and Europe, especially in urban areas and STD clinics. In 2004, rates of positive urethral gonorrhea tests were higher in HIV-positive MSM compared to HIV-negative MSM. (See "Diagnosis of gonococcal infections".)
In addition, up to 25 to 30 percent of men with gonococcal urethritis also have concurrent chlamydia infection [2]. When N. gonorrhoeae cannot be detected, the term "nongonococcal urethritis" (NGU) is used. Although most cases of NGU are due to C. trachomatis, other etiologies include T. vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum [3-7]. In some areas of Africa, T. vaginalis is the most common cause of urethritis [5] and is also identified in 10 to 20 percent of urethral swabs from asymptomatic men presenting to STD clinics [5-7]. (See "Genital Chlamydia trachomatis infections in men".) Urethritis can also occur secondarily to primary genital herpes simplex virus infection. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)
Prostatitis — Acute prostatitis is most commonly bacterial in origin and caused by gram-negative rods (eg, Enterobacteriaceae, Pseudomonas, Proteus) and gram-positive organisms (Enterococcus, S. aureus). Gonorrhea and chlamydia can also cause acute prostatitis. In the absence of instrumentation or anatomic abnormalities, isolation of S. aureus should prompt the clinician to consider hematogenous spread and the possibility of underlying endocarditis.
Chronic prostatitis may be due to some of the same bacterial organisms especially the gram-negative rods, as well as some fungi (depending on the host immune status). (See "Acute and chronic bacterial prostatitis".)
Epididymitis — In men under the age of 35, C. trachomatis is the most common organism responsible for bacterial epididymitis, although gonococcal infection can also contribute to some cases. Sexually transmitted organisms may also be responsible for epididymitis in older men, but bacteriuria secondary to obstructive urinary disease (eg, prostatic hyperplasia) is more common, involving organisms such as E. coli and other coliforms. Men who engage in anal insertive intercourse are at increased risk for epididymitis due to coliform bacteria [2]. (See "Evaluation of the acute scrotum in adults".)
Urinary tract infection — As seen in women, the most common causes of urinary tract infection in men are enteric gram-negative pathogens, such as E. coli. (See "Acute uncomplicated cystitis, pyelonephritis, and asymptomatic bacteriuria in men".)
DIAGNOSIS — Sexually active men with dysuria should be evaluated for urethritis and its associated pathogens. The presence of urethritis can be confirmed by one of the following findings [8]:
   Mucopurulent or purulent discharge on examination
   >5 polymorphonuclear cells (PMNs) per oil immersion field from the Gram's stain of a urethral swab
   Positive leukocyte esterase ("dipstick") on first-void urine or the presence of >10 WBCs per high power field of the first-void urine.
Micturition just prior to examination may hamper detection of sexually transmitted infections. Generally, it should be avoided for at least two hours priors to obtaining specimens.
A Gram's stain specimen for examination of PMNs and any organisms can be collected from expressed penile discharge or from inside the urethra. A calcium alginate swab should be inserted gently at least 2 cm into the urethra and rotated 360 degrees, with care not to force the tip past an obstruction. The swab can then be rolled across a clean microscope slide for air drying and Gram's stain evaluation.
More than four PMNs per high power field is abnormal and is seen in 60 to 90 percent of patients with urethritis [9,10]. The presence of PMNs without any visible organisms is consistent with NGU, whereas gonococcal urethritis may be diagnosed by the demonstration of gram-negative intracellular or extracellular diplococci in the urethral exudate. Because of the specificity of the urethral Gram's stain, a confirmatory culture for gonorrhea is not necessary in men, as it is in women.

Εμένα γνωστός ουρολόγος που πρότεινε να πάρω OMNIC TOKAS. Βλέπω μάλιστα αποτελέσματα. Τα φάρμακα αυτά έχουν σημαντική θέση στη θεραπεία της χρόνιας προστατίτιδας- χρόνιου πυελικού άλγους. Σύμφωνα με τις παγκόσμιες ιατρικές οδηγίες από το καλύτερο συνδρομητικό ιατρικό site
http://www.chronic-prostatitis.com/index.php?topic=244.0
όλοι οι α1 αποκλειστές (Οmnic ή Xatral) λαμβάνονται μία φορά την ημέρα μετά το φαγητό. εσείς έχετε πάρει ποτέ;;;;;
από κάτω οδηγίες πρώτα για το Οmnic tocas (Tamsulosin) και έπειτα για το δέυτερο α1 αποκλειστή Xatral OD (Alfuzosin)

Acute and chronic bacterial prostatitis
Authors
Alain Meyrier, MD
Thomas Fekete, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. |This topic last updated:Φεβ 1, 2012.
