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Clinical classification of chronic prostatitis: a preliminary investigation

Wei-Dong HUANG, Pei LIU, Wen-Jie HUANG

Xinjiang Jiayin Andrology Hospital, Urumuqi 830006, China

Asian J Androl  2000 Dec; 2:  311-313

Keywords: chronic bacterial prostatitis; clinical classification; curative efficacy
Abstract
Aim: To propose a practical clinical classification for the chronic prostatitis (CP). Methods: The clinical features and the findings in the expressed prostatic secretion (EPS) in 804 cases of CP patients were retrospectively analyzed. Results: Four types of CP were identified based on the clinical manifestations and the amounts of white blood cells (WBC) and lecithin in EPS. They were the latent type (85 cases; 10.6%), the common type (423 cases; 52.6%), the persisting type (104 cases; 12.9%), and the active type (192 cases, 23.9%). The therapeutic efficacy for these 4 subtypes were 40.4%, 76.8%, 30.8% and 37%, respectively; a statistical difference was noticed between the common type and the persisting type (P<0.01). Conclusion: The method of classification proposed by the authors may help clinicians in the diagnosis and predicting the prognosis of CP.

1 Introduction

Prostatitis is conventionally classified into 4 types, i.e. acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), non-bacterial prostatitis (NBP) and prostatodynia (PD)[1]. Among them the incidence of CBP is the highest with a complex etiology, a protracted course, and nonspecific clinical manifestations[2]. The results of EPS assessment by the traditional approach may not correspond to the clinical manifestations. The present paper was designed to pursue a new clinical classification of chronic prostatitis in order to help the clinicians in the diagnosis and programming their therapeutic scheme.
2 Materials and methods

2.1 Subjects

Eight hundred and four CBP patients, aged  21-48 (average 32.5) years, visiting this clinic from January 1996 to December 1998 were recruited. All were confirmed by EPS assessment, among whom 85 were asymptomatic and diagnosed at the time of routine health examination or infertility assessment.

2.2 Diagnostic criteria

2.2.1 Clinical manifestations

CBP could be clinically graded according to the presence and severity of its symptoms. Grade I patients are those having one of the following symptoms at a time, Grade II, 2 symptoms persistently or 3 symptoms alternately, and Grade III, 3 symptoms persistently.

(a) Paruria: a constant desire to void, pain on urination, a viscid secretion at the urethral opening, and/or a burning pain in the urethra.
(b) Pain: pain at the perineum, lower limb and/or lumbosacral region, sometimes radiating to the penis, testis or medial aspect of the thigh.
(c)  Erection disturbance: impotence, ejaculation praecox, etc.

2.2.2 Laboratory findings

(a) WBC count in EPS was classified into three grades. a: <10/high power field (HP),  b: 1020/HP, c: >20/HP. 
(b) Lecithin bodies in EPS was classified into four grades.  For the assessment of the amount of lecithin, we recommend that the field be divided into four quadrants. Lecithin bodies that are evenly and densely distributed in every quadrant will be considered >75% (equivalent to the traditional ++++, which is basically normal). If they are scattered all over the fields or densely distributed in 3 quadrants, 75% (equivalent to +++); 2 quadrants will be 50% or ++ and 1 quadrant, 25% or +. The distribution density of lecithin bodies in normal males served as the controls which was recorded by photomicrography.

2.2.3 Meares-Stamey test

The Diagnostic Criteria for CBP: the bacterial counting in EPS and/or VBS3 (the third voided bladder specimen) is greater than 5000/mL, the bacterial counting in EPS  >10 time more than those in VBS1 and VBS2, and/or the bacterial counting in VBS3 >2 times more than those in VBS1 and VBS2.

2.3 Treatment

All the patients received the following combination treatment with urethroprostatic douching/draining as the principal measure[3].

(a) Urethroprostatic douching/draining was performed once every other day using a two-ballon-three-channel prostatic irrigating catheter (Chida Co, Zhanjiang, China, Patent ZL97224826.9), 10 irrigations constituting a course. 
(b) Transrectal prostatic micrometer-wave therapy (HZ-Q100 micrometer-wave prostatic therapeutic apparatus, Electronic Equipment Factory, Shanghai University, Shanghai) was performed- once a day for 30 min, to improve the local blood circulation and accelerate drug absorption.
(c) Carbostyril antibiotics in conventional dosage level were taken orally or by intravenous drip q.d., 15 days constituting a course.

