Patient reported frequency and severity of urological symptoms

Presenting symptoms (described by patients and recorded by urologists) in 1074 patients with prostatitis.(1)

Symptom	N (%)
Frequency	689 (64.2)
Obstructive voiding	675 (62.8)
Perineal pain or discomfort	630 (58.7)
Suprapubic pain or discomfort	492 (45.8)
Penile pain or discomfort	360 (33.5)
Premature ejaculation	305 (28.4)
Malaise	229 (21.3)
Urethral discharge	220 (20.5)
Inguinal pain or discomfort	216 (20.1)
Erectile dysfunction	205 (19.1)
Haematospermia	169 (15.7)
Voiding difficulties	162 (15.1)
Fever	159 (14.8)
Purulent urine	150 (14.0)
Abnormal seminal fluid	97 (9.0)
Myalgia	64 (6.0)
Abnormal urine (mucus)	61 (5.7)
Haematuria	46 (4.3)

	Mean (sd) score
	frequency	severity
Penile pain or discomfort	55.2 (386/699)	1.3 (1.4)	3.1 (2.7)
Perineal pain or discomfort	81.6 (666/816)	2.2 (1.3)	4.5 (2.5)
Suprapubic pain or discomfort	74.6 (561/779)	2.0 (1.4)	4.3 (2.5)
Ejaculatory pain or discomfort	63.9 (461/721)	1.4 (1.3)	3.3 (2.4)
Testicular pain or discomfort	43.9 (302/688)	0.9 (1.2)	2.5 (2.5)
Lumbar/inguinal/thigh pain	35.4 (240/678)	0.8 (1.3)	2.3 (2.8)
or discomfort
Incomplete bladder emptying	72.8 (541/743)	1.8 (1.4)	3.7 (2.7)
Burning during micturition	81.7 (652/798)	2.0 (1.3)	4.2 (2.5)
Urgency	72.4 (514/710)	1.7 (1.4)	3.9 (2.8)
Urinary frequency	86.4 (717/830)	2.4 (1.4)	5.0 (2.7)

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(1) Rizzo M, Marchetti F, Travaglini F, Trinchieri A, Nickel JC. Prevalence, diagnosis and treatment of prostatitis in Italy: a prospective urology outpatient practice study. BJU Int 92(9):955-959, 2003.

Women

It may be of interest that women are affected by similar disorders (interstitial cystitis, vulvodynia and vulvo-vestibulitis(1)) that may co-involve Skene’s glands (also known as the lesser vestibular or paraurethral glands), which are the vestigial female homologue of the prostate. Not all women have these as I said above they are vestigial. Causes are unclear, but vestibulitis mat be related to contraceptives.
Curio: many men have a vestigial uterus the utriculum.

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, interstitiell cystit, vulvodyni
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(1) Vulvodynia: Toward Understanding a Pain Syndrome Workshop, April 14-15, 2003, Bethesda, USA

HPA axis and sympathetic nervous system

At the 2006 and 2007 AUA meetings a couple of interesting presentations were held. "Heart rate variability and sympathetic skin response in men with CPPS" by U Yilmaz et al., looked at the heart rate (ECG) and hand and foot sympathetic response (by electrical nerve stimulation). CPPS patients differed from controls indicating a possible altered autonomic response.
"CPPS patients show evidence of allostatic overload" by Lee Jaeseop et al. was a small study of CRH (corticotropin releasing hormone), DHEA, EGF (epidermal growth factor), galanin and neuropeptide Y levels in urine. The assumption is that abnormal values indicate HPA axis dysregulation. The researchers found that CRH and DHEA was higher, and NPY and galanin lower, in CPPS patients compared to controls.

Anderson et al. reported that circadian cortisol levels differed in sufferers.
Another group, Dimitrakov et al., did a similar study to "identify adrenocortical hormone abnormalities as indicators of endocrine dysfunction". Their results did also indicate a possible HPA axis dysregulation too. More specifically they found higher progesterone, androstenedione and testosterone; and lower corticosterone and aldosterone than in controls. DHEA and estradiol did not differ in this study. The group suggests additional studies searching for signs of late-onset non-classical (congenital) adrenal hyperplasia. (Addenda: it would have been very interesting if they would also had measured prolaction, LH and FSH levels. Dr D Shoskes has purportedly measured prolactin in CPPS patienst and found no abnormalities.)

This is interesting as the micturition irregularities and pain in CPPS patients also are indicative of a possible HPA axis dyregulation. But the question to be asked is of course: are these changes part of the underlying cause of CPPS or an effect e.g. sleep disturbances caused by e.g. the micturition problems.

