Prostatitis: Diagnostik und Therapie

Zusammenfassung

Die Prostatitis ist eine häufige und komplexe Erkrankung. Im Verlauf der letzten 40 Jahre haben sich verschiedene Stadien der wissenschaftlichen Wahrnehmung, zum Teil mit Erfolgen und zum Teil mit Irrwegen aufgezeigt. Während die akute Prostatitis fast immer einer akuten Infektion entspricht, finden sich beim chronischen Prostatitissyndrom nur in etwa 10% der Fälle ursächliche Erreger. Das Erregerspektrum entspricht im Wesentlichen dem von komplizierten Harnwegsinfektionen mit vornehmlich Gram-negativen Erregern. In manchen Studien werden aber auch atypische Erreger, wie Chlamydia trachomatis und Mykoplasmen gefunden. Bei der überwiegenden Mehrzahl der Fälle werden multifaktorielle Ursachen angenommen. Dies führte schließlich zur Phänotypisierung der Beschwerdesymptomatik mit multimodalen Therapiekonzepten. Bei eindeutig infektiöser (Mit-)Ursache der Beschwerden haben Antibiotika – allen voran Fluorchinolone – nach wie vor einen hohen Stellenwert. Ansonsten erfolgen multimodale Therapiestrategien, die auf Evidenz-basierten monotherapeutischen Studien aufbauen. Bisher liegen nur wenige Studien zu multimodalen Kombinationstherapien vor.

Abstract

The prostatitis syndrome is a frequent and complex disease. During the last 40 years the scientific perception has shifted between sometimes success and sometimes disappointment. Whereas acute prostatitis is most frequently considered an infectious disease, in only about 10% of cases with a chronic prostatitis syndrome can pathogens be identified. The bacterial spectrum is similar to that of complicated urinary tract infections with mainly Gram-negative pathogens. In some studies atypical pathogens, such as Chlamydia trachomatis and mycoplasmas, can be found in a considerable proportion. In most cases, however, a multifactorial aetiology is discussed. This has lead to a phenotyping directed multimodal treatment approach, considering the main symptoms. In prostatitis of microbial origin antibiotics, particulary fluorquinolones, are still the therapy of first choice. In the other cases multimodal treatment strategies are used considering evidence-based monotherapeutic studies. The evidence for multimodal combination treatment is still sparse.

Schlüsselwörter

Prostatitis - Prostatitissyndrom - Beckenschmerzsyndrom - Phänotypisierung - Antibiotikatherapie

Key words

prostatitis - prostatitis syndrome - chronic pelvic pain ­syndrome - phenotyping, antibiotic therapy

