This is an intriguing aspect of CP/CPPS symptoms. Question is what it means? Many auto-immune diseases show seasonal patterns superimposed on shorter term flare-remission patterns.
• General seasonal variation with all symptoms worsening during winter and improving during summer.
• Cold/winter exacerbated micturition problems (cold induced diuresis?). Caused by cold seat, cold feets, immersion in cold water and shivering etc.
• Cold/winter tension-induced muscular pains and aches (myalgia)?
• Cold/winter induced arthralgia (joint aches, but joints are not swollen or reddish)?
• Cold/winter induced fibrinogen production? This is inferred from the fact that a majority of treatments have an anti-thrombotic component and research (e.g. 1-2).
• Winter related dryness of eyes and nose? (Note that winter air is drier than summer air due to lower absolute humidity. Average water content below zero degress Celsius is below 5 grams water per kg air.)
• The micturition problems do also seem to follow a cyclical pattern (duration of about three weeks?) of exacerbations and improvement.
• There may also be a weak circadian rhythm.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, biologiska rytmer
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(1) Rudnicka AR, Rumley A, Lowe, GDO, Strachan DP. Diurnal, Seasonal, and Blood-Processing Patterns in Levels of Circulating Fibrinogen, Fibrin D-Dimer, C-Reactive Protein, Tissue Plasminogen Activator, and von Willebrand Factor in a 45-Year-Old Population. Circulation 115:996-1003, 2007.
(2) Crawford VLS, McNerlan SE, Stout RW. Seasonal changes in platelets, fibrinogen and factor VII in elderly people. Age and Ageing 32:661-665, 2003.
Some examples of human chronobiology:
One study showed e.g. that cortisol peaked in december, FT3 (thyroid hormone) and growth hormone in april, insulin in february, while prolactin and parathyroid hormone showed no variation. (Del Ponte A, Guagnano MT, Sensi S. Time-Related Behaviour of Endocrine Secretion: Circannual Variations of FT3, Cortisol, Hgh and Serum Basal Insulin in Healthy Subjects. Chronobiol Int 1(4):297-300, 1984.)
(Minor update/edit march 4th 2009)
Monday, February 23, 2009
Thursday, February 19, 2009
Abdominal symptom cluster
Notice that this is not a "mixed" symptom cluster as I have bunched together problems that do likely have no gastro-intestinal origin whith those that most likely have.
1) One group of symptoms do most likely originate from the scrotum, but cause pain felt from the "upper" abdomen or elsewhere. These are:
• Flank pain (between iliac crest, hip, and lowest rib) from mild to appendicitis-like. A common cause is a focal source in the scrotum that is referred to one or both flanks. If this focal source, ususally sized 2-3 millimiters across, is palpated it should cause both localized pain to this little spot as well as pain in the flanks, and maybe nausea. INDICATIVE
• Appendicitis-like pain (see flank pain above for comments)
• Nausea (a common cause is scrotal pain)
2) The second group of problems is more clearly gastro-intestinal. These are:
• Constipation (may be related to flares)
• Abdominal distension (“swollen belly”)
• “Golf-ball in the rectum” feeling (this is similar to chronic proctalgia)
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, buksmärtor
1) One group of symptoms do most likely originate from the scrotum, but cause pain felt from the "upper" abdomen or elsewhere. These are:
• Flank pain (between iliac crest, hip, and lowest rib) from mild to appendicitis-like. A common cause is a focal source in the scrotum that is referred to one or both flanks. If this focal source, ususally sized 2-3 millimiters across, is palpated it should cause both localized pain to this little spot as well as pain in the flanks, and maybe nausea. INDICATIVE
• Appendicitis-like pain (see flank pain above for comments)
• Nausea (a common cause is scrotal pain)
2) The second group of problems is more clearly gastro-intestinal. These are:
• Constipation (may be related to flares)
• Abdominal distension (“swollen belly”)
• “Golf-ball in the rectum” feeling (this is similar to chronic proctalgia)
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, buksmärtor
Tuesday, February 17, 2009
Sickness behaviour symptom cluster
A combination of symptoms generally found after immune activation regardless of source (viral, bacterial, fungal, protozoal, pain, tissue damage etc). Clinically often noticed. Has been studied in cancer treatment. All these symptoms/signs can be regarded as indicative for CPPS-sufferers as they often wax and wane during the course of the illness, while no other obvious source can be found. Actually CPPS has been reported to occasionally go in remission when a CPPS sufferer falls ill in the flu, or catches a cold etc.
Notice that some of the symptoms below are more or less synonyms (anhedonia and depression; fatigue, asthenia, sleepiness and tiredness).
• Malaise: “A feeling of general discomfort or uneasiness, an 'out-of-sorts' feeling...” (From Stedman’s.)
