Editing Chronic Pelvic Pain Syndrome & Prostatitis (section)

=== Diagnosis and Evaluation ===

* '''<span style="color:#ff0000">Mandatory (3):</span>'''
*# '''<span style="color:#ff0000">History and physical exam, including digital rectal examination</span>'''
*# '''<span style="color:#ff0000">Labs: Urinalysis/culture</span>'''
*# '''<span style="color:#ff0000">Other: Pelvic floor assessment</span>'''
* '''<span style="color:#ff0000">Recommended (6):</span>'''
*# '''<span style="color:#ff0000">Two-glass lower urinary tract evaluation</span>'''
*# '''<span style="color:#ff0000">Symptom inventory or index (NIH-Chronic Prostatitis Symptom Index [NIH-CPSI])</span>'''
*# '''<span style="color:#ff0000">Sexual function assessment (questionnaire)</span>'''
*# '''<span style="color:#ff0000">Flow rate</span>'''
*# '''<span style="color:#ff0000">Post-void residual</span>'''
*# '''<span style="color:#ff0000">Urine cytology</span>'''
* '''Not recommended for routine initial evaluation'''
** '''Four-glass lower urinary tract evaluation'''
** '''Semen analysis and culture'''
** '''Sexually transmitted infection evaluation or urethral culture'''
** '''Urodynamics'''
** '''Video-urodynamics (including flow-EMG)'''
*** Chronic LUTS in young men may be misdiagnosed as chronic non-bacterial prostatitis when in fact they indicate a cohort of men with undiagnosed chronic voiding dysfunction.
** '''Transrectal ultrasound of the prostate'''
*** The diagnostic value of US in differentiating benign from malignant prostate disease is controversial, and the further differentiation of the various benign conditions of the prostate is even more so
** '''Pelvic imaging—US, CT scan, MRI'''
** '''Prostate-specific antigen (PSA)'''
*** PSA levels can be markedly elevated during an acute episode of bacterial prostatitis and slowly resolve to normal levels over the course of 6 weeks to many months, provided there is no recurrence of infection
** '''Cystoscopy'''
*** '''Not indicated in the majority of men with CP/CPPS''' but can probably be justified in men whose condition is refractory to standard therapy
** Prostate biopsy
*** The importance and interpretation of prostate biopsies in prostatitis performed for reasons other than prostate cancer screening are unclear.
** Evaluation of Suspected Seminal Vesiculitis
*** Occasionally, seminal vesiculitis can occur as a consequence of local bacterial infection in acute and chronic bacterial prostatitis, and patients can develop seminal vesicle abscesses
* '''<span style="color:#ff0000">History and Physical exam</span>'''
** '''<span style="color:#ff0000">History</span>'''
*** '''<span style="color:#ff0000">Phenotype Assessment in Chronic Prostatitis and CPPS</span>'''
**** '''<span style="color:#0000ff">UPOINT</span> <span style="color:#ff0000">is a 6-point clinical classification system that categorizes the phenotype of patients with CPPS into one or more of 6 clinically identifiable domains:</span>'''
****# '''<span style="color:#0000ff">U</span><span style="color:#ff0000">rinary</span>'''
****# '''<span style="color:#0000ff">P</span><span style="color:#ff0000">sychosocial</span>'''
****# '''<span style="color:#0000ff">O</span><span style="color:#ff0000">rgan-specific</span>'''
****# '''<span style="color:#0000ff">I</span><span style="color:#ff0000">nfection</span>'''
****# '''<span style="color:#0000ff">N</span><span style="color:#ff0000">eurologic/systemic</span>'''
****# '''<span style="color:#0000ff">T</span><span style="color:#ff0000">enderness (muscle)</span>'''
**** '''Guidelines for the management of CP/CPPS have recommended that patients be clinically phenotyped during evaluation and treated according to individual phenotypes identified'''
** '''<span style="color:#ff0000">Physical exam</span>'''
*** '''<span style="color:#ff0000">Category I (acute bacterial prostatitis): hot, boggy, and exquisitely tender prostate.</span>''' '''The expression of prostatic fluid is believed to be totally unnecessary and perhaps even harmful.'''