• Literatur

• 1 Schaeffer AJ, Anderson RU, Krieger JN et al. Consensus statement on prostatitis. The assessment and management of male pelvic pain syndrome, including prostatitis. In: Edition MLUTD. Hrsg 6^th International Conference on New Developments in Prostate Cancer and Prostate Diseases. Paris: Health Publications; 2006: 343-375
• 2 Wagenlehner FM, Naber KG, Bschleipfer T et al. Prostatitis and male pelvic pain syndrome: diagnosis and treatment. Dtsch Arztebl Int 2009; 106: 175-183
• 3 Snow DC, Shoskes DA. Pharmacotherapy of prostatitis. Expert Opin Pharmacother 2010; 11: 2319-2330
• 4 Vahlensieck W. Neue Aspekte der Prostatitis – Teil 1: Pathophysiologie und Diagnostik. Vita 2004; 5: 6-8
• 5 Ludwig M. Prostatitissyndrom und Vesikulitis. In: Facharztwissen Urologie. Differenzierte Diagnostik und Therapie. Schmelz U, Sparwasser C, Weidner W. Hrsg Springer; Heidelberg: 3. Auflage in press
• 6 Grabe M, Bjerklund-Johansen TE, Botto H et al. Guidelines on urological infections. European Association of Urology 2012;
• 7 Nickel JC, Shoskes D, Wang Y et al. How does the pre-massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome?. J Urol 2006; 176: 119-124
• 8 Ludwig M, Schroeder-Printzen I, Lüdecke G et al. Comparison of expressed prostatic secretions with urine after prostatic massage – a means to diagnose chronic prostatitis/inflammatory chronic pelvic pain syndrome. Urology 2000; 55: 175-177
• 9 Kulchavenya E, Azizoff A, Brizhatyuk E et al. Improved diagnostics of chronic inflammatory prostatitis. Minerva Urol Nefrol 2012; 64: 273-278
• 10 Ludwig M, von Keitz A. Zielgerichtete Diagnostik und Therapie des Prostatitissyndroms. Urol Urogynäkol 2011; 18: 11-15
• 11 Hochreiter W, Ludwig M, Weidner W et al. National Institutes of Health (NIH)-Chronic Prostatitis Symptom Index. Urologe. 2001. 40. 16-17
• 12 Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol 1968; 5: 492-518
• 13 Drach GW. Prostatitis: Man’s hidden infection. Urol Clin North Am 1975; 2: 499-520
• 14 Wagenlehner FME, Naber KG, Weidner W. Prostatitis – gestern und heute. Chemother J 2011; 20: 200-203
• 15 Krieger JN, Nyberg Jr L, Nickel JC. NIH consensus definition and classification of prostatitis. Jama 1999; 282: 236-237
• 16 Vahlensieck W. Neue Aspekte der Prostatitis – Teil 2: Klassifikation und Therapie. Vita 2004; 7/8: 18-20
• 17 Shoskes DA, Nickel JC, Dolinga R et al. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009; 73: 538-542 discussion 542–543
• 18 Shoskes DA, Nickel JC, Rackley RR et al. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis 2009; 12: 177-183
• 19 Magri V, Wagenlehner F, Perletti G et al. Use of the UPOINT chronic prostatitis/chronic pelvic pain syndrome classification in European patient cohorts: sexual function domain improves correlations. J Urol 2010; 184: 2339-2345
• 20 Barza M. Anatomical barriers for antimicrobial agents. Eur J Clin Microbiol Infect Dis 1993; 12: S31-S35
• 21 Perletti G, Wagenlehner FM, Naber KG et al. Enhanced distribution of fourth-generation fluoroquinolones in prostatic tissue. Int J Antimicrob Agents 2009; 33: 206-210
• 22 Naber K. Antibiotic treatment of chronic bacterial prostatitis. In: Nickel J. Hrsg. Textbook of prostatitis. Oxford: ISIS medical media Ltd; 1999: 285-292
• 23 Naber KG, Kinzig M, Sorgel F et al. Penetration of ofloxacin into prostatic fluid, ejaculate and seminal fluid. Infection 1993; 21: 98-100
• 24 Naber KG, Sorgel F, Kinzig M et al. Penetration of ciprofloxacin into prostatic fluid, ejaculate and seminal fluid in volunteers after an oral dose of 750 mg. J Urol 1993; 150: 1718-1721
• 25 Naber CK, Steghafner M, Kinzig-Schippers M et al. Concentrations of gatifloxacin in plasma and urine and penetration into prostatic and seminal fluid, ejaculate, and sperm cells after single oral administrations of 400 milligrams to volunteers. Antimicrob Agents Chemother 2001; 45: 293-297
• 26 Bulitta JB, Kinzig M, Naber CK et al. Population pharmacokinetics and penetration into prostatic, seminal, and vaginal fluid for ciprofloxacin, levofloxacin, and their combination. Chemotherapy 2011; 57: 402-416
• 27 Naber KG, Roscher K, Botto H et al. Oral levofloxacin 500 mg once daily in the treatment of chronic bacterial prostatitis. Int J Antimicrob Agents 2008; 32: 145-153
• 28 Wagenlehner F, Roscher K, Naber KG. Praxisdaten zur Behandlung der chronischen bakteriellen Prostatitis mit Levofloxacin. Aktuel Urol 2011; 42: 184-189
• 29 Weidner W, Schiefer HG, Krauss H et al. Chronic prostatitis: a thorough search for etiologically involved microorganisms in 1,461 patients. Infection 1991; 19: S119-S125
• 30 Skerk V, Markovinovic L, Zekan S et al. The significance of Chlamydia trachomatis in urethritis and prostatitis – differences in therapeutic approach – Croatian experience. J Chemother 2009; 21: 63-67
• 31 Barbalias GA, Nikiforidis G, Liatsikos EN. α-Blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol 1998; 159: 883-887
• 32 Magri V, Trinchieri A, Pozzi G et al. Efficacy of repeated cycles of combination therapy for the eradication of infecting organisms in chronic bacterial prostatitis. Intern J Antimicrob Agents 2007; 29: 549-556
• 33 Wagenlehner FM, Schneider H, Ludwig M et al. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol 2009; 56: 544-551
• 34 Cohen JM, Fagin AP, Hariton E et al. Therapeutic intervention for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a systematic review and metaanalysis 2012; PLos ONE 7/8:e41941
• 35 Thakkinstian A, Attia J, Anothaisintawee T et al. α-blockers, antibiotics and anti-inflammatories have a role in the management of chronic prostatitis/chronic pelvic pain syndrome. BJU intern 2012; 110: 1014-1022
• 36 Bach D, Vahlensieck Jr W. Urologische Erkrankungen. In: Lehrbuch Naturheilverfahren. Kraft K, Stange R. Hrsg Hippokrates Stuttgart. 2010: 673-684
• 37 Vahlensieck W. Neue Aspekte der Prostatitis – Teil 3: Stationäre Rehabilitation. Vita 2004; 9: 10-12
• 38 Costigan M, Scholz J, Woolf CJ. Neuropathic pain: a maladaptive response of the nervous system to damage. Annu Rev Neurosci 2009; 32: 1-32
• 39 Allsop SA, Erstad DJ, Brook K et al. The DABBEC Phenotyping System: towards a mechanistic understanding of CP/CPPS. Nat Rev Urol 2011; 8: 107-113
• 40 Litwin SM, McNaughton-Collins M, Fowler Jr FJ et al. The National Institutes of Health Chronic Prostatitis Symptom Index: Development and validation of a new outcome measure. J Urol 1999; 162: 369-375
• 41 Brähler E, Kupfer J, Ludwig M et al. Untersuchungen zur Symptomatik der Prostatitis in Deutschland. Der Giessener Prostatitissymptomscore. Urologe A 2001; 40: 12-15
• 42 Krieger JN, Egan KJ, Ross SO et al. Chronic pelvic pains represent the most prominent urogenital symptoms of “chronic prostatitis”. Urology. 1996; 48: 715-721 discussion 721–722
• 43 Nickel JC, Sorensen R. Transurethral microwave thermotherapy for nonbacterial prostatitis: a randomized double-blind sham controlled study using new prostatitis specific assessment questionnaires. J Urol 1996; 155: 1950-1954 discussion 1954–1955
• 44 Barry MJ, Fowler Jr FJ, O‘Leary MP et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992; 148: 1549-1557 discussion 1564
• 45 Nickel JC, Downey J, Young I et al. Asymptomatic inflammation and/or infection in benign prostatic hyperplasia. BJU Int 1999; 84: 976-981
• 46 Nelson WG, De Marzo AM, DeWeese TL et al. The role of inflamma­tion in the pathogenesis of prostate cancer. J Urol. 2004; 172: S6-S11; discussion S11–S12