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chronic pelvic pain syndrome
369 CLINICAL SIGNIFICANCE AND MANAGEMENT OF CHRONIC PROSTATITIS ASSOCIATEDWITH GRAM POSITIVEBACTERIA Nickel J.C.t, Zadeikis N. 2, SpiveyJ.M.2, Wn S.C.3 ~Kingston General Hospital, Dept. of Urology, Kingston, Ontario, Canada, 2Ortho-McNeal Pharmaceuticals, AntMnfectives,Raritan, United States, 3Ortho-McNealPharmaceuticals, Statistics, Raritan, United States INTRODUCTION & OBJECTIVES: Gram positive bacteria are commonly cultured when evaluating men presenting with chronic prostatitis (CBP). Except for Enterocoeci sp., generally considered umpathogens,the clinical significance of isolating grampositiveorganismsthat are not generally considered uropathogethcis unknown. We comparedthe clinical benefits of eradicating traditional nropathogens (TU) and non-traditional uropathogens (NTU) from prostate specific specimensJn men treated with levofloxacinor ciproftoxacin. MATERIAL & METHODS: Men with prostatitis-like symptomsand any bacteria localized (> 10 CFU in EPS/VB3 compared to VB1, VB2) were treated with levofloxacin (LVX) or cipmfloxacin (CIP) for 4 weeks with 6 month foIlow-upin a randomized controlled trial in CBR This subgroup analysis compares the rates of bacterial eradication and clinical success (cure + improvement) of the group who had TU localization (gram negative bacteria and Enterocoecus faecalis) with the group who had NTU (Coagulase negative staphylococcus sp., Streptococcus sp.) at the test of cure visit (5-12 days afer end of therapy). 95% confidenceintervals (CI) were constructedaroundthe difference betweenthe TU / NTUgroupsand LVX/ CIP groups. RESULTS: 26i microbiologicallyevaluable men with prostatitis (mean age - 51.3 years, mean duration of symptoms= 8.4 weeks, previousantibiotic treatment - 107 or 41%) were available for analyses.The table showsthe bacterial eradication rates and clinical-successrates following4 weeks of antibiotic therapyin the TU groupand NTU group. TU n-136 Bacterial Eradication % 74.3 Clinical Success% 76.5
NTU n-125 77.6 71.2
95% CI
p
-15.7 to 9.1 -7.7 to 18.3
0.56 0.40
370 ULTRASOUND EVALUATION OF BLADDER N E C K C O M P L E X ALTERATIONS IN CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME Dellabella M., Milanese G., Muzzonigro G. Polytechnic University of the Marche Region, School of Medicine, Urology, Ancona, Italy INTRODUCTION & OBJECTIVES: Alterations of the bladder neck complex are frequently observed during transrectal ultrasound (TRUS) evaluation of patients affected by CP/CPPS. Such lesions are not well described in the literature. The aim of this prospective study was to evaluate the incidence of the bladder neck complex alterations and to correlate these lesions with other clinical parameters in young men affected by CP/CPPS. MATERIAL & METHODS: The bladder neck complex ultrasound alterations resulted in 15/25 (60%) consecutive CP/CPPS patients. We compared the ultrasound finding between 15 CP/CPPS patients and 15 healthy volunteers, All the men were < 50 years old; In each patient we evaluated both the IPSS score and NIH-CPSI score. The Qmax and the PVR were also recorded. The following ultrasound parameters were measured: prostate volume (PV), the hypoechoic periuretral zone volume (HPV), the posterior prostate lip thickness (LT), the bladder neck thickness (NT), the detrusor thickness (DT). Furthermore we evaluated the presence of prostate hyperechoic anterior stroma (AS) and of periuretral calcifications (PC).
In both groupsthere was a statistically significant correlationbetween clinical and microbiological outcomes (Chi square analysis con'elation between outcomes; TU group p- 0.0018, NTU group p-0.0049). Bacterial eradication and clinical successrateswithLVX treatmentwere at least as good comparedto CIP treatment for each group(TU and NTU).
RESULTS: No differences were found in mean age and PV between the CP/CPPS group and the control group. In the CP/CPPS group resulted a significant reduction of the mean Qmax (14.5 vs. 26.0 mI/sec; p<0.0001), a greater mean NIH-CPSI score (19.9 vs. 0.9; p<0.0001) and a higher PVR (28.1 vs. 2.5 ml; p - 0.012) with respect to the control group. TRUS revealed significant differences among the two groups for all the evaluated parameters, but not for the PC frequency. There were close correlations between the NIH-CPSI score and HPV (rho = 0.798, p<0.0001), and between NIH-CPSI score and LT (Itlo = 0.813; (p<0.0001).