• Fatigue: “…a lessened capacity for work and reduced efficiency of accomplishment, usually accompanied by a feeling of weariness, sleepiness, or irritability; may also supervene when, from any cause, energy expenditure outstrips restorative processes…” (From Stedman’s.)
• Asthenia: weakness, “lack of motor activity or strength”.
• Tiredness / sleepiness.
• Depression / dejection (lessened interest in other people, withdrawal etc). It may be noted that a subgroup of clinically depressed people have excess levels of (pro-) inflammatory mediators (substances).
• Anhedonia / listlessness (“…sensation of boredom and lassitude due to absence of stimulation, monotony, or lack of interest in one's surroundings.” From Stedman’s.)
• Lessened hunger / difficulty putting on weight (“anorexia”).
• Anxiety (withdrawal, feeling uncomfortable / nervous in public places or social situations, “paranoia”) etc..
• Irritability normally co-occuring with fatigue / tiredness etc, but may also occur for no obvious reason.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, sjukdomsbeteende
Notice that some of the symptoms below are more or less synonyms (anhedonia and depression; fatigue, asthenia, sleepiness and tiredness).
• Malaise: “A feeling of general discomfort or uneasiness, an 'out-of-sorts' feeling...” (From Stedman’s.)
• Fatigue: “…a lessened capacity for work and reduced efficiency of accomplishment, usually accompanied by a feeling of weariness, sleepiness, or irritability; may also supervene when, from any cause, energy expenditure outstrips restorative processes…” (From Stedman’s.)
• Asthenia: weakness, “lack of motor activity or strength”.
• Tiredness / sleepiness.
• Depression / dejection (lessened interest in other people, withdrawal etc). It may be noted that a subgroup of clinically depressed people have excess levels of (pro-) inflammatory mediators (substances).
• Anhedonia / listlessness (“…sensation of boredom and lassitude due to absence of stimulation, monotony, or lack of interest in one's surroundings.” From Stedman’s.)
• Lessened hunger / difficulty putting on weight (“anorexia”).
• Anxiety (withdrawal, feeling uncomfortable / nervous in public places or social situations, “paranoia”) etc..
• Irritability normally co-occuring with fatigue / tiredness etc, but may also occur for no obvious reason.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, sjukdomsbeteende
Sunday, February 15, 2009
Ejaculatory-genital symptom cluster
These are all anecdotal (meaning patient or practitioner observations). Notice that if you have pain in the left scrotum/testicle, then you should have left sided penile and flank pain (may be bilateral though). Focal thigh pain should also be leftsided. Most of these symptoms are indicative. If it is not sure if indicative a (Ind?) has been added at the end of the symptom/sign description.
Penile paresthesia-like symptoms:
• Penis / glans pain / discomfort (not necessarily at urination).
• Penile numbness / insensitivity to “friction” and maybe also diminished feeling of orgasm (diminished “sexual excitability”). Less noticeable in circumcised men? (Ind?).
• “Ejaculatory dyssynergia”: uncoordinated (early, unexpected, partially “failed”, “incomplete”) ejaculation.
Pain phenomena:
• Painful ejaculation (epidydimitis?).
• Groin pain / discomfort.
• Pain / discomfort from the scrotum (often referred to as testicular pain, orchialgia, or “tight trousers feeling” or “uncomfortable chair feeling”).
• Perineal spasms and pain / discomfort (lasting seconds to minutes and then disappearing completely -- this is similar to proctalgia fugax that is centerad around the anus).
• Focal thigh pain or pain down one leg associated with scrotal pain (many other possible causes though: knee problems, leg length, sciatica etc).
Other:
• Receding foreskin during flares (Ind?).
• Discoloration (bluish-whitish-pinkish mottled hue) of glans (Ind?).
• Semen abnormalities (yellowish, “watery”, non-homogenous look) (Ind?).
• Decreased / low libido. (Added march 4th 2009)
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster
Penile paresthesia-like symptoms:
• Penis / glans pain / discomfort (not necessarily at urination).
• Penile numbness / insensitivity to “friction” and maybe also diminished feeling of orgasm (diminished “sexual excitability”). Less noticeable in circumcised men? (Ind?).
• “Ejaculatory dyssynergia”: uncoordinated (early, unexpected, partially “failed”, “incomplete”) ejaculation.
Pain phenomena:
• Painful ejaculation (epidydimitis?).
• Groin pain / discomfort.
• Pain / discomfort from the scrotum (often referred to as testicular pain, orchialgia, or “tight trousers feeling” or “uncomfortable chair feeling”).
• Perineal spasms and pain / discomfort (lasting seconds to minutes and then disappearing completely -- this is similar to proctalgia fugax that is centerad around the anus).
