Chronic prostatitis/chronic pelvic pain syndrome
Chronic nonbacterial prostatitis, also known as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), is long term pelvic pain and symptoms with urination without evidence of a bacterial infection. It affects about 2 to 6% of men.
|Chronic nonbacterial prostatitis|
|Other names||Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), prostatodynia, painful prostate|
|Differential diagnosis||Bacterial prostatitis, benign prostatic hypertrophy, overactive bladder, cancer|
The cause is unknown. Diagnosis involves ruling out other potential causes of the symptoms such as bacterial prostatitis, benign prostatic hypertrophy, overactive bladder, and cancer. CP/CPPS and interstitial cystitis are sometimes referred to jointly as "UCPPS" (urologic chronic pelvic pain syndrome).
Recommended treatments include multimodal therapy, physiotherapy, and a trial of alpha blocker medication or antibiotics in certain newly diagnosed cases. Tentative evidence supports some non medication based treatments.
Signs and symptoms
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by pelvic or perineal pain without evidence of urinary tract infection, lasting longer than 3 months, as the key symptom. Symptoms may wax and wane. Pain can range from mild to debilitating. Pain may radiate to the back and rectum, making sitting uncomfortable. Pain can be present in the perineum, testicles, tip of penis, pubic or bladder area. Dysuria, arthralgia, myalgia, unexplained fatigue, abdominal pain, constant burning pain in the penis, and frequency may all be present. Frequent urination and increased urgency may suggest interstitial cystitis (inflammation centred in bladder rather than prostate). Post-ejaculatory pain, mediated by nerves and muscles, is a hallmark of the condition, and serves to distinguish CP/CPPS patients from men with BPH or normal men. Some patients report low libido, sexual dysfunction and erectile difficulties.
Pelvic floor dysfunction
One theory is that CP/CPPS is a psychoneuromuscular (psychological, neurological, and muscular) disorder. The theory proposes that anxiety or stress results in chronic, unconscious contraction of the pelvic floor muscles, leading to the formation of trigger points and pain. The pain results in further anxiety and thus worsening of the condition.
Nerves, stress and hormones
A 2016 review suggested that although the peripheral nervous system is responsible for starting the condition, the central nervous system (CNS) is responsible for continuing the pain even without continuing input from the peripheral nerves.
Overlap with BPS/IC
Some researchers have suggested that CPPS is a form of bladder pain syndrome/interstitial cystitis (BPS/IC). In 2007 the NIDDK began to group IC/PBS and CP/CPPS under the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS). Therapies shown to be effective in treating IC/PBS, such as quercetin, have also shown some efficacy in CP/CPPS. Recent research has focused on genomic and proteomic aspects of the related conditions.
There are no definitive diagnostic tests for CP/CPPS. It is a poorly understood disorder, even though it accounts for 90–95% of prostatitis diagnoses. CP/CPPS may be inflammatory (Category Ⅲa) or non-inflammatory (Category Ⅲb), based on levels of pus cells in expressed prostatic secretions (EPS), but these subcategories are of limited use clinically. In the inflammatory form, urine, semen, and other fluids from the prostate contain pus cells (dead white blood cells or WBCs), whereas in the non-inflammatory form no pus cells are present. Recent studies have questioned the distinction between categories Ⅲa and Ⅲb, since both categories show evidence of inflammation if pus cells are ignored and other more subtle signs of inflammation, like cytokines, are measured.
In 2006, Chinese researchers found that men with categories Ⅲa and Ⅲb both had significantly and similarly raised levels of anti-inflammatory cytokine TGFβ1 and pro-inflammatory cytokine IFN-γ in their EPS when compared with controls; therefore measurement of these cytokines could be used to diagnose category Ⅲ prostatitis. A 2010 study found that nerve growth factor could also be used as a biomarker of the condition.
For CP/CPPS patients, analysis of urine and expressed prostatic secretions for leukocytes is debatable, especially due to the fact that the differentiation between patients with inflammatory and non-inflammatory subgroups of CP/CPPS is not useful. Serum PSA tests, routine imaging of the prostate, and tests for Chlamydia trachomatis and Ureaplasma provide no benefit for the patient.