2.4 Effectiveness

Effective criteria consisted of an improvement of clinical manifestations to Grade I or below, an increase in lecithin bodies in EPS to 75%, and a decrease in WBC to <10/HP.

2.5 Statistical analysis

The data were analyzed with the chi square test and P<0.05 was set as significant.

3 Results

In 804 CP patients, 527 were diagnosed as CBP by  means of the Meares-Stamey test; the microorganisms found were shown in Table 1.

Table 1. Pathogenic organism in chronic prostatitis.

Disease

Pathogenic microorganism

n

%

NBP

Mycete

10

1.2

Trichomonad

4

0.5

Mycoplasma urealyticum

106

13.2

Chlamydia (CT)

37

4.6

No microorganism

120

14.9

CBP

S. areus

423

52.6

S. epidermidis

44

5.5

S. saprophyticus

30

3.7

S. treptococci type A

12

1.5

E. coli

18

2.2

On the basis of the observations on WBC and lecithin bodies in EPS, CP may be classified into four subtypes: the latent type, the common type, the persisting type and the active type. The incidence was the highest in the common type (52.6%), followed in order by the active type (23.9%), the persisting type (12.9%) and the latent type (10.6%) (Table 2). With regard to the curative efficacy a significant difference was found between the chronic common type and other 3 types (P<0.01) (Table 3).

Table 2. Clinical and laboratory findings in CP subtypes.

 

Common
(n=423, 52.6%)

Latent
(n=85, 10.6%)

Persisting
(n=104, 12.9%)

Active
(n=192,23.9%)

WBC (per HP field)

>20

1020

<10

1020

Lecithin distribution (%)

2550

>50

<25

<25

Clinical symptoms

>II

noneI

III

>II

Table 3.  Therapeutic efficacy in CP subtypes.

 

Cases

Effective cases

Total Effectiveness

First course

Second course

Cases

%

Common

423

260

49

309

73.0c

Latent

85

34

8

42

42.9

Persisting

104

19

13

32

30.8

Active

192

57

14

71

37.0

cP<0.01, compared with any of the other 3 subtypes.

4 Discussion

The Meares-Stamey test has a notable diagnostic value in the assessment for CBP[4], and is accepted by most clinicians to be the final diagnostic criterion[5]. The diagnosis for NBP, however, relies more on changes in WBC in EPS[6]. Transrectal prostatic ultrasonography provides some helpful evidence in differentiating PD from other types of prostatitis[7]. The diagnosis for CP is not an easy task, as the disease usually takes a long course and the symptoms are nonspecific, variegated, and commonly complicated with some other ailments[8].  Bacterial culture and WBC count in EPS were sometimes helpful, but the EPS results may be at times difficult to interpret or even inconsistent with the clinical symptoms.

The present study indicates that the WBC counts and lecithin distribution in EPS may provide important information for the diagnosis for CP.  In conclusion the authors believe that the proposed method of CP classification help clinicians in the diagnosis and prognosis of CP.

References

[1] Meares EM Jr. Acute and chronic prostatitis: diagnosis and treatment. Infect Dis Clin North Am 1987; 1: 853-73.
[2] Stewart C. Prostatitis. Emerg Med Clin North Am 1998; 3: 391-402.
[3] Huang WD. Effect of double-capsule-triple-duct prostatic irrigating catheter on CBP treatment. Chin J Androl (China) 1998; 2: 36.
[4] Sibert L,Grise P,Boillot B,Loulidi S,Guerin JG. Diagnosis value of Stamey's test in chronic prostatitis. Prof Urol 1996; 6: 107-11.
[5] Jara J, Moncada I, Herranz F, Duran R, Lledo E, Palacio A, et al. Chronic prostatitis: diagnostic and therapeutic considerations. Acta Urol ESP 1996; 20: 261-8.
[6] Thin RN. The chronic prostatitis syndromes. J R Army Med Corps 1997; 143: 155-9.
[7] Doble A, Carter SS. Ultrasonographic findings in prostatitis. Urol Clin North Am 1989; 16:763-77
[8] Pewitt EB, Schaeffer AJ. Urinary tract infection in Urology, including acute and chronic prostatitis. Infet Dis Clin North Am 1997; 11: 623-46.
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Correspondence to: Dr. Wei-Dong HUANG, Xinjiang Jiayin Andrology Hospital, 17 Qiantang River Road, Urumuqi 830006, China. 
Tel: +86-991-384 4011   Fax: +86-991-384 8046
e-mail: wdhuang@cta.cq.cn
Received 2000-07-03      Accepted 2000-10-26