INTRODUCTION — The prostate is subject to various inflammatory disorders [1]. In one five-year survey of 58,955 ambulatory visits to clinicians by men over the age of 18 years, genitourinary tract symptoms accounted for 5 percent of all complaints [2]. Prostatitis was listed as a diagnosis in nearly two million encounters annually in the United States National Ambulatory Medical Care Surveys.
Prostatitis syndromes tend to occur in young and middle-aged men. The symptoms of prostatitis are common and often not recognized by clinicians. These symptoms include pain (in the perineum, lower abdomen, testicles, penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen. Impotence is occasionally attributed to prostatitis; however, it occurs no more commonly than in men of a similar age without prostatitis [3]. In a large population-based Canadian questionnaire study, over 20 percent of the men had complaints compatible with chronic prostatitis, and 8 to 10 percent had moderate to severe symptoms [4]. The men with the most severe symptoms also had poorer general health and recurrent complaints.
Definitions of these syndromes, acute prostatitis, and chronic bacterial prostatitis, will be reviewed here. Chronic prostatitis/pelvic pain syndrome is discussed separately. (See "Chronic prostatitis/chronic pelvic pain syndrome".)
DEFINITIONS — Inflammatory or irritative conditions of the prostate were traditionally classified according to the following schema (table 1) [5]:
•   Acute prostatitis.
•   Chronic bacterial prostatitis.
•   Nonbacterial prostatitis, which presents with similar symptoms and signs as chronic prostatitis (including pyuria) except that cultures of urine and expressed prostatic secretions are negative.
•   Prostatodynia, which also presents with similar symptoms and signs as chronic prostatitis except that the cultures are negative and pyuria is absent.
A classification approach supported by the National Institutes of Health (NIH) to standardize definitions and facilitate research made the following recommendations [6]:
•   Adding an entity called asymptomatic inflammatory prostatitis.
•   Combining nonbacterial prostatitis and prostatodynia into an entity called chronic prostatitis/pelvic pain syndrome.
The inflammatory subset of this syndrome included patients with significant numbers of inflammatory cells in expressed prostatic secretions, post-prostate massage urine or seminal fluid. The noninflammatory chronic prostatitis/pelvic pain subset included the remainder of the patients with chronic prostatitis or pelvic pain. (See "Chronic prostatitis/chronic pelvic pain syndrome".)
Thus, the newer schema defined the following categories:
•   I. Acute prostatitis
•   II. Chronic bacterial prostatitis
•   IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory
•   IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory
•   IV. Asymptomatic inflammatory prostatitis
Maneuvers performed in the urology office can help refine the categorization of patients. For example, including post-massage urine and seminal fluid for the assessment of inflammatory cells effectively doubles the number of people in the inflammatory subset (as compared with the older distinction using only purulent prostatic secretions) [7].
ACUTE PROSTATITIS — Entry of microorganisms into the prostate gland almost always occurs via the urethra. In most cases, bacteria migrate from the urethra or bladder through the prostatic ducts, with intraprostatic reflux of urine. As a result, there may be concomitant infection in the bladder or epididymis.
Risk factors for acute prostatitis are said to include trauma (eg, bicycle or horseback riding), dehydration, and sexual abstinence. However, these have not been established by well controlled studies. Prostatitis can also occur in patients with chronic indwelling bladder catheters and in those who perform intermittent catheterization [8]. A urethral stricture is a possible etiology that should be sought after the acute episode by means of contrast medium urethrography.
Microbiology — The flora of acute prostatitis reflects the spectrum of agents causing urethritis, urinary tract infection, and deeper genital infection. Gram-negative infections, especially with Enterobacteriaceae (typically Escherichia coli or Proteus spp), are most common [9]. Rarely, organisms, such as Burkholderia pseudomallei, have been reported to cause acute prostatitis and prostatic abscess in association with bacteremia [10]. Recurrent infection after completion of therapy is usually caused by the same organism that was found in the original infection [11].