Extraprostatic abdominal/pelvic tenderness is present in >50% of patients with chronic pelvic pain syndrome but only 7% of controls. Healthy men have slightly more bacteria in their semen than men with CPPS. The high prevalence of WBCs and positive bacterial cultures in the asymptomatic control population raises questions about the clinical usefulness of the standard 4-glass test as a diagnostic tool in men with CP/CPPS. By 2000, the use of the four-glass test by American urologists was rare, with only 4% using it regularly.
Experimental tests that could be useful in the future include tests to measure semen and prostate fluid cytokine levels. Various studies have shown increases in markers for inflammation such as elevated levels of cytokines, myeloperoxidase, and chemokines.
Some conditions have similar symptoms to chronic prostatitis: bladder neck hypertrophy and urethral stricture may both cause similar symptoms through urinary reflux (inter alia) and can be excluded through flexible cystoscopy and urodynamic tests.
A distinction is sometimes made between "IIIa" (Inflammatory) and "IIIb" (Noninflammatory) forms of CP/CPPS, depending on whether pus cells (WBCs) can be found in the expressed prostatic secretions (EPS) of the patient. Some researchers have questioned the usefulness of this categorisation, calling for the Meares–Stamey four-glass test to be abandoned.
In 2007, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) began using the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS), for research purposes, to refer to pain syndromes associated with the bladder (i.e. interstitial cystitis/painful bladder syndrome, IC/PBS) and the prostate gland (i.e. chronic prostatitis/chronic pelvic pain syndrome, CP/CPPS).
Older terms for this condition are "prostatodynia" (prostate pain) and non-bacterial chronic prostatitis.
- Urinary symptoms
- Psychological dysfunction
- Organ-specific symptoms
- Infectious causes
- Neurologic dysfunction
- Tenderness of the pelvic floor muscles
The UPOINT system allows for individualized and multimodal therapy.
Some protocols focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points) including digital intrarectal massage, physical therapy to the area and progressive relaxation therapy to reduce causative stress. A device, that is typically placed in the rectum, has also been created for use together with relaxation. This process has been called the Stanford protocol or the Wise-Anderson protocol. The American Urological Association in 2014 listed manual physical therapy as a second line treatment. Kegel exercises are not recommended. Treatment may also include a program of "paradoxical relaxation" to prevent chronic tensing of the pelvic musculature.
- Treatment with antibiotics is controversial. Some have found benefits in symptoms, while others have questioned the utility of a trial of antibiotics. Antibiotics are known to have anti-inflammatory properties and this has been suggested as an explanation for their partial efficacy in treating CPPS. Antibiotics such as fluoroquinolones, tetracyclines and macrolides have direct anti-inflammatory properties in the absence of infection, blocking inflammatory chemical signals (cytokines) such as interleukin-1 (IL-1), interleukin-8 and tumor necrosis factor (TNF), which coincidentally are the same cytokines found to be elevated in the semen and EPS of men with chronic prostatitis. The UPOINT diagnostic approach suggests that antibiotics are not recommended unless there is clear evidence of infection.
- The effectiveness of alpha blockers (tamsulosin, alfuzosin) is questionable in men with CPPS. A 2006 meta-analysis found that they are moderately beneficial when the duration of therapy was at least 3 months.
- An estrogen reabsorption inhibitor such as mepartricin improves voiding, reduces urological pain and improves quality of life in patients with chronic non-bacterial prostatitis.
- Therapies that have not been properly evaluated in clinical trials although there is supportive anecdotal evidence include gabapentin, benzodiazepines and amitriptyline.
Transurethral needle ablation of the prostate has been shown to be ineffective in trials.
In the general population chronic pelvic pain syndrome occurs in about 0.5% in a given year. It is found in men of any age, with the peak incidence in men aged 35–45 years. However, the overall prevalence of symptoms suggestive of CP/CPPS is 6.3%. The role of the prostate was questioned in the cause of CP/CPPS when both men and women in the general population were tested using the (1) National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) —with the female homologue of each male anatomical term used on questionnaires for female participants— (2) the International Prostate Symptom Score (IPSS), and (3) additional questions on pelvic pain. The prevalence of symptoms suggestive of CPPS in this selected population was 5.7% in women and 2.7% in men, placing in doubt the role of the prostate gland. New evidence from 2008 suggests that the prevalence of CP/CPPS is much higher in teenage males than once suspected.