CONCLUSIONS: Clinically acceptable microbiological and clinical responsesto fluoroquinolone therapy in chronic 'bacterial' prostatitis were not dependent on whetherTU bacteria or NTU gram positive organismswere isolated in prostate specific specimens.The data supportsthe growingbody of evidence that implicatesNTU in the etiology of chronic 'bacterial'prostatitis. It farther suggests that recently diagnosed patients with CBP associated with NTU warrant treatment and flouroquinolonesare effective antibiotictherapy.
CONCLUSIONS: The ultrasound evaluation of bladder-neck complex in this pathology could be useful for the possible role that such alterations could have on the pathogenesis of obstructive symptoms. The extimation of posterior lip and bladder neck could offer quantitative parameters to study the therapeutic effect of different drugs in CP/CPPS.
371
372
THE STUDY OF K A L L I K R E I N - K I N I N SYSTEM COMPONENTS ACTIVITY IN PATIENTS W I T H CHRONIC PELVIC PAIN SYNDROME
BIOFEEDBACK PHYSICAL THERAPY FOR CHRONIC PELVIC PAIN SYNDROME TYPE 3
Kogan M.~, Mikashinovich Z?, Shangichev A.~, Chernogubova E. 2, Belousov I.
Cornel E. 1, De Wit R J, Van Haarst E. 2
~Rostov State Medical University, Department of Urology, Rostov On Don, Russia, 2Rostov State Medical University, Department of Biochemistry, Rostov On Don, Russia
1Twente Hospital Group Loc. SMT, Dept. of Urology, Hengeto, The Netherlands, 2St. Lucas Andmas Hospital, Dept. of Urology, Amsterdam, The Netherlands
INTRODUCTION & OBJECTIVES: Activation of kallikrein-kinin system (KKS) is paramount importance with the onset of inflammatory processes. This research objective was to study kallika'ein-kinin system activity in blood serum and prostate gland secretion in patients with chronic pelvic pain syndrome (CPPS) for definition of a role of an inflammation in development of CPPS. MATERIAL & METHODS: Kallikrein and prekallikrein content, total arginineesteraseactivity, al-proteolytic inhibitor and a z - macroglobulin content in blood serum and prostate gland secretion in 48 patients with CPPS were determined. The patients were divided in two groups. 24 Patients with IIIA form of CPPS constituted the first group, 24 patients with IIIB form of CPPS formed the second group. The control group -10 healthy people.
RESULTS: At IIIA and IIIB forms an increase in the maintenance of kallikrein on 16%, but decrease in the contents of prekallikrein on 10% in blood serum was determined. Total arginine-esterase activities of blood serum do not differ from such in the control group. In IIIB form of CPPS kallikrein activity and kallikrein formation factor is accordingly 1.45 (p<0.001) and 1.69 (p<0.001) times higher than in IIIA form of CPPS. Content of a2-macroglobulin in blood serum in IIIB form is 1.57 (p<0.001) times reduced compared to IIIA form. In patients with CPPS, components of KKS are present in prostate gland secretion. In normal prostate gland, they are absent. Thus, in IIIA form contents of kallikrein, prekallikrein and total arginine-esterase activity are 3.45 (p<0.001), 3.80 (!o<0.001) and 2.75 (p<0.001) times higher than corresponding characteristics in IIIB form. In IIIA form a2-macroglobulin is determined, but it is absent in IIIB form. CONCLUSIONS: IIIA and IIIB form have various pathophysiology. Presence of KKS components in prostate gland secretion is the evidence of inflammation and disorder of hematoprostatic barrier permeability in patients with CPPS.