Clinical presentation — The typical signs and symptoms of acute prostatitis include spiking fever, chills, malaise, myalgia, dysuria, pelvic or perineal pain, and cloudy urine. With the exception of fever and chills, these symptoms are similar to those of lower urinary tract infection; it is important to appreciate, however, that isolated acute cystitis does not commonly occur in men, in whom virtually all lower UTIs are due to prostatitis [12,13]. Men with acute cystitis often have a functional or anatomic abnormality, with prostatic hypertrophy and genitourinary instrumentation being the major predispositions to these complicated UTIs.
Swelling of the acutely inflamed prostate can cause obstructive symptoms, ranging from dribbling and hesitancy to acute urinary retention. Rarely, patients lack these local symptoms, and present with the clinical picture of a constitutional or flu-like illness. Clearly, the diagnosis of prostatitis is challenging in this setting.
Early diagnosis and treatment of acute prostatitis are important for both symptom control and the prevention of secondary problems, such as gram-negative sepsis, prostatic abscess, or metastatic infection (eg, spinal or sacroiliac infection) [14].
Diagnosis — Clinical symptoms, together with an edematous and tender prostate on physical examination, should prompt a presumptive diagnosis of acute prostatitis. Digital rectal examination should be performed gently; vigorous prostate massage should be avoided since it is uncomfortable, allows no additional diagnostic or therapeutic benefit, and increases risk for bacteremia.
A urine Gram stain and culture should be obtained in all men suspected of having acute prostatitis. Gram stain of the urine, if positive, can be used as a guide to initial therapy. Confirmatory laboratory findings include pyuria, peripheral leukocytosis, and occasionally, positive blood cultures.
An elevated serum prostate specific antigen (PSA) level is also potentially consistent with a diagnosis of acute prostatitis, although a PSA should not be considered to be a standard diagnostic test for prostatitis. Elective serum PSA for prostate cancer screening should be deferred for one month following acute prostatitis [15]. (See "Measurement of prostate specific antigen".)
Treatment — A variety of antimicrobials may be used for treatment of acute prostatitis. The barrier between the microcirculation and the prostate gland stroma limits drug entry to passive diffusion, which only permits non-protein-bound, lipophilic antimicrobial agents to reach therapeutic levels within the gland. In addition, the low pH of prostatic fluid permits antibiotics with alkaline pKas (such as quinolones and sulfonamides) to achieve high concentrations in prostatic tissue more readily than antibiotics with acidic pKas. However, antibiotic prostatic penetration in the setting of inflammation occurs more readily [16].
Patients with acute bacterial prostatitis may need to be hospitalized for parenteral antibiotic therapy if they cannot tolerate oral medication or if they demonstrate signs of sepsis, such as hypotension or altered mental status. In such cases, shock due to gram-negative bacteremia may occur abruptly and be life threatening.
In general, antibiotic coverage should be administered empirically pending the culture results. A Gram stain of the urine may be helpful in choosing empiric antibiotic coverage. Regional patterns of resistance to various antimicrobials can help in the initial selection of empiric therapy, but clinical response and culture reports will be useful in guiding therapeutic changes.
•   Patients with gram-negative rods should be treated with trimethoprim-sulfamethoxazole (TMP-SMX or cotrimoxazole; one double-strength tab PO every 12 hours) or a fluoroquinolone (ciprofloxacin 500 mg PO every 12 hours or levofloxacin 500 mg PO once daily) if oral therapy is indicated. Other agents with good to excellent penetration into prostatic fluid and tissue include tetracyclines, macrolides, sulfonamides, and nitrofurantoin [17]. For patients who need parenteral therapy, an aminoglycoside (gentamicin or tobramycin 5 mg/kg daily) may be combined with intravenous levofloxacin or ciprofloxacin.
If a urine Gram stain is not performed, the patient should be treated as if infected with gram-negative rods until additional culture data are available.
•   Gram-positive cocci in chains usually indicate enterococcal infection, which should be treated with amoxicillin 500 mg PO every eight hours. If parenteral therapy is necessary, ampicillin can be given at a dose of 2 g IV every six hours.