*** '''<span style="color:#ff0000">Categories II (chronic bacterial prostatitis) and III (CPPS) are usually unremarkable</span> (except for pain)'''
*** DRE should be performed after the patient has produced pre-prostatic massage urine specimens (see later) and after the perineal and pelvic examination.
*** The degree of elicited pain during prostatic palpation is variable and is unhelpful in differentiating a prostatitis syndrome
* '''<span style="color:#ff0000">Symptom assessment</span>'''
** The validated NIH-CPSI is a useful research and clinical tool for evaluating chronic prostatitis and chronic pelvic pain syndrome patients.
*** The final CPSI consists of 9 questions that address the '''<span style="color:#ff0000">3 most important domains of the CP experience:'''
***# '''<span style="color:#ff0000">Pain</span>'''
***# '''<span style="color:#ff0000">Urinary function</span>'''
***# '''<span style="color:#ff0000">Quality of life</span>'''
* '''<span style="color:#ff0000">Lower Urinary Tract Cytologic Examination and Culture Techniques</span>'''
** '''<span style="color:#ff0000">Category I (acute bacterial prostatitis): a urine culture is the only laboratory evaluation of the lower urinary tract required</span>'''
** '''<span style="color:#ff0000">Category II/II: 4-glass urine collection</span>'''
**# '''<span style="color:#ff0000">Voided bladder–1 (VB1): the first 10 mL of urine and represents the urethral specimen</span>'''
**# '''<span style="color:#ff0000">VB2: similar to a midstream urine collection and represents the bladder urine</span>'''
**# '''<span style="color:#ff0000">Expressed prostatic secretion (EPS): should be collected directly into a sterile container during prostatic massage</span>'''
**# '''<span style="color:#ff0000">VB3: first 10 mL of urine voided after prostatic massage, includes any EPS trapped in the prostatic urethra</span>'''
**#* See CW11 Figure 13-4
*** All 4 specimens are sent to the clinical microbiology laboratory for quantitative culture. Aliquots of the 3 urine specimens are centrifuged for 5 minutes and the sediment examined under high power for leukocytes (including aggregates of leukocytes), macrophages, oval fat bodies, erythrocytes, bacteria, and fungal hyphae.
*** '''<span style="color:#ff0000">Interpreting results</span>'''
**** '''<span style="color:#ff0000">Category II, chronic bacterial prostatitis, is diagnosed if there is a 10x increase in bacteria in the EPS or VB3 specimen compared with the VB1 and VB2 specimens</span>'''
**** '''<span style="color:#ff0000">Category IIIA CP/CPPS is diagnosed when no uropathogenic bacteria are cultured, but excessive leukocytosis</span>''' (usually defined as more than 5 to 10 WBCs per high-power field [HPF]) '''is noted in the prostate-specific specimens (EPS or VB3 or both).'''
**** '''<span style="color:#ff0000">Category IIIB CP/CPPS is diagnosed when no uropathogenic bacteria are cultured and there is no significant leukocytosis noted on microscopic examination of EPS or the sediment of VB3.</span>'''
** '''<span style="color:#ff0000">2-glass test</span>'''
*** '''<span style="color:#ff0000">A simple, cost-effective alternative to categorize patients with CP</span>'''
*** '''<span style="color:#ff0000">Patient provides</span>'''
***# '''<span style="color:#ff0000">Midstream pre-massage urine specimen</span>'''
***# '''<span style="color:#ff0000">Urine specimen (initial 10 mL) after prostatic massage</span>'''
*** Microscopy (sediment) and culturing of these 2 specimens allows categorization of the majority of patients with a CP syndrome
* '''Secretory dysfunction of the prostate, characterized by an alteration in the composition of prostatic secretions, can be diagnostic of patients with prostatitis'''