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Upper genital tract infection in men

Prostatitis

Half of all men experience symptoms of prostatitis at some time in their lives, usually when they are 50 years old or more. The numbers of patients with chronic prostatitis are increasing in most countries [Joly-Guillou & Lasry, 1999]. The symptoms of prostatitis (inflammation of the prostate) include back pain, discomfort when passing urine or at ejaculation, and sometimes an ache in the region immediately behind the penis. The association of prostatitis with raised semenal white blood cells and immunoglobulin [lay reader: both components of the host immune response] make it likely that infection is the cause in many of these cases. The most frequently recognized causes of prostatitis and epididymitis in older men or in men with urethral structural abnormalities, are classical urinary tract pathogens rather than sexually transmitted pathogens. Management of these infections requires identification of the causative agent in urine or prostatic secretion by growth on bacterial culture media followed by antibiotic treatment specifically targeted to that organism [Bowie, 1990].  However, the majority of men with such symptoms do not have an infection that can be documented [Bowie, 1990; Krieger et al., 1996] . These men respond poorly to medications. Men with documented chronic bacterial prostatitis require long courses of antimicrobials to effect cure. In some cases, however, the disease is intractable, and chronic suppression with antimicrobials may be necessary [Bowie, 1990].

One possibility is that infection may be caused by bacteria such as chlamydiae, which cannot be cultured on conventional bacteriological culture media [Shortliffe et al., 1992].  Broad spectrum methods [global PCR] based on the detection of bacterial nucleic acid are therefore particularly attractive, along with more targeted methods for the detection of C. trachomatis and other recognized pathogens [Guo et al., 1997]. One study of 135 men with chronic "abacterial" prostatitis and no functional abnormalities of the lower urinary tract found the sexually transmitted organisms Mycoplasma genitalium, C. trachomatis, or T. vaginalis by detection of amplified DNA in just 10 patients (8%). However broad-spectrum nucleic acid amplification based tests [global PCR]  found the bacterial genes tetM-tetO-tetS encoding  tetracycline resistance in in 25% of the patients.  Nucleic acid corresponding to bacterial ribosomes [16S rRNA by PCR] [lay reader: ribosomes are organelles which synthesize protein directed by the genetic code] was found in 77% of subjects, amongst whom those harboring bacterial tetracycline resistance genes formed a subset. Patients with in whom bacterial ribosomal 16S rRNA was detected were significantly more likely [ P <0.001] to have raised white blood cells in their prostatic secretion  [> or = 1,000 leukocytes per mm³ ] than men whose prostatic secretion was negative. It would be expected that a proportion of the bacteria detected by such broad ranging techniques would be organisms present in the normally sparse bacterial flora of the male urinary tract. It is important to remember that the association of an organism with a disease does not prove that it plays a causative role. Nevertheless, sequencing of the bacterial ribosomal nucleic acid detected revealed that some of these organisms were not normal skin or gut flora bacteria. It was concluded that patients with prostatitis harbor bacteria which are not readily detected by conventional bacterial culture, but which can be demonstrated by broad spectrum nucleic acid amplification and which may play a significant role in chronic prostatitis [Krieger et al., 1996]. 

In another study,  chlamydial antigen was found in 14 of 55 patients (25.4%) with non-bacterial prostatitis, but in only (6%) of comparable control patients without prostatitis (P = 0.0268).  The difference between the two groups was statistically significant (p = 0.0268). After treatment with doxycycline 100 mg twice daily for 10 days, the clinical cure rate in the prostatitis group was 80% [Mutlu et al., 1998]. There can be little doubt that C. trachomatis is associated with some cases of prostatitis [Ostaszewska et al., 1998] and it seems likely that it is a cause.  In one study, C. trachomatis was directly detected [in situ hybridization] in 18 of 78 cases (20.6%) of chronic prostatitis [Gumus et al., 1997]. In general, C. trachomatis and other agents of sexually transmissible disease are more likely to be found in the relatively small proportion of chronic prostatitis patients who are under 35 years of age. However one of the problems is trying to determine the role of bacteria generally in prostatitis is that patient compliance with  traditional antibiotic treatments such as tetracycline and erythromycin is often poor, both because of gastrointestinal side effects and because of the considerable dosage regime. Azithromycin, which requires very few drug doses,  was thus considered particularly attractive [Joly-Guillou & Lasry, 1999].

To summarize, C. trachomatis is associated with prostatitis in younger men.  It seems likely that it plays a causal role, though this has yet to be proven. In older men with urinary tract abnormalities, recognized urinary tract pathogens play an important role. In the vast majority of men with prostatitis, however,  no specific bacterial pathogen is recognized and they often respond poorly to antibacterial agents [Dale et al., 2001]. Broad spectrum techniques, such as global PCR, capable of amplifying any bacterial ribosomal nucleic acid, offer special promise for research into this common problem.

NEXT: Epididymitis

[MEW] Updated March 2002

References

Bowie, W. R. (1990). Approach to men with urethritis and urologic complications of sexually transmitted diseases. Medical Clinics of North America 74, 1543 - 1557.

Dale A, Wilson J, Forster G, Daniels D, Brook G. (2001). Management of chronic prostatitis in Genitourinary Medicine clinics in the United Kingdom's North Thames Region 2000. International Journal of STD and AIDS. 12, 256 - 259.

Gumus, B., Sengil, A. Z., Solak, M., Fistik, T., Alibey, E., Cakmak, E. A. & Yeter, M. (1997). Evaluation of non-invasive clinical samples in chronic chlamydial prostatitis by using in situ hybridization. Scandinavian Journal of Urology and Nephrology 31, 449 - 451.

Guo, H., Lu, G., Zhang, Q. & Xiong, X. (1997). Detection of Chlamydia trachomatis by polymerase chain reaction assay in nonbacterial prostatitis. Chinese Medical Journal (English) 110, 177 - 179.

Joly-Guillou, M. L. & Lasry S. (1999). Practical recommendations for the drug treatment of bacterial infections of the male genital tract including urethritis, epididymitis and prostatitis. Drugs 57, 743 - 750.

Krieger, J. N., Riley, D. E., Roberts, M. C. & Berger RE. (1996). Prokaryotic DNA sequences in patients with chronic idiopathic prostatitis. Journal of Clinical Microbiology 34, 3120 - 3128.   Full article   

Mutlu, N., Mutlu, B., Culha, M., Hamsioglu, Z., Demirtas, M. &, Gokalp A. (1998). The role of Chlamydia trachomatis in patients with non-bacterial prostatitis. International Journal of Clinical Practice 52, 540 - 541.

Ostaszewska I, Zdrodowska-Stefanow B, Badyda J, Pucilo K, Trybula J, Bulhak V. (1998). Chlamydia trachomatis: probable cause of prostatitis. International Journal of STD and AIDS 9, 350 - 353.

Shortliffe, L. M., Sellers, R. G., Schachter, J. (1992). The characterization of nonbacterial prostatitis: search for an etiology. Journal of Urology 148, 1461 - 1466.

Taylor-Robinson D. (1998). Comment: Chlamydia trachomatis as a probable cause of prostatitis. International Journal of STD and AIDS 9, 779.

NEXT: Epididymitis