•   Gram-positive cocci in clusters are most often due to Staphylococcus aureus or coagulase-negative staphylococci (eg, S. epidermidis), which should be treated with a cephalosporin (eg, cephalexin 500 mg PO every six hours) or a penicillinase-resistant penicillin (eg, dicloxacillin 500 mg PO every six hours). Choices for parenteral therapy include cefazolin (1 g IV every eight hours), nafcillin (2 g IV every four to six hours), or for methicillin-resistant S. aureus, vancomycin (30 mg/kg/d in two divided doses with adjustments made for renal insufficiency).
When S. aureus is recovered from a urine culture, it is important to perform blood cultures to be certain the bacteriuria reflects local infection and not seeding of the urine in association with bacteremia. (See "Complications of Staphylococcus aureus bacteremia".)
Nonsteroidal antiinflammatory drugs (NSAIDs) can be given to relieve pain, speed the clearing of inflammation, and liquefy prostatic secretions [18]. Rarely, acute urinary retention develops during an episode of acute prostatitis. In this setting, bladder drainage must be done by suprapubic catheterization. Passage of a catheter through the inflamed urethra into the bladder is contraindicated in patients with acute prostatitis.
Patients initiated on parenteral antibiotics may be switched to oral antibiotics following improvement in fever and clinical symptoms. Antibiotics should be administered for four to six weeks to ensure eradication of the infection [19]. Prolonged therapy is required because of limited antimicrobial penetration into the prostate and the development of protected microcolonies deep within the inflamed gland that are difficult to reach with antimicrobials.
Clinical course — In most cases, fever abates and dysuria disappears within two to six days after the start of therapy. Acute phase reactants (eg, sedimentation rate, C reactive protein) and the PSA, if obtained, return to normal more gradually [15]. Clinical studies using a fluoroquinolone suggest that a negative urine culture at seven days following initiation of therapy predicts cure at the conclusion of the full four to six week course of therapy [20]. If the urine culture is still positive at seven days,

Chronic prostatitis/chronic pelvic pain syndrome
Author
Michel Pontari, MD
Section Editor
Michael P O'Leary, MD, MPH
Deputy Editor
David M Rind, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. |This topic last updated:Μαϊ 14, 2012.
INTRODUCTION — Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a clinical syndrome, defined primarily on the basis of urologic symptoms and/or pain or discomfort in the pelvic region. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms [1].
The clinical manifestations, evaluation, and management of CP/CPPS will be reviewed here. Acute prostatitis and chronic bacterial prostatitis are discussed separately. (See "Acute and chronic bacterial prostatitis".)
DEFINITIONS — A number of terms have been used to describe the syndrome now commonly called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). These include prostatodynia (painful prostate) and abacterial prostatitis.
A classification approach supported by the National Institutes of Health (NIH) to standardize definitions and facilitate research is the currently accepted categorization of prostate syndromes [2]. This schema defines the following categories:
•   I. Acute prostatitis
•   II. Chronic bacterial prostatitis
•   IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory
•   IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory
•   IV. Asymptomatic inflammatory prostatitis
Acute and chronic bacterial prostatitis (classes I and II, respectively) are discussed in detail elsewhere. (See "Acute and chronic bacterial prostatitis".)
Research guidelines define CP/CPPS as chronic pelvic pain for at least three of the preceding six months in the absence of other identifiable causes [3]. The inflammatory subset of CP/CPPS (class IIIA) includes patients with inflammatory cells in expressed prostatic secretions, postprostate massage urine, or seminal fluid. The noninflammatory CP/CPPS (class IIIB) subset includes the remainder of the patients with chronic prostatitis or pelvic pain. The distinction between inflammatory and noninflammatory CP/CPPS is generally for research purposes only, as there is no evidence that patients in the two subgroups have different symptoms or respond differently to therapy.
In contrast to the symptomatic patient presenting with CP/CPPS, asymptomatic inflammatory prostatitis (class IV) is typically diagnosed incidentally during prostate biopsy or an infertility or cancer work-up. This entity is not sufficiently studied to have an adequate understanding of its natural history, need for therapy, or response to treatment.
EPIDEMIOLOGY — Chronic prostatitis is a common condition worldwide, affecting approximately 2 to 10 percent of all adult men [4].
In one United States survey of 58,955 ambulatory visits to physicians by men over the age of 18 years, genitourinary tract symptoms accounted for 5 percent of all complaints, and prostatitis was listed as a diagnosis in nearly two million encounters annually [5]. Most men diagnosed with "prostatitis" have CP/CPPS rather than acute or chronic bacterial prostatitis [2].