• Focal thigh pain or pain down one leg associated with scrotal pain (many other possible causes though: knee problems, leg length, sciatica etc).
Other:
• Receding foreskin during flares (Ind?).
• Discoloration (bluish-whitish-pinkish mottled hue) of glans (Ind?).
• Semen abnormalities (yellowish, “watery”, non-homogenous look) (Ind?).
• Decreased / low libido. (Added march 4th 2009)
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster
Friday, February 13, 2009
Micturition problems symptom cluster
All of the below items are regarded as indicative for CP/CPPS, but also for infection, and in part for dyssynergia (detrusor (sphincter) dyssynergia) or obstruction.
• Diuresis/Pollakiuria: frequent urination/micturition of varying amounts (normal is about 3-6 times tops during the day and none during sleep).
• Nocturia (nycturia): micturition urge that is causing the interruption or shortening of normal sleep. Especially if often and repeatedly recurring.
• Urinary urgency: a sudden and pressing urge to urinate (normally this feeling should slowly start to grow as the bladder is distended, ie filled, beyond a certain cut-off).
Dysuria and stranguria like problems:
• Difficulty and/or painful urination in general.
• Dribbling, weak (slow) and split stream without burning sensation or pain.
• Start-stop micturition (especially at the end of micturition). A feeling of having to “squirt out” the last drops.
• A feeling of not having completely emptied the bladder.
Other:
• Urine smell (despite no obvious alimentary source like asparagus, white wine or selenium yeast supplements).
• “Foaming urine”, i.e. when stream hits enclosed water surface, without any proteinuria.
• Sporadic dark urine?, despite adequate water intake and no no obvious alimentary source.
• Penile paresthesia-like problems: burning sensation or pain in urether or tip of penis when urinating and not.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, miktion
• Diuresis/Pollakiuria: frequent urination/micturition of varying amounts (normal is about 3-6 times tops during the day and none during sleep).
• Nocturia (nycturia): micturition urge that is causing the interruption or shortening of normal sleep. Especially if often and repeatedly recurring.
• Urinary urgency: a sudden and pressing urge to urinate (normally this feeling should slowly start to grow as the bladder is distended, ie filled, beyond a certain cut-off).
Dysuria and stranguria like problems:
• Difficulty and/or painful urination in general.
• Dribbling, weak (slow) and split stream without burning sensation or pain.
• Start-stop micturition (especially at the end of micturition). A feeling of having to “squirt out” the last drops.
• A feeling of not having completely emptied the bladder.
Other:
• Urine smell (despite no obvious alimentary source like asparagus, white wine or selenium yeast supplements).
• “Foaming urine”, i.e. when stream hits enclosed water surface, without any proteinuria.
• Sporadic dark urine?, despite adequate water intake and no no obvious alimentary source.
• Penile paresthesia-like problems: burning sensation or pain in urether or tip of penis when urinating and not.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster, miktion
Tuesday, February 10, 2009
The concept of symptom clusters
The concept of symptom clusters -- "a stable group of two or more concurrent symptoms that are related to one another and independent of other symptoms” was advanced some years ago as a viable way of systematically improve the treatment of primarily cancer patients.(1,2) Clusters, even if the concept is not used, are also the common way of describing diseases of unknown etiology: aka “syndromes”.
Ideally clustering should help identify patient subgroups and indicate possible underlying causes.
A couple of CPPS clusters are tentatively singled out below. The "micturition" and "ejaculatory-genital" clusters are the common reason that advice is sought from a urologist, as these, especially frequency and dribbling and sexual disturbances, conspicuously affect daily life.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster
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(1) Dodd M, Janson S, Facione N, Faucett J, Froelicher ES, Humphreys J, Lee K, Miaskowski C, Puntillo K, Rankin S, Taylor D. Advancing the science of symptom management. J Adv Nurs 33(5):668-676, 2001.
(2) Barsevick AM. The elusive concept of the symptom cluster. Oncol Nurs Forum 34(5):971-980, 2007.
Ideally clustering should help identify patient subgroups and indicate possible underlying causes.
A couple of CPPS clusters are tentatively singled out below. The "micturition" and "ejaculatory-genital" clusters are the common reason that advice is sought from a urologist, as these, especially frequency and dribbling and sexual disturbances, conspicuously affect daily life.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, symptomkluster
____________________
(1) Dodd M, Janson S, Facione N, Faucett J, Froelicher ES, Humphreys J, Lee K, Miaskowski C, Puntillo K, Rankin S, Taylor D. Advancing the science of symptom management. J Adv Nurs 33(5):668-676, 2001.