In recent years, the prognosis for CP/CPPS has improved with the advent of multimodal treatment, phytotherapy, protocols aimed at quieting the pelvic nerves through myofascial trigger point release, anxiety control and chronic pain therapy.
In a preliminary 2005 open label study of 16 treatment-recalcitrant CPPS patients, controversial entities known as nanobacteria were proposed as a cause of prostatic calcifications found in some CPPS patients. Patients were given EDTA (to dissolve the calcifications) and 3 months of tetracycline (a calcium-leaching antibiotic with anti-inflammatory effects, used here to kill the "pathogens"), and half had significant improvement in symptoms. Scientists have expressed strong doubts about whether nanobacteria are living organisms, and research in 2008 showed that "nanobacteria" are merely tiny lumps of abiotic limestone.
The evidence supporting a viral cause of prostatitis and chronic pelvic pain syndrome is weak. Single case reports have implicated herpes simplex virus (HSV) and cytomegalovirus (CMV), but a study using PCR failed to demonstrate the presence of viral DNA in patients with chronic pelvic pain syndrome undergoing radical prostatectomy for localized prostate cancer. The reports implicating CMV must be interpreted with caution, because in all cases the patients were immunocompromised. For HSV, the evidence is weaker still, and there is only one reported case, and the causative role of the virus was not proven, and there are no reports of successful treatments using antiviral drugs such as aciclovir.
Due to the concomitant presence of bladder disorders, gastrointestinal disorders and mood disorders, research has been conducted to understand whether CP/CPPS might be caused by problems with the hypothetical bladder-gut-brain axis.
Research has been conducted to understand how chronic bladder pain affects the brain, using techniques like MRI and functional MRI; as of 2016, it appeared that people with CP/CPPS have increased grey matter in the primary somatosensory cortex, the insular cortex and the anterior cingulate cortex and in the central nucleus of the amygdala; studies in rodents have shown that blocking the metabotropic glutamate receptor 5, which is expressed in the central nucleus of the amygdala, can block bladder pain.
As of 2018 use of extracorporeal shockwave therapy had been studied as a potential treatment for this condition in three small studies; there were short term improvements in symptoms and few adverse effects, but the medium terms results are unknown, and the results are difficult to generalize due to low quality of the studies.
Society and culture
Notable cases have included:
- John Anderson – Deputy Prime Minister of Australia
- James Boswell – author of Life of Samuel Johnson
- John Cleese – British actor
- Vincent Gallo – movie director
- Glenn Gould – pianist
- John F. Kennedy – President of the United States of America
- Tim Parks – British novelist, translator and author.
- Howard Stern – radio personality
- William Styron – author (Sophie's Choice)
- Franco, JVA (14 May 2018). "Intervention for treating chronic prostatitis and chronic pelvic pain in men". The Cochrane Database of Systematic Reviews. 5: CD012551. doi:10.1002/14651858.CD012551.pub3. PMC 6494451. PMID 29757454. Retrieved 11 March 2019.
- Doiron, RC; Nickel, JC (June 2018). "Evaluation of the male with chronic prostatitis/chronic pelvic pain syndrome". Canadian Urological Association Journal. 12 (6 Suppl 3): S152–S154. doi:10.5489/cuaj.5322. PMC 6040610. PMID 29875039.
- Doiron, RC; Nickel, JC (June 2018). "Management of chronic prostatitis/chronic pelvic pain syndrome". Canadian Urological Association Journal. 12 (6 Suppl 3): S161–S163. doi:10.5489/cuaj.5325. PMC 6040620. PMID 29875042.
- Holt JD, Garrett WA, McCurry TK, Teichman JM (2016). "Common Questions About Chronic Prostatitis". Am Fam Physician. 93 (4): 290–6. PMID 26926816.
- Ferri, Fred F. (2018). Ferri's Clinical Advisor 2019 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 1149. ISBN 9780323550765.
- Franco, JV; Turk, T; Jung, JH; Xiao, YT; Iakhno, S; Garrote, V; Vietto, V (12 May 2018). "Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome". The Cochrane Database of Systematic Reviews. 5: CD012551. doi:10.1002/14651858.CD012551.pub3. PMC 6494451. PMID 29757454.
- Schaeffer AJ (2007). "Epidemiology and evaluation of chronic pelvic pain syndrome in men". Int J Antimicrob Agents. 31: S108–11. doi:10.1016/j.ijantimicag.2007.08.027. PMID 18164597.