In a large population-based Canadian study, 10 percent of the men had complaints compatible with chronic prostatitis, and 7 percent had moderate to severe symptoms [6]. The prevalence seems to peak in the fifth decade, but declines thereafter:
•   11 percent ages 20 to 39
•   13 percent ages 40 to 49
•   10 percent ages 50 to 59
•   9 percent ages 60 to 69
•   7 percent ages 70 to 74
ETIOLOGY — The etiology of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is unknown. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms [1].
Although bacterial infection has been suspected, particularly in the inflammatory subset of CP/CPPS, a bacterial etiology has not been consistently identified. Most experts believe that inflammatory and noninflammatory CP/CPPS are both noninfectious disorders [7,8]. Studies of Chlamydia, Mycoplasma, and Ureaplasma, which have all been implicated in chronic prostatitis, have generally concluded that they are not responsible for CP/CPPS [9-12]. Several investigators have performed polymerase chain reaction (PCR) testing looking for evidence of bacteria in prostatic tissues, but these have yielded negative results [13,14]. One study cultured prostatic biopsy specimens obtained via the transperineal approach from men with CP/CPPS and from normal volunteers [15]. There was no difference in the number of patients from whom bacteria were cultured (38 versus 36 percent, respectively).
Additionally, there appears to be little correlation between histologic prostatic inflammation and presence or absence of CP/CPPS symptoms [16]. Leukocytes can be found in the prostatic fluid of asymptomatic men, and there appears to be no correlation between the presence of leukocytes and symptoms [17].
Noninfectious etiologies have been proposed for CP/CPPS, but none has been proven [17]. These include inflammation due to trauma, autoimmunity, reaction to normal prostate flora or some other factor, neurogenic pain, increased prostate tissue pressure, and the interplay of somatic and psychologic factors [17-19]. Psychological stress, including anxiety and fear of severe illness, appears to be common in men with symptoms of CP/CPPS and may be a contributing factor [20,21].
CLINICAL MANIFESTATIONS — The symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) include pain (in the perineum, lower abdomen, testicles, penis, and with ejaculation), voiding difficulty (including bladder irritation and bladder outlet obstruction), and sometimes blood in the semen. Chronic prostatitis may also lead to problems with daily activities, depression, and overall quality of life [22]. CP/CPPS is also associated with erectile dysfunction and ejaculatory pain [23-25].
There is an association of chronic pelvic pain syndromes with other pain syndromes, such as irritable bowel syndrome (IBS), chronic fatigue syndrome, and fibromyalgia [26]. Given the overlapping innervation of the bowel and bladder [27], irritation of the bowel can result in lower abdominal pain and urinary symptoms as well. (See "Clinical manifestations and diagnosis of irritable bowel syndrome" and "Clinical features and diagnosis of chronic fatigue syndrome" and "Clinical manifestations and diagnosis of fibromyalgia in adults".)
The clinical course of CP/CPPS, with or without treatment, is not well-defined [28]. The patient usually will experience a relapsing-remitting pattern where the severity and frequency of flares decreases, usually over many months.
DIFFERENTIAL DIAGNOSIS — Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a diagnosis of exclusion.
The clinical presentation of CP/CPPS can be similar to that of chronic bacterial prostatitis, as both may present with urinary frequency, dysuria, and perineal pain. However, CP/CPPS does not present with low-grade fever, which can occur with chronic bacterial prostatitis. In patients with chronic bacterial prostatitis, the rectal examination may also demonstrate prostatic hypertrophy, tenderness, and edema, which does not occur in CP/CPPS. The evaluation of chronic bacterial prostatitis is discussed in detail elsewhere. (See "Acute and chronic bacterial prostatitis", section on 'Chronic bacterial prostatitis'.)
Other causes should also be considered prior to making a diagnosis of CP/CPPS [2]:
•   Urethritis (see "Infectious causes of dysuria in adult men")
•   Urogenital cancer (see "Clinical presentation, diagnosis, and staging of bladder cancer" and "Urethral cancer in men")
•   Urinary tract disease (see "Lower urinary tract symptoms in men")
•   Urethral stricture (see "Treatment of urethral stricture disease in men")
•   Neurologic disease affecting the bladder, such as spinal cord injury and lumbar spinal stenosis (see "Chronic complications of spinal cord injury", section on 'Urinary complications' and