INTRODUCTION & OBJECTIVES: Men with chronic pelvic pain syndrome (CPPS) type III experience chronic pelvic pain of uncertain aetiology with varying degrees of urinary symptoms. Recent studies suggest that the symptoms of CPPS type III may be due to or associated with pelvic foor muscle dysfunction. Therapies such as biofeedback physical therapy and pelvic floor re-education, aimed to improve relaxation and proper use of the pelvic floor muscles, are expected to give symptom improvement. The objective of this prospective study was to evaluate the effect of biofeedback physical therapy on the symptoms of men with CCPS type III. MATERIAL & METHODS: Between March 2000 to March 2004, 33 consecutive men who were diagnosed with CPPS type III participated in a pelvic floor biofeedback re-educating program. Diagnosis was based on history including the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) questionnaire, physical examination including pelvic floor muscle tonus, urine analysis, uroflowmetry with residual urine measurement and transrectal ultrasonogi:aphy of the prostate. The NIHCPSI total score is a valid, reliable and responsive measure ofprostatitis symptoms and was therefore used for diagnosis and to monitor the effect of therapy. Moreover, pelvic floor muscle tonus measurements were used not only to complete diagnosis but also to monitor the effect of the biofeedback physical therapy. For statistical analysis the Wilcoxon signed ranks test for paired samples was performed. RESULTS: Two of the 33 men dropped out. In the remaining 31 men, mean age 45 years (range from 25 years to 70 years) the mean total NIH-CPSI changed from 24 (range 16-34) at baseline to 13 (range 1-25) after treatment (p < 0001).Regarding the specific domains of the NIH-CPSI, a significant decrease was seen in all sub domains. The mean value of the pelvic muscle tonus, (normal value 1 mV), was 4.4 at diagnosis (range 2-10) and decreased to 1.6 (range 0.5-2.8) after treatment (p= 0.002). CONCLUSIONS: Our study clearly demonstrates the significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS type III patients. The observation that the EMG results correlated with the NIH-CPSI score appears to emphasize that the pelvic floor plays an important role in the pathophysiology of CP/CPPS type III.
European Urology Supplements 4 (2005) No. 3, pp. 95
NTU n-125 77.6 71.2
95% CI
p
-15.7 to 9.1 -7.7 to 18.3
0.56 0.40
370 ULTRASOUND EVALUATION OF BLADDER N E C K C O M P L E X ALTERATIONS IN CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME Dellabella M., Milanese G., Muzzonigro G. Polytechnic University of the Marche Region, School of Medicine, Urology, Ancona, Italy INTRODUCTION & OBJECTIVES: Alterations of the bladder neck complex are frequently observed during transrectal ultrasound (TRUS) evaluation of patients affected by CP/CPPS. Such lesions are not well described in the literature. The aim of this prospective study was to evaluate the incidence of the bladder neck complex alterations and to correlate these lesions with other clinical parameters in young men affected by CP/CPPS. MATERIAL & METHODS: The bladder neck complex ultrasound alterations resulted in 15/25 (60%) consecutive CP/CPPS patients. We compared the ultrasound finding between 15 CP/CPPS patients and 15 healthy volunteers, All the men were < 50 years old; In each patient we evaluated both the IPSS score and NIH-CPSI score. The Qmax and the PVR were also recorded. The following ultrasound parameters were measured: prostate volume (PV), the hypoechoic periuretral zone volume (HPV), the posterior prostate lip thickness (LT), the bladder neck thickness (NT), the detrusor thickness (DT). Furthermore we evaluated the presence of prostate hyperechoic anterior stroma (AS) and of periuretral calcifications (PC).
In both groupsthere was a statistically significant correlationbetween clinical and microbiological outcomes (Chi square analysis con'elation between outcomes; TU group p- 0.0018, NTU group p-0.0049). Bacterial eradication and clinical successrateswithLVX treatmentwere at least as good comparedto CIP treatment for each group(TU and NTU).
RESULTS: No differences were found in mean age and PV between the CP/CPPS group and the control group. In the CP/CPPS group resulted a significant reduction of the mean Qmax (14.5 vs. 26.0 mI/sec; p<0.0001), a greater mean NIH-CPSI score (19.9 vs. 0.9; p<0.0001) and a higher PVR (28.1 vs. 2.5 ml; p - 0.012) with respect to the control group. TRUS revealed significant differences among the two groups for all the evaluated parameters, but not for the PC frequency. There were close correlations between the NIH-CPSI score and HPV (rho = 0.798, p<0.0001), and between NIH-CPSI score and LT (Itlo = 0.813; (p<0.0001).
CONCLUSIONS: Clinically acceptable microbiological and clinical responsesto fluoroquinolone therapy in chronic 'bacterial' prostatitis were not dependent on whetherTU bacteria or NTU gram positive organismswere isolated in prostate specific specimens.The data supportsthe growingbody of evidence that implicatesNTU in the etiology of chronic 'bacterial'prostatitis. It farther suggests that recently diagnosed patients with CBP associated with NTU warrant treatment and flouroquinolonesare effective antibiotictherapy.
CONCLUSIONS: The ultrasound evaluation of bladder-neck complex in this pathology could be useful for the possible role that such alterations could have on the pathogenesis of obstructive symptoms. The extimation of posterior lip and bladder neck could offer quantitative parameters to study the therapeutic effect of different drugs in CP/CPPS.
371
372
THE STUDY OF K A L L I K R E I N - K I N I N SYSTEM COMPONENTS ACTIVITY IN PATIENTS W I T H CHRONIC PELVIC PAIN SYNDROME
BIOFEEDBACK PHYSICAL THERAPY FOR CHRONIC PELVIC PAIN SYNDROME TYPE 3
Kogan M.~, Mikashinovich Z?, Shangichev A.~, Chernogubova E. 2, Belousov I.