(2) Barsevick AM. The elusive concept of the symptom cluster. Oncol Nurs Forum 34(5):971-980, 2007.
Monday, February 9, 2009
Symptoms and signs
CPPS is a slow disease evolving usually over many years. The patient commonly begins feeling weak with influenza like symptoms(fatigue/malaise) and having occasional discomfort with diffuse urinary problems like dribbling and penile "insensitivity" (paresthesia) that progresses in the worst case to severely debilitating pain and urgency. Progress can be sudden and rapid (within a few weeks), and an assumed triggering event is sometimes mentioned. Help is usually sought when pain and/or urinary and sexual problems begin to interfere with everyday life or there is a sudden obvious increase in symptoms. Sudden onset of urgency seems btw to be an important cause to seek medical advice. Stabilization and even permanent remission may occur after many years.
The common denominators for prostatitis/CPPS are symptoms emanating especially from the pelvis, groin and uro-genital apparatus.(1) The disease has a distinct periodicity / cyclicity with recurring flares (exacerbations) and improvements (remissions). Anecdotal evidence and studies also indicate that winter and spring see more flares and pain (discomfort, pressure-like sensations), while symptoms tend to vane or disappear during the summer (cold seems to worsen problems, while sun and heat ameliorates them).
Many patients indicate that flares are triggered by cold (freezing in general, just the feet, sitting on cold surfaces and swims in cold water). Also bicycling and vibrations from motorcycles and similar have been mentioned as problematical. Symptoms that may indicate a myofascial/tension disorder.
A small study noted that: "The informants also reported that cold exposure caused aggravation of symptoms and provoked their relapse. Sitting on cold objects, spending time in cold, damp or windy surroundings and walking on a cold floor were provocative and thus were avoided."(2)
A detailed review of symptom frequency can be found in "Symptoms correlated with prostatitis".(3) "A summary report on the impact of Prostatitis and Benign Prostatic Hyperplasia on men's lives and those of their families"(4) is also available.
In my next posts I will discuss symptom clusters and suggest clusters in CPPS (I have grouped symptoms, documented and anecdotal--I will also add INDICATIVE after the symptoms/signs that are most likely indicative of CPPS).
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
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(1) Moon TD et al., Urinary symptomatology in younger men, J Urol 50:700-703, 1997
(2) Hedelin H, Jonsson K. Chronic abacterial prostatitis and cold exposure. Scand J Urol Nephrol. 2007 May 9;1-6 [Epub ahead of print].
(3) Guercini F, Pajoncini C, Bini V, Porena M. Symptoms correlated with prostatitis. International Continence Society 2002:237.
(4) Bernardes J, Cameron E, Dunn P.“A summary report on the impact of Prostatitis and Benign Prostatic Hyperplasia on men's lives and those of their families” (“http://uk.groups.yahoo.com/group/bps-assoc/files/ Kings Fund Full Report (pdf)”)
The common denominators for prostatitis/CPPS are symptoms emanating especially from the pelvis, groin and uro-genital apparatus.(1) The disease has a distinct periodicity / cyclicity with recurring flares (exacerbations) and improvements (remissions). Anecdotal evidence and studies also indicate that winter and spring see more flares and pain (discomfort, pressure-like sensations), while symptoms tend to vane or disappear during the summer (cold seems to worsen problems, while sun and heat ameliorates them).
Many patients indicate that flares are triggered by cold (freezing in general, just the feet, sitting on cold surfaces and swims in cold water). Also bicycling and vibrations from motorcycles and similar have been mentioned as problematical. Symptoms that may indicate a myofascial/tension disorder.
A small study noted that: "The informants also reported that cold exposure caused aggravation of symptoms and provoked their relapse. Sitting on cold objects, spending time in cold, damp or windy surroundings and walking on a cold floor were provocative and thus were avoided."(2)
A detailed review of symptom frequency can be found in "Symptoms correlated with prostatitis".(3) "A summary report on the impact of Prostatitis and Benign Prostatic Hyperplasia on men's lives and those of their families"(4) is also available.
In my next posts I will discuss symptom clusters and suggest clusters in CPPS (I have grouped symptoms, documented and anecdotal--I will also add INDICATIVE after the symptoms/signs that are most likely indicative of CPPS).
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
___________________
(1) Moon TD et al., Urinary symptomatology in younger men, J Urol 50:700-703, 1997
(2) Hedelin H, Jonsson K. Chronic abacterial prostatitis and cold exposure. Scand J Urol Nephrol. 2007 May 9;1-6 [Epub ahead of print].
(3) Guercini F, Pajoncini C, Bini V, Porena M. Symptoms correlated with prostatitis. International Continence Society 2002:237.
