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Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a pelvic pain condition in men, and should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and acute bacterial prostatitis. This condition is also known as chronic non-bacterial prostatitis.
The name of this disorder is evolving. 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).
Signs and symptomsEdit
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterised 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 discomfort to debilitating. Pain may radiate to back and rectum, making sitting difficult. 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.
The annual prevalence in the general population of chronic pelvic pain syndrome is 0.5%. 38% of primary care providers, when presented with a vignette of a man with CPPS, indicate that they have never seen such a patient. However, the overall prevalence of symptoms suggestive of CP/CPPS is 6.3%. The role of the prostate was questoned in the etiology 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 homolog of each male anatomical term use 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 suggests that the prevalence of CP/CPPS is much higher in teenage males than once suspected.
Theories of etiologyEdit
Nerves, stress and hormonesEdit
In 2008, a literature review for the years 1966 to 2003 was performed using the MEDLINE database of the United States National Library of Medicine, finding that the symptoms of CP/CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological and endocrine systems.
Theories behind the disease include stress-driven hypothalamic-pituitary-adrenal axis dysfunction and adrenocortical hormone (endocrine) abnormalities, neurogenic inflammation, and myofascial pain syndrome. In the latter two categories, dysregulation of the local nervous system due to past trauma, infection or an anxious disposition and chronic albeit unconscious pelvic tensing lead to inflammation that is mediated by substances released by nerve cells (such as substance P). The prostate (and other areas of the genitourinary tract: bladder, urethra, testicles) can become inflamed by the action of the chronically activated pelvic nerves on the mast cells at the end of the nerve pathways. Similar stress-induced genitourinary inflammation has been shown experimentally in other mammals. However, there is no correlation between inflammation on histological examination of the prostate and the National Institutes of Health Chronic Prostatitis Symptom Index.
The bacterial infection theory that for so long had held sway in this field was shown to be unimportant in a 2003 study from the University of Washington team led by Dr Lee and Professor Richard Berger. The study found that one third of both normal men and patients had equal counts of similar bacteria colonizing their prostates. This view was endorsed by Dr Anthony Schaeffer, Professor and Chairman of the Department of Urology at Northwestern University, in a 2003 editorial of The Journal of Urology, in which he stated that "...these data suggest that bacteria do not have a significant role in the development of the chronic pelvic pain syndrome", and a year later with his colleagues he published studies showing that antibiotics are essentially useless for CP/CPPS. Since the publication of these studies, the research focus has shifted from infection to neuromuscular, behavioral, psychological, and genetic etiologies for UCPPS (CP/CPPS and IC/PBS), where the interplay between the lower urinary tract and other physiological systems is stressed. UCPPS is now studied as a systemic disorder. In support of this approach, a 2005 study showed that stress is correlated to Cat III prostatitis.
Overlap with interstitial cystitis/painful bladder syndromeEdit
Some researchers have suggested that CPPS is a form of interstitial cystitis/painful bladder syndrome (IC/PBS). A large multicenter prospective randomized controlled study showed that Elmiron was slightly better than placebo in treating the symptoms of CPPS, however the primary endpoint did not reach statistical significance. Other therapies shown more effective than Elmiron in treating IC/PBS, such as quercetin and Elavil (amitriptyline), can help with chronic prostatitis. In 2007 the NIDDK began to group IC/PBS and CP/CPPS under the umbrella term Urologic Chronic Pelvic Pain Syndromes (UCPPS).
Additional theories and observations include:
- Nanobacteria — 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 calcification and symptoms found in CPPS. Patients were treated with 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. Research in 2008 showed that "nanobacteria" are merely tiny lumps of abiotic limestone. Confirmation of the clinical efficacy of the treatment awaits placebo controlled studies.
- Viruses — 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.
The ambient temperature appears to play a role as cold is frequently reported as causing symptom aggravation and heat is often reported to be ameliorating. It appears that cold is one of the factors that can trigger a process resulting in CP/CPPS. Cold also causes aggravation of symptoms and can initiate a relapse. A survey showed that the occurrence of prostatitis symptoms in men living in northern Finland —a cold climate—is higher than that reported in other parts of the world. This could be partly caused by the cold climate.