- Luzzi GA (2002). "Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management". Journal of the European Academy of Dermatology and Venereology. 16 (3): 253–6. doi:10.1046/j.1468-3083.2002.00481.x. PMID 12195565.
- Clemens, J Quentin; Meenan, Richard T; O'Keeffe Rosetti, Maureen C; Gao, Sara Y; Calhoun, Elizabeth A (Dec 2005). "Incidence and clinical characteristics of National Institutes of Health type III prostatitis in the community". J Urol. 174 (6): 2319–22. doi:10.1097/01.ju.0000182152.28519.e7. PMID 16280832.
- Shoskes DA, Landis JR, Wang Y, Nickel JC, Zeitlin SI, Nadler R (August 2004). "Impact of post-ejaculatory pain in men with category III chronic prostatitis/chronic pelvic pain syndrome". J. Urol. 172 (2): 542–7. doi:10.1097/01.ju.0000132798.48067.23. PMID 15247725.
- Anderson, RU; Wise, D; Nathanson, NH (October 2018). "Chronic Prostatitis and/or Chronic Pelvic Pain as a Psychoneuromuscular Disorder--A Meta-analysis". Urology. 120: 23–29. doi:10.1016/j.urology.2018.07.022. PMID 30056195.
- Pontari MA, Ruggieri MR (May 2008). "Mechanisms in prostatitis/chronic pelvic pain syndrome". J. Urol. 179 (5 Suppl): S61–7. doi:10.1016/j.juro.2008.03.139. PMC 3591463. PMID 18405756.
- Sadler, KE; Kolber, BJ (July 2016). "Urine Trouble: Alterations in Brain Function Associated with Bladder Pain". The Journal of Urology. 196 (1): 24–32. doi:10.1016/j.juro.2015.10.198. PMC 4914416. PMID 26905019.
- Theoharides TC, Cochrane DE (2004). "Critical role of mast cells in inflammatory diseases and the effect of acute stress". J. Neuroimmunol. 146 (1–2): 1–12. doi:10.1016/j.jneuroim.2003.10.041. PMID 14698841.
- Theoharides TC, Kalogeromitros D (2006). "The critical role of mast cells in allergy and inflammation". Ann. N. Y. Acad. Sci. 1088 (1): 78–99. Bibcode:2006NYASA1088...78T. doi:10.1196/annals.1366.025. PMID 17192558.
- Sant GR, Kempuraj D, Marchand JE, Theoharides TC (2007). "The mast cell in interstitial cystitis: role in pathophysiology and pathogenesis". Urology. 69 (4 Suppl): 34–40. CiteSeerX 10.1.1.383.9862. doi:10.1016/j.urology.2006.08.1109. PMID 17462477.
- Lee JC; Muller CH; Rothman I; et al. (February 2003). "Prostate biopsy culture findings of men with chronic pelvic pain syndrome do not differ from those of healthy controls". J. Urol. 169 (2): 584–7, discussion 587–8. CiteSeerX 10.1.1.605.5540. doi:10.1016/s0022-5347(05)63958-4. PMID 12544312.
- Schaeffer AJ (2003). "Editorial: Emerging concepts in the management of prostatitis/chronic pelvic pain syndrome". J. Urol. 169 (2): 597–598. doi:10.1016/S0022-5347(05)63961-4. PMID 12544315.
- Theoharides, TC.; Whitmore, K.; Stanford, E.; Moldwin, R.; O'Leary, MP. (Dec 2008). "Interstitial cystitis: bladder pain and beyond". Expert Opin Pharmacother. 9 (17): 2979–94. CiteSeerX 10.1.1.470.7817. doi:10.1517/14656560802519845. PMID 19006474.
- Murphy, AB.; Macejko, A.; Taylor, A.; Nadler, RB. (2009). "Chronic prostatitis: management strategies". Drugs. 69 (1): 71–84. doi:10.2165/00003495-200969010-00005. PMID 19192937.
- Dimitrakov, J.; Dimitrakova, E. (2009). "Urologic chronic pelvic pain syndrome—looking back and looking forward". Folia Med (Plovdiv). 51 (3): 42–4. PMID 19957562.