(4) Bernardes J, Cameron E, Dunn P.“A summary report on the impact of Prostatitis and Benign Prostatic Hyperplasia on men's lives and those of their families” (“http://uk.groups.yahoo.com/group/bps-assoc/files/ Kings Fund Full Report (pdf)”)
Saturday, February 7, 2009
Main view thoughts on causes
If NIH-I&II are excluded the answer is quite honestly simply: nobody knows for sure! But the following ideas and hypotheses on etiology and pathogenesis have been put forth (see Karlovsky (1), Pontari and Ruggieri (2), for a fuller review):
Popular ideas
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
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(1) Karlovsky ME, Pontari MA. Theories of prostatitis etiology. Curr Urol Rep 3(4):307-312, 2002.
(2) Pontari MA, Ruggeri MR Mechanisms in prostatitis/chronic pelvic pain syndrome. J Urol 172(3):839-845 2004
Popular ideas
- Undiscovered micro-organism causing "hidden" chronic infection (i.e. unhealed). The most popular vectors are bacteria. This has been pursued with pig-headed insistence despite no proof. But, remember Helicobacter pylori...
- Neuro-muscular or musculoskeletal disorders, e.g. myofascial pain.
- Persistent inflammation triggered by an inappropriate immunological response to a previous, and supposedly healed, infection.
- Auto-immune condition.
- Persistent neuropathy (damage to nerves controlling pain regulation/signaling) possibly caused by any of the above causes (or neurogenic inflammation and/or "idiopathic" mast cell activation). Pudendal neuropathy is popular, but oft unproven.
- Estrogen-similar substances, e.g. soy flavonoids.
- Endocrinological (hormonal) disorders.
- Psychological (when you do not know cause nor what to do blame the patient...).
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
__________________
(1) Karlovsky ME, Pontari MA. Theories of prostatitis etiology. Curr Urol Rep 3(4):307-312, 2002.
(2) Pontari MA, Ruggeri MR Mechanisms in prostatitis/chronic pelvic pain syndrome. J Urol 172(3):839-845 2004
Prevalence
Prostatitis is thought to be the most common urological complaint for patients under 50 years of age. It is estimated to occur in 5-8% (and maybe up to 16%) of the male population (as lifetime prevalence). About 90-95% of these cases are attributable to CP/CPPS. Frequency increases with age and seemingly has a northward increase. The mean patient is a male between 38 and 48 years that has suffered from diffuse problems for up to, commonly, eight years. But onset can begin at as early an age as the upper teens.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
Wednesday, February 4, 2009
Historical notes
The below is mainly extracted from “Epidemiologic and diagnostic aspects of prostatitis" by A Mehik (1) and "A headache in the pelvis" by Wise and Anderson.
The first "modern" description of prostatitis was made by Verdies in 1838 and later confirmed by Young, Gereghty and Stevens in 1903. Some researchers focused on finding a bacterial cause, while the Freudian lot branded the patients as mentally ill and suffering of anal/rectal psychoses (Cumming and Chittenden, 1938), problems with the "male sexual identity" etc etc. (The usual crap. The unfortunate gut reaction of the medical establishments to not knowing things has a long history of attributing the messenger of bad tidings, i.e. the patient, with being possessed by the devil, although the modern version is usually that the sufferer must be a bed-wetting mental case with severe hypochondria.)
Kretschmer noted already in 1937 that the causes probably were multiple. The first detailed descriptions were presented by Ritter and Lippow in 1938 and by Grant also in 1938. During 1940s and 50ties it was generally believed that the cause was gonococcal infection. By 1957 Campbell noted that non-bacterial causes were common. New technology saw a rise in research during the 60ties and 70ties (especially Meares and Stamey), but the direction was still for bacterial or psychological causes.
The 90ties and the turn of the millennium saw a new flurry of research, especially in the USA and Canada, and interest also started to be directed at neuromuscular causes. The thought that neuromuscular causes may lie behind pelvic pain was not new. Thiele and Shapiro had as early as in the 30ties pointed at this possibility, but it went largely ignored, until Sinaki and Segura in 1979 drew attention to the possibility of pelvic floor tension causing prostatitis.
Most recently the question has been raised if the cause may be immune reaction / HPA axis dysfunction. Several lines of evidence (symptoms and signs) do in my opinion indicate that this is a real possibility, regardless if it is a cause or an effect.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
____________________
(1) Mehik A. Epidemiological and diagnostical aspects of prostatitis. Doctoral dissertation presented at the University of Oulu (Uleåborg), Oulu University Press 2001
The first "modern" description of prostatitis was made by Verdies in 1838 and later confirmed by Young, Gereghty and Stevens in 1903. Some researchers focused on finding a bacterial cause, while the Freudian lot branded the patients as mentally ill and suffering of anal/rectal psychoses (Cumming and Chittenden, 1938), problems with the "male sexual identity" etc etc. (The usual crap. The unfortunate gut reaction of the medical establishments to not knowing things has a long history of attributing the messenger of bad tidings, i.e. the patient, with being possessed by the devil, although the modern version is usually that the sufferer must be a bed-wetting mental case with severe hypochondria.)