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, hypofysen, HPA-axeln
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(1) Dimitrakov J, Joffe HV, Soldin SJ, Bolus R, Buffington CA, Nickel JC. Adrenocortical hormone abnormalities in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 71(2):261-266, 2008.

Socio-economic differences and education

No or small differences in incidence due to economic or education level differences have been found, although lower socio-economic status (SES) predict that symptoms will be experienced as worse / more painful (1). Why this difference in experience? Two causes are probable: a) worse nutrition and more stress caused by the lower SES causing an objectively more severe disease, or b) subjectively experiencing being more ill.

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb
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(1) McNaughton Collins M, Pontari MA, O'Leary MP, Calhoun EA, Santanna J, Landis JR, Kusek JW, Litwin MS,.Quality of life is impaired in men with chronic prostatitis: the Chronic Prostatitis Collaborative Research Network.J Gen Intern Med 16(10):656-662, 2001.

Leukocytes, urates and citrates

Leukocyte (white blood cells) counts and common inflammatory markers have little or no correlation with CP/CPPS. Whether this be in urine (VB3), semen and or prostatic secretions. Cytokines show better correlation. See further discussion below in the sections on micro-organisms and inflammation.

Urates and other compounds typical for urine have been found in the prostate and prostatic calculi indicating reflux.

Added 2009-04-26
Various small studies have found a correlation between expressed prostatic secretion and semen contents of uric acid (urates) and CPPS symptoms. The assumption is that uric acid (urates) cause an inflammatory reaction and that the presence of uric acid is caused by reflux. (1-3)

Reflux, or retrograde flow, is the "backflow" of urine towards the prostate or kidney instead of out of the body. Causes of reflux are either "uncoordinated muscules" (dyssynergia) or physical abnormalities or urinary tract infections.

Citrate levels may be decreased in CPPS sufferers. (4)

Andra bloggar om CPPS, kroniskt bäckenbottensmärtsyndrom, kronisk abakteriell prostatit, NIHIIIb, urater, urinreflux
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(1) Persson BE, Ronquist G. Evidence for a mechanistic association between nonbacterial prostatitis and levels of urate and creatinine in expressed prostatic secretion. J Urol. 155(3):958-60, 1996.
(2) Hou BS, Xia XY, Pan LJ, Yang B, Shao Y, Shang XJ, Yao B, Cui YX, Huang YF. [Determination of uric acid in the expressed prostatic secretion of chronic prostatitis patients and its clinical significance]. Zhonghua Nan Ke Xue 14(3):245-7, 2008. Summary only, article in Chinese.
(3) Motrich RD, Olmedo JJ, Molina R, Tissera A, Minuzzi G, Rivero VE. Uric acid crystals in the semen of a patient with symptoms of chronic prostatitis. Fertil Steril. 85(3):751.e1-751.e4. 2006.
(4) Chen J, Xu Z, Zhao H, Jiang X. Citrate in expressed prostatic secretions has the feasibility to be used as a useful indicator for the diagnosis of category IIIB prostatitis. Urol Int. 78(3):230-4, 2007.
and
Chen J, Zhao HF, Xu ZS. The prostate has secretory dysfunction for category IIIA and IIIB prostatitis. J Urol. 177(6):2166-9, 2007.

General findings

In addition to patient self-reported symptoms various standard tests are performed to check for patient health (e.g. PSA test), bacteria and hyperplasia. All these are usually negative or within the normal range. The CPPS patient is 'healthy and well' despite pain, tiredness, frequency etc. And that quality of life is affected by conditions affecting micturition has been concluded repeatedly(1). It may be noted that older men with LUTS (lower urinary tract symptoms)(2) seem more prone to injuries from falls.(3)
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(1) E.g. Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int. 2008 Jun;101(11):1388-95. And 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", discussions on self-help group message boards etc.
(2) This is a borderline wastebasket term. For a fuller discussion see:
Chapple CR, Wein AJ, Abrams P, Dmochowski RR, Giuliano F, Kaplan SA, McVary KT, Roehrborn CG. Lower urinary tract symptoms revisited: a broader clinical perspective. Eur Urol 54(3):563-569, 2008.
(3) Kellogg Parsons J, Mougey J, Lambert L, Wilt TJ, Fink HA, Garzotto M, Barrett-Connor E, Marshall LM. Lower urinary tract symptoms increase the risk of falls in older men. BJU Int. 2009 Jan 9. [Epub ahead of print]