- Rourke W, Khan SA, Ahmed K, Masood S, Dasgupta P, Khan MS (June 2014). "Painful bladder syndrome/interstitial cystitis: aetiology, evaluation and management". Arch Ital Urol Androl. 86 (2): 126–31. doi:10.4081/aiua.2014.2.126. PMID 25017594.
- Habermacher GM, Chason JT, Schaeffer AJ (2006). "Prostatitis/chronic pelvic pain syndrome". Annu. Rev. Med. 57: 195–206. doi:10.1146/annurev.med.57.011205.135654. PMID 16409145.
- A Pontari, M. (Dec 2002). "Inflammation and anti-inflammatory therapy in chronic prostatitis". Urology. 60 (6 Suppl): 29–33, discussion 33–4. CiteSeerX 10.1.1.383.9485. doi:10.1016/S0090-4295(02)02381-6. PMID 12521589.
- Ding XG, Li SW, Zheng XM, Hu LQ (2006). "[IFN-gamma and TGF-beta1, levels in the EPS of patients with chronic abacterial prostatitis]". Zhonghua Nan Ke Xue (in Chinese). 12 (11): 982–4. PMID 17146921.
- Watanabe, T.; Inoue, M.; Sasaki, K.; Araki, M.; Uehara, S.; Monden, K.; Saika, T.; Nasu, Y.; Kumon, H.; Chancellor, Michael B. (Sep 2010). "Nerve growth factor level in the prostatic fluid of patients with chronic prostatitis/chronic pelvic pain syndrome is correlated with symptom severity and response to treatment". BJU Int. 108 (2): 248–51. doi:10.1111/j.1464-410X.2010.09716.x. PMID 20883485.
- Weidner W, Anderson RU (2007). "Evaluation of acute and chronic bacterial prostatitis and diagnostic management of chronic prostatitis/chronic pelvic pain syndrome with special reference to infection/inflammation". Int J Antimicrob Agents. 31 (2): S91–5. doi:10.1016/j.ijantimicag.2007.07.044. PMID 18162376.
- Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S (2008). "Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study". J. Urol. 179 (2): 556–60. doi:10.1016/j.juro.2007.09.088. PMC 2664648. PMID 18082223.
- Nickel JC, Alexander RB, Schaeffer AJ, Landis JR, Knauss JS, Propert KJ (2003). "Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls". J. Urol. 170 (3): 818–22. doi:10.1097/01.ju.0000082252.49374.e9. PMID 12913707.
- McNaughton Collins, M.; Fowler, FJ.; Elliott, DB.; Albertsen, PC.; Barry, MJ. (Mar 2000). "Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?". Urology. 55 (3): 403–7. doi:10.1016/S0090-4295(99)00536-1. PMID 10699621.
- Leslie A Aaron; et al. (2001). "Comorbid Clinical Conditions in Chronic Fatigue: A Co-Twin Control Study". J Gen Intern Med. 16 (1): 24–31. doi:10.1111/j.1525-1497.2001.03419.x. PMC 1495162. PMID 11251747.
- Khadra, A.; Fletcher, P.; Luzzi, G.; Shattock, R.; Hay, P. (May 2006). "Interleukin-8 levels in seminal plasma in chronic prostatitis/chronic pelvic pain syndrome and nonspecific urethritis". BJU Int. 97 (5): 1043–6. doi:10.1111/j.1464-410X.2006.06133.x. PMID 16643489.
- He, L.; Wang, Y.; Long, Z.; Jiang, C. (Dec 2009). "Clinical Significance of IL-2, IL-10, and TNF-alpha in Prostatic Secretion of Patients With Chronic Prostatitis". Urology. 75 (3): 654–7. doi:10.1016/j.urology.2009.09.061. PMID 19963254.
- Pasqualotto, FF.; Sharma, RK.; Potts, JM.; Nelson, DR.; Thomas, AJ.; Agarwal, A. (Jun 2000). "Seminal oxidative stress in patients with chronic prostatitis". Urology. 55 (6): 881–5. doi:10.1016/S0090-4295(99)00613-5. PMID 10840100.
- Penna, G.; Mondaini, N.; Amuchastegui, S.; Degli Innocenti, S.; Carini, M.; Giubilei, G.; Fibbi, B.; Colli, E.; et al. (Feb 2007). "Seminal plasma cytokines and chemokines in prostate inflammation: interleukin 8 as a predictive biomarker in chronic prostatitis/chronic pelvic pain syndrome and benign prostatic hyperplasia". Eur Urol. 51 (2): 524–33, discussion 533. doi:10.1016/j.eururo.2006.07.016. hdl:2158/687725. PMID 16905241.