Kretschmer noted already in 1937 that the causes probably were multiple. The first detailed descriptions were presented by Ritter and Lippow in 1938 and by Grant also in 1938. During 1940s and 50ties it was generally believed that the cause was gonococcal infection. By 1957 Campbell noted that non-bacterial causes were common. New technology saw a rise in research during the 60ties and 70ties (especially Meares and Stamey), but the direction was still for bacterial or psychological causes.
The 90ties and the turn of the millennium saw a new flurry of research, especially in the USA and Canada, and interest also started to be directed at neuromuscular causes. The thought that neuromuscular causes may lie behind pelvic pain was not new. Thiele and Shapiro had as early as in the 30ties pointed at this possibility, but it went largely ignored, until Sinaki and Segura in 1979 drew attention to the possibility of pelvic floor tension causing prostatitis.
Most recently the question has been raised if the cause may be immune reaction / HPA axis dysfunction. Several lines of evidence (symptoms and signs) do in my opinion indicate that this is a real possibility, regardless if it is a cause or an effect.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
____________________
(1) Mehik A. Epidemiological and diagnostical aspects of prostatitis. Doctoral dissertation presented at the University of Oulu (Uleåborg), Oulu University Press 2001
Tuesday, February 3, 2009
ISOP, some additional notes on why I blog
Today I made a little plug for my blog on the ISOP (http://home.swipnet.se/isop/) forum. ISOP is actually the reason why "it occured to me I could edit and publish on a 'blog'". While the site contains interesting material and information it was also more or less totally unstructured, a mass of garishly coloured disparate facts devoid of any analyses or summaries. Mostly cut and paste abstracts.
Do not misunderstand me! Lennart Branthle does a fantastic job (here in Sweden) trying to lobby for recognition of the disease and the need for adequate research and treatment, but I was not interested in that.
I was interested in hypotheses.
I was interested in thoughts 'outside the box'.
Facts need to be analyzed. Ideas need to be formulated. But to be able to do that some sort of review and overview is needed. Besides of the thinking. Starting to take/keep notes was my way to make sense of the mass of facts. To start to try to discern possible patterns.
I cannot say I will suggest something revolutionary, but at least I hope that my ideas and thoughts may help someone in some way. Be it ideas for treatment, or ideas for research (hopeful thought). Or just help by being a thorough overview.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, ISOP
Do not misunderstand me! Lennart Branthle does a fantastic job (here in Sweden) trying to lobby for recognition of the disease and the need for adequate research and treatment, but I was not interested in that.
I was interested in hypotheses.
I was interested in thoughts 'outside the box'.
Facts need to be analyzed. Ideas need to be formulated. But to be able to do that some sort of review and overview is needed. Besides of the thinking. Starting to take/keep notes was my way to make sense of the mass of facts. To start to try to discern possible patterns.
I cannot say I will suggest something revolutionary, but at least I hope that my ideas and thoughts may help someone in some way. Be it ideas for treatment, or ideas for research (hopeful thought). Or just help by being a thorough overview.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, ISOP
Monday, February 2, 2009
Current definition and classification
Technically the term means inflammation of the prostate. An inflammation is caused by the reaction of the immune-system of your body against substances deemed foreign by said body. These may be parasites, pollen, dust, bacteria, viruses and others.
(To simplify: if the foreign body is external and “non-living” the reaction is called an allergy otherwise it is an infection. An auto-immune reaction is directed against your own bodily tissues. The immune reactions of your body are commonly classified in four hypersensitivity types.)
The current classification is according to the American National Institute of Health (NIH) consensus presented in 1995 and published for clinical use in 1999. It is the currently most common.