Cornel E. 1, De Wit R J, Van Haarst E. 2
~Rostov State Medical University, Department of Urology, Rostov On Don, Russia, 2Rostov State Medical University, Department of Biochemistry, Rostov On Don, Russia
1Twente Hospital Group Loc. SMT, Dept. of Urology, Hengeto, The Netherlands, 2St. Lucas Andmas Hospital, Dept. of Urology, Amsterdam, The Netherlands
INTRODUCTION & OBJECTIVES: Activation of kallikrein-kinin system (KKS) is paramount importance with the onset of inflammatory processes. This research objective was to study kallika'ein-kinin system activity in blood serum and prostate gland secretion in patients with chronic pelvic pain syndrome (CPPS) for definition of a role of an inflammation in development of CPPS. MATERIAL & METHODS: Kallikrein and prekallikrein content, total arginineesteraseactivity, al-proteolytic inhibitor and a z - macroglobulin content in blood serum and prostate gland secretion in 48 patients with CPPS were determined. The patients were divided in two groups. 24 Patients with IIIA form of CPPS constituted the first group, 24 patients with IIIB form of CPPS formed the second group. The control group -10 healthy people.
RESULTS: At IIIA and IIIB forms an increase in the maintenance of kallikrein on 16%, but decrease in the contents of prekallikrein on 10% in blood serum was determined. Total arginine-esterase activities of blood serum do not differ from such in the control group. In IIIB form of CPPS kallikrein activity and kallikrein formation factor is accordingly 1.45 (p<0.001) and 1.69 (p<0.001) times higher than in IIIA form of CPPS. Content of a2-macroglobulin in blood serum in IIIB form is 1.57 (p<0.001) times reduced compared to IIIA form. In patients with CPPS, components of KKS are present in prostate gland secretion. In normal prostate gland, they are absent. Thus, in IIIA form contents of kallikrein, prekallikrein and total arginine-esterase activity are 3.45 (p<0.001), 3.80 (!o<0.001) and 2.75 (p<0.001) times higher than corresponding characteristics in IIIB form. In IIIA form a2-macroglobulin is determined, but it is absent in IIIB form. CONCLUSIONS: IIIA and IIIB form have various pathophysiology. Presence of KKS components in prostate gland secretion is the evidence of inflammation and disorder of hematoprostatic barrier permeability in patients with CPPS.
INTRODUCTION & OBJECTIVES: Men with chronic pelvic pain syndrome (CPPS) type III experience chronic pelvic pain of uncertain aetiology with varying degrees of urinary symptoms. Recent studies suggest that the symptoms of CPPS type III may be due to or associated with pelvic foor muscle dysfunction. Therapies such as biofeedback physical therapy and pelvic floor re-education, aimed to improve relaxation and proper use of the pelvic floor muscles, are expected to give symptom improvement. The objective of this prospective study was to evaluate the effect of biofeedback physical therapy on the symptoms of men with CCPS type III. MATERIAL & METHODS: Between March 2000 to March 2004, 33 consecutive men who were diagnosed with CPPS type III participated in a pelvic floor biofeedback re-educating program. Diagnosis was based on history including the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) questionnaire, physical examination including pelvic floor muscle tonus, urine analysis, uroflowmetry with residual urine measurement and transrectal ultrasonogi:aphy of the prostate. The NIHCPSI total score is a valid, reliable and responsive measure ofprostatitis symptoms and was therefore used for diagnosis and to monitor the effect of therapy. Moreover, pelvic floor muscle tonus measurements were used not only to complete diagnosis but also to monitor the effect of the biofeedback physical therapy. For statistical analysis the Wilcoxon signed ranks test for paired samples was performed. RESULTS: Two of the 33 men dropped out. In the remaining 31 men, mean age 45 years (range from 25 years to 70 years) the mean total NIH-CPSI changed from 24 (range 16-34) at baseline to 13 (range 1-25) after treatment (p < 0001).Regarding the specific domains of the NIH-CPSI, a significant decrease was seen in all sub domains. The mean value of the pelvic muscle tonus, (normal value 1 mV), was 4.4 at diagnosis (range 2-10) and decreased to 1.6 (range 0.5-2.8) after treatment (p= 0.002). CONCLUSIONS: Our study clearly demonstrates the significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS type III patients. The observation that the EMG results correlated with the NIH-CPSI score appears to emphasize that the pelvic floor plays an important role in the pathophysiology of CP/CPPS type III.
European Urology Supplements 4 (2005) No. 3, pp. 95