- Chiari R (1983). "Urethral obstruction and prostatitis". Int Urol Nephrol. 15 (3): 245–55. doi:10.1007/BF02083011. PMID 6654631.
- Hruz P, Danuser H, Studer UE, Hochreiter WW (2003). "Non-inflammatory chronic pelvic pain syndrome can be caused by bladder neck hypertrophy". Eur. Urol. 44 (1): 106–10, discussion 110. doi:10.1016/S0302-2838(03)00203-3. PMID 12814683.
- Romero Pérez P, Mira Llinares A (1996). "[Complications of the lower urinary tract secondary to urethral stenosis]". Actas Urol Esp (in Spanish). 20 (9): 786–93. PMID 9065088.
- "Prostatitis: Benign Prostate Disease: Merck Manual Professional". Retrieved 2010-04-17.
- "Treatment of Chronic Prostatitis". Nat Clin Pract Urol. 1 (1). 2004. Retrieved 2010-04-18.
- "Multi-disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network". NIDDK. 2007. Retrieved 2008-01-11.
- Shoskes DA, Nickel JC, Dolinga R, Prots D (2009). "Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity". Urology. 73 (3): 538–42, discussion 542–3. CiteSeerX 10.1.1.384.4216. doi:10.1016/j.urology.2008.09.074. PMID 19118880.
- Sandhu J, Tu HV (2017). "Recent advances in managing chronic prostatitis/chronic pelvic pain syndrome". F1000Res. 6: 1747. doi:10.12688/f1000research.10558.1. PMC 5615772. PMID 29034074.
- Potts, J; Payne, RE (May 2007). "Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key". Cleveland Clinic Journal of Medicine. 74 (Suppl 3): 63–71. doi:10.3949/ccjm.74.Suppl_3.S63. PMID 17549825.
- "Diagnosis and Treatment Interstitial Cystitis/Bladder Pain Syndrome". www.auanet.org. 2014. Retrieved 15 July 2018.
- McNeil, Donald G. (30 December 2013). "A Fix for Stress-Related Pelvic Pain". Retrieved 15 July 2018.
- Anothaisintawee, T; Attia, J; Nickel, JC; Thammakraisorn, S; Numthavaj, P; McEvoy, M; Thakkinstian, A (Jan 5, 2011). "Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis". JAMA: The Journal of the American Medical Association. 305 (1): 78–86. doi:10.1001/jama.2010.1913. PMID 21205969.
- Wagenlehner, FM.; Naber, KG.; Bschleipfer, T.; Brähler, E.; Weidner, W. (Mar 2009). "Prostatitis and male pelvic pain syndrome: diagnosis and treatment". Dtsch Arztebl Int. 106 (11): 175–83. doi:10.3238/arztebl.2009.0175. PMC 2695374. PMID 19568373.
- Shoskes DA (June 2001). "Use of antibiotics in chronic prostatitis syndromes". Can J Urol. 8 Suppl 1: 24–8. PMID 11442994.
- Zhu Y, Wang C, Pang X, Li F, Chen W, Tan W (May 2014). "Antibiotics are not beneficial in the management of category III prostatitis: a meta analysis". Urol J. 11 (2): 1377–85. PMID 24807747.
- Yang G, Wei Q, Li H, Yang Y, Zhang S, Dong Q (2006). "The effect of alpha-adrenergic antagonists in chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis of randomized controlled trials". J. Androl. 27 (6): 847–52. doi:10.2164/jandrol.106.000661. PMID 16870951.
...treatment duration should be long enough (more than 3 months)
- Cohen JM, Fagin AP, Hariton E, Niska JR, Pierce MW, Kuriyama A, Whelan JS, Jackson JL, Dimitrakoff JD (2012). "Therapeutic Intervention for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/ CPPS): A Systematic Review and Meta-Analysis". PLoS ONE. 7 (8): e41941. Bibcode:2012PLoSO...741941C. doi:10.1371/journal.pone.0041941. PMC 3411608. PMID 22870266.