Bacterial prostatitis—NIH-I and NIH-II
Obviously pathogenic micro-organisms can only be identified as the promoters and cause of inflammation in very few cases, which also are pretty easily treated with antibiotics. This condition is called acute bacterial prostatitis (NIH-I) if onset is sudden and causing obvious illness. Prostate is also abnormal in NIH-I. If infection recurs – usually with milder symptoms than the acute form – it is called chronic bacterial prostatitis (NIH-II). This is more common in older (>50y) men. Only 5-10% of the prostatitis diagnosed patients are thought to suffer from bacterial prostatitis. Curiously only about 5% of IC patients also show “gross inflammatory disease” . (1)
Chronic prostatitis / chronic pelvic pain syndrome—NIH-IIIa and NIH-IIIb
If no obviously pathogenic or known micro-organism can be identified the condition is called chronic prostatitis/chronic pelvic pain syndrome (NIH-III, CP/CPPS; idiopathic or abacterial prostatitis). If markers of inflammation (white blood cells above a certain cut-off in semen, VB3-urine, first void after prostatic massage, and EPS) are found the condition is further sub-categorized as inflammatory CP/CPPS (NIH-IIIa), else non-inflammatory CP/CPPS (NIH-IIIb). The latter condition is also known as “pelvic myoneuropathy”, ”pelvic myofascial syndrome” or “prostatodynia” or “pelvic floor tension myalgia” depending on assumed cause. A study indicated that NIH-III patients can roughly be divided in 25% type ‘a’ and 75% type ‘b’ (2), while another found that only 33% had an inflamed prostate (with 5% having moderate or severe inflammation)(3) . It should be noted that the official leukocyte count is of questionable use, as correlation with symptoms is low (4) and as up to 20% of healthy controls have higher levels ! (5)
Do note that before the NIH system the term chronic prostatitis commonly encompassed NIH-II, NIH-IIIa and NIH-IIIb.
Asymptomatic inflammatory prostatitis—NIH-IV
Sometimes inflammation of the prostate is discovered incidentally or by biopsy, in patients not expressing any symptoms or concerns common to other prostatitis sufferers. This condition is called asymptomatic inflammatory prostatitis (NIH-IV).
Addendum feb 4
The current classification has hung around since the early forties in one way or another with various renamings of the four categories. It still does not take into account (obviously) the possibility of non-prostate related causes, and is essentially misleading by its focus on leukocytes and infection.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, NIHIIIa
__________________
(1) Moldwin RM Similarities between IC and male CPPS. Curr Urol Rep 3:313-318
(2) Hosseini A, Ehrèn I, Peter Wiklund P. The use of intraprostatic nitric oxide measurements to differentiate between inflammatory and non-inflammatory abacterial chronic prostatitis.
(3) True LD, Berger RE, Rothman I, Ross SO, Krieger JN. Prostate histopathology and the chronic prostatitis/chronic pelvic pain syndrome: a prospective biopsy study. J Urol. 162(6):2014-2018, 1999.
(4) Schaeffer AJ, Datta NS, Fowler JE et al. Overview summary statement-diagnosis and management of CP/CPPS. Urology 60(6):1-4, 2002
(5) Nickel JC, Alexander RB, Schaeffer AJ et al. Leukocytes and bacteria in men with CP/CPPS compared to asymptomatic controls. J Urol 170(3):818-822, 2003.
(To simplify: if the foreign body is external and “non-living” the reaction is called an allergy otherwise it is an infection. An auto-immune reaction is directed against your own bodily tissues. The immune reactions of your body are commonly classified in four hypersensitivity types.)
The current classification is according to the American National Institute of Health (NIH) consensus presented in 1995 and published for clinical use in 1999. It is the currently most common.
Bacterial prostatitis—NIH-I and NIH-II
Obviously pathogenic micro-organisms can only be identified as the promoters and cause of inflammation in very few cases, which also are pretty easily treated with antibiotics. This condition is called acute bacterial prostatitis (NIH-I) if onset is sudden and causing obvious illness. Prostate is also abnormal in NIH-I. If infection recurs – usually with milder symptoms than the acute form – it is called chronic bacterial prostatitis (NIH-II). This is more common in older (>50y) men. Only 5-10% of the prostatitis diagnosed patients are thought to suffer from bacterial prostatitis. Curiously only about 5% of IC patients also show “gross inflammatory disease” . (1)
Chronic prostatitis / chronic pelvic pain syndrome—NIH-IIIa and NIH-IIIb
If no obviously pathogenic or known micro-organism can be identified the condition is called chronic prostatitis/chronic pelvic pain syndrome (NIH-III, CP/CPPS; idiopathic or abacterial prostatitis). If markers of inflammation (white blood cells above a certain cut-off in semen, VB3-urine, first void after prostatic massage, and EPS) are found the condition is further sub-categorized as inflammatory CP/CPPS (NIH-IIIa), else non-inflammatory CP/CPPS (NIH-IIIb). The latter condition is also known as “pelvic myoneuropathy”, ”pelvic myofascial syndrome” or “prostatodynia” or “pelvic floor tension myalgia” depending on assumed cause. A study indicated that NIH-III patients can roughly be divided in 25% type ‘a’ and 75% type ‘b’ (2), while another found that only 33% had an inflamed prostate (with 5% having moderate or severe inflammation)(3) . It should be noted that the official leukocyte count is of questionable use, as correlation with symptoms is low (4) and as up to 20% of healthy controls have higher levels ! (5)
Do note that before the NIH system the term chronic prostatitis commonly encompassed NIH-II, NIH-IIIa and NIH-IIIb.