- Curtis Nickel, J; Baranowski, AP; Pontari, M; Berger, RE; Tripp, DA (2007). "Management of Men Diagnosed With Chronic Prostatitis/Chronic Pelvic Pain Syndrome Who Have Failed Traditional Management". Reviews in Urology. 9 (2): 63–72. PMC 1892625. PMID 17592539.
- Leskinen, MJ.; Kilponen, A.; Lukkarinen, O.; Tammela, TL. (Aug 2002). "Transurethral needle ablation for the treatment of chronic pelvic pain syndrome (category III prostatitis): a randomized, sham-controlled study". Urology. 60 (2): 300–4. doi:10.1016/S0090-4295(02)01704-1. PMID 12137830.
- Taylor BC; Noorbaloochi S; McNaughton-Collins M; et al. (May 2008). "Excessive antibiotic use in men with prostatitis". Am. J. Med. 121 (5): 444–9. doi:10.1016/j.amjmed.2008.01.043. PMC 2409146. PMID 18456041.
- Daniel Shoskes (2008). Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Humana Press. p. 171. ISBN 978-1-934115-27-5.
- Daniels NA, Link CL, Barry MJ, McKinlay JB (May 2007). "Association between past urinary tract infections and current symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome". J Natl Med Assoc. 99 (5): 509–16. PMC 2576075. PMID 17534008.
- "NIH CPSI". www.ucpps.org. Retrieved 2009-11-10.
- Marszalek M, Wehrberger C, Temml C, Ponholzer A, Berger I, Madersbacher S (April 2008). "Chronic Pelvic Pain and Lower Urinary Tract Symptoms in Both Sexes: Analysis of 2749 Participants of an Urban Health Screening Project". Eur. Urol. 55 (2): 499–507. doi:10.1016/j.eururo.2008.03.073. PMID 18395963.
- Nickel, JC.; Tripp, DA.; Chuai, S.; Litwin, MS.; McNaughton-Collins, M.; Landis, JR.; Alexander, RB.; Schaeffer, AJ.; et al. (Jan 2008). "Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome". BJU Int. 101 (1): 59–64. doi:10.1111/j.1464-410X.2007.07196.x. PMID 17924985.
- Duclos, AJ.; Lee, CT.; Shoskes, DA. (Aug 2007). "Current treatment options in the management of chronic prostatitis". Ther Clin Risk Manag. 3 (4): 507–12. PMC 2374945. PMID 18472971.
- Shoskes, DA.; Katz, E. (Jul 2005). "Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome". Curr Urol Rep. 6 (4): 296–9. doi:10.1007/s11934-005-0027-0. PMID 15978233.
- Bergman, J.; Zeitlin, SI. (Mar 2007). "Prostatitis and chronic prostatitis/chronic pelvic pain syndrome". Expert Rev Neurother. 7 (3): 301–7. doi:10.1586/14737220.127.116.111. PMID 17341178.
- Shoskes DA, Thomas KD, Gomez E (2005). "Anti-nanobacterial therapy for men with chronic prostatitis/chronic pelvic pain syndrome and prostatic stones: preliminary experience". J. Urol. 173 (2): 474–7. doi:10.1097/01.ju.0000150062.60633.b2. PMID 15643213.
- Rempe S, Hayden JM, Robbins RA, Hoyt JC (December 2007). "Tetracyclines and pulmonary inflammation". Endocr Metab Immune Disord Drug Targets. 7 (4): 232–6. doi:10.2174/187153007782794344. PMID 18220943.
- Urbano P, Urbano F (2007). "Nanobacteria: facts or fancies?". PLOS Pathogens. 3 (5): e55. doi:10.1371/journal.ppat.0030055. PMC 1876495. PMID 17530922.
- Michael Hopkin (2008). "Nanobacteria theory takes a hit". Nature. doi:10.1038/news.2008.762. Retrieved 2008-04-29.
- Martel J, Young JD (April 2008). "Purported nanobacteria in human blood as calcium carbonate nanoparticles". Proc. Natl. Acad. Sci. U.S.A. 105 (14): 5549–54. Bibcode:2008PNAS..105.5549M. doi:10.1073/pnas.0711744105. PMC 2291092. PMID 18385376.
- Dhar NB, Shoskes DA (2007). "New therapies in chronic prostatitis". Curr Urol Rep. 8 (4): 313–8. doi:10.1007/s11934-007-0078-5. PMID 18519016.