Asymptomatic inflammatory prostatitis—NIH-IV
Sometimes inflammation of the prostate is discovered incidentally or by biopsy, in patients not expressing any symptoms or concerns common to other prostatitis sufferers. This condition is called asymptomatic inflammatory prostatitis (NIH-IV).
Addendum feb 4
The current classification has hung around since the early forties in one way or another with various renamings of the four categories. It still does not take into account (obviously) the possibility of non-prostate related causes, and is essentially misleading by its focus on leukocytes and infection.
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, NIHIIIa
__________________
(1) Moldwin RM Similarities between IC and male CPPS. Curr Urol Rep 3:313-318
(2) Hosseini A, Ehrèn I, Peter Wiklund P. The use of intraprostatic nitric oxide measurements to differentiate between inflammatory and non-inflammatory abacterial chronic prostatitis.
(3) True LD, Berger RE, Rothman I, Ross SO, Krieger JN. Prostate histopathology and the chronic prostatitis/chronic pelvic pain syndrome: a prospective biopsy study. J Urol. 162(6):2014-2018, 1999.
(4) Schaeffer AJ, Datta NS, Fowler JE et al. Overview summary statement-diagnosis and management of CP/CPPS. Urology 60(6):1-4, 2002
(5) Nickel JC, Alexander RB, Schaeffer AJ et al. Leukocytes and bacteria in men with CP/CPPS compared to asymptomatic controls. J Urol 170(3):818-822, 2003.
Sunday, February 1, 2009
What is chronic prostatitis / chronic pelvic pain syndrome ?
That is the million-dollar question! It is possible that several different conditions, still to define/discover, are the underlying cause to CP/CPPS symptoms. It is also questionable if the prostate is involved. Research “is dominated by hypotheses, all of which lack a substantial evidential standing”. “Ethiogenic theories vary from the abstruse to the fashionable… and sadly often of confusion in medical thinking” (P. Hanno (1)). CPPS is most likely both under- and over-diagnosed.
“Patients with chronic pelvic pain syndrome (2) demonstrate no evidence of inflammation. They do not have urethritis, urogenital cancer, urethral stricture, or neurological disease involving the bladder. Indeed, they exhibit no overt renal tract disease.” What is known is that the men categorized with this label present with fairly similar symptoms and problems, that the condition is more common the more north you live and that it shows a relapsing (flare) and remitting (improvement) pattern superimposed on a seasonal pattern with wintertime exacerbations.
“If I knew how to really cure CPPS I would be world famous, make millions, afford an apartment over-looking Central Park, one in Aspen and one in Miami and only need to work three months a year” (Anonymous).
“We must break down the difference between the urologist, gynecologist and gastroenterologist and treat the pelvic floor as a single unit” (GR Sant).
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
____________________
(1) IC Epidemiology Task Force Report of the Bethesda Oct 29, 2003 meeting. Draft 1/6/2004.
(2) A syndrome is, according to the Oxford Concise Medical Dictionary, “a combination of signs and/or symptoms that forms a distinct clinical picture indicative of a particular disorder” but is not necessarily of a related etiology. That is why the word “syndrome” is used in CPPS. Unfortunately in the case of CPPS it is rather a label to “a combination of signs and/or symptoms”. Period.
“Patients with chronic pelvic pain syndrome (2) demonstrate no evidence of inflammation. They do not have urethritis, urogenital cancer, urethral stricture, or neurological disease involving the bladder. Indeed, they exhibit no overt renal tract disease.” What is known is that the men categorized with this label present with fairly similar symptoms and problems, that the condition is more common the more north you live and that it shows a relapsing (flare) and remitting (improvement) pattern superimposed on a seasonal pattern with wintertime exacerbations.
“If I knew how to really cure CPPS I would be world famous, make millions, afford an apartment over-looking Central Park, one in Aspen and one in Miami and only need to work three months a year” (Anonymous).
“We must break down the difference between the urologist, gynecologist and gastroenterologist and treat the pelvic floor as a single unit” (GR Sant).
Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
____________________
(1) IC Epidemiology Task Force Report of the Bethesda Oct 29, 2003 meeting. Draft 1/6/2004.
(2) A syndrome is, according to the Oxford Concise Medical Dictionary, “a combination of signs and/or symptoms that forms a distinct clinical picture indicative of a particular disorder” but is not necessarily of a related etiology. That is why the word “syndrome” is used in CPPS. Unfortunately in the case of CPPS it is rather a label to “a combination of signs and/or symptoms”. Period.
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