- Capodice JL, Bemis DL, Buttyan R, Kaplan SA, Katz AE (2005). "Complementary and alternative medicine for chronic prostatitis/chronic pelvic pain syndrome". Evid Based Complement Alternat Med. 2 (4): 495–501. doi:10.1093/ecam/neh128. PMC 1297501. PMID 16322807.
- Herati AS, Moldwin RM (2013). "Alternative therapies in the management of chronic prostatitis/chronic pelvic pain syndrome". World J Urol. 31 (4): 761–6. doi:10.1007/s00345-013-1097-0. PMID 23740129.
- Leskinen MJ; Vainionp R; Syrjnen S; et al. (2003). "Herpes simplex virus, cytomegalovirus, and papillomavirus DNA are not found in patients with chronic pelvic pain syndrome undergoing radical prostatectomy for localized prostate cancer". Urology. 61 (2): 397–401. doi:10.1016/S0090-4295(02)02166-0. PMID 12597955.
- Benson PJ, Smith CS (1992). "Cytomegalovirus prostatitis". Urology. 40 (2): 165–7. doi:10.1016/0090-4295(92)90520-7. PMID 1323895.
- Mastroianni A, Coronado O, Manfredi R, Chiodo F, Scarani P (1996). "Acute cytomegalovirus prostatitis in AIDS". Genitourinary Medicine. 72 (6): 447–8. doi:10.1136/sti.72.6.447. PMC 1195741. PMID 9038649.
- McKay TC, Albala DM, Sendelbach K, Gattuso P (1994). "Cytomegalovirus prostatitis. Case report and review of the literature". International Urology and Nephrology. 26 (5): 535–40. doi:10.1007/bf02767655. PMID 7860201.
- Doble A, Harris JR, Taylor-Robinson D (1991). "Prostatodynia and herpes simplex virus infection". Urology. 38 (3): 247–8. doi:10.1016/S0090-4295(91)80355-B. PMID 1653479.
- Leue, C; Kruimel, J; Vrijens, D; Masclee, A; van Os, J; van Koeveringe, G (March 2017). "Functional urological disorders: a sensitized defence response in the bladder-gut-brain axis". Nature Reviews. Urology. 14 (3): 153–163. doi:10.1038/nrurol.2016.227. PMID 27922040.
- Franco, JV; Turk, T; Jung, JH; Xiao, YT; Iakhno, S; Garrote, V; Vietto, V (26 January 2018). "Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome". The Cochrane Database of Systematic Reviews. 1: CD012551. doi:10.1002/14651858.CD012551.pub2. PMC 6491290. PMID 29372565.
- "Anderson goes". Australian Broadcasting Corporation Transcript. 2005-06-23. Retrieved 2008-05-12.
- The Intimate Sex Lives of Famous People. Doubleday. 2008. ISBN 9781932595291. Retrieved 2010-12-21.
- Allison Reitz (July 2009). "John Cleese tour pays the 'Alimony' with West Coast comedy shows". tickenews.com. Archived from the original on 2009-07-28. Retrieved 2009-07-28.
The star of Monty Python and "A Fish Called Wanda" has been diagnosed with prostatitis, the inflammation of the prostate gland and is undergoing treatment.
- Roger Ebert. "The whole truth from Vincent Gallour Flies". Chicago Sun Times. Archived from the original on 2008-05-13. Retrieved 2008-05-30.
- "Glenn Gould as Patient". Archived from the original on 2008-06-07. Retrieved 2008-05-12.
- Dallek, Robert (2003). An Unfinished Life: John F. Kennedy 1917-1963. Boston: Little, Brown. pp. 123. ISBN 978-0-316-17238-7.
- Jeffries, Stuart (3 July 2010). "Teach Us to Sit Still: A Sceptic's Search for Health and Healing by Tim Parks". The Guardian. Retrieved 10 May 2019.
- Astier, Henri. "Prostatitis: 'How I meditated away chronic pelvic pain'". BBC. Retrieved 10 May 2019.
- "The Howard Stern Show for September 4, 2007". Howard Stern. Retrieved 2008-05-12.
- "The Howard Stern Show for September 5, 2007, PULLING OUT A PLUM". Howard Stern. Retrieved 2008-05-12.
- Leavitt, David (2008-05-11). "Styron's Choices". NY Times. Retrieved 2008-05-12.