There are no definitive diagnostic tests for CP/CPPS. This is a poorly understood disorder, even though it accounts for 90%-95% of prostatitis diagnoses. It is found in men of any age, with the peak onset in the early 30s. 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.
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.
Normal 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. The use of the four-glass test by American urologists is now 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 cytoscopy and urodynamic tests.
A 2007 review article by Drs Potts and Payne in the Cleveland Clinic Journal of Medicine states:
"Indeed, chronic abacterial prostatitis (also known as chronic pelvic pain syndrome) is both the most prevalent form and also the least understood and the most challenging to evaluate and treat. This form of prostatitis may respond to non-prostate-centered treatment strategies such as physical therapy, myofascial trigger point release, and relaxation techniques."
Physical and psychological therapyEdit
Category III prostatitis may have no initial trigger other than anxiety, often with an element of OCD or other anxiety-spectrum problem. This is theorized to leave the pelvic area in a sensitized condition resulting in a loop of muscle tension and heightened neurological feedback (neural pain wind-up). Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress.
Aerobic exercise can help those sufferers who are not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms are not exacerbated by exercise. Acupuncture has reportedly benefited some patients.
For chronic nonbacterial prostatitis (Cat III), also known as CP/CPPS, which makes up the majority of men diagnosed with "prostatitis", a treatment called the "Wise-Anderson Protocol" (aka the "Stanford Protocol"), , has recently been published. This is a combination of:
- Medication (using tricyclic antidepressants and benzodiazepines)
- Psychological therapy (paradoxical relaxation, an advancement and adaptation, specifically for pelvic pain, of a type of progressive relaxation technique developed by Edmund Jacobson during the early 20th century)
- Physical therapy (trigger point release therapy on pelvic floor and abdominal muscles, and also yoga-type exercises with the aim of relaxing pelvic floor and abdominal muscles).
Anecdotal evidence suggests that food allergies and intolerances may have a role in exacerbating CP/CPPS, perhaps through mast cell mediated mechanisms. Specifically patients with gluten intolerance or celiac disease report severe symptom flares after sustained gluten ingestion. Patients may therefore find an elimination diet helpful in lessening symptoms by identifying problem foods. Studies are lacking in this area.
There is a substantial list of medications used to treat this disorder. Some of them are:
- Quercetin has shown effective in a randomized, placebo-controlled trial in chronic prostatitis using 500 mg twice a day for 4 weeks Subsequent studies showed that quercetin, a mast cell inhibitor, reduces inflammation and oxidative stress in the prostate.
- Pollen extract (Cernilton) has also been shown effective in randomized placebo controlled trials.
- At least one study suggests that multi-modal therapy (aimed at different pathways such as inflammation and neuromuscular dysfunction simultaneously) is better long term than monotherapy.
- Commonly used therapies that have not been properly evaluated in clinical trials although there is supportive anecdotal evidence gabapentin, benzodiazepines and amitriptyline.
Therapies shown to be ineffective by randomized placebo/sham controlled trials:
- Levaquin — antibiotics are generally not recommended. Any improvement on antibiotics is likely to be evanescent, and due to the anti-inflammatory effects of the antibiotic.
- Alpha blockers for 6 weeks or less. 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. However a 2004 trial found no benefit from alfuzosin during 6 weeks of treatment and a 2008 clinical trial of alfuzosin found it was no better than placebo for treating CPPS in treatment naive recently diagnosed men.
- Transurethral needle ablation of the prostate (TUNA)
Surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.
In recent years the prognosis for CP/CPPS has improved greatly with the advent of multimodal treatment, phytotherapy, protocols aimed at quieting the pelvic nerves through myofascial trigger point release and anxiety control, and chronic pain therapy.
Notable people who suffered from CP/CPPSEdit
- John Anderson — Deputy Prime Minister of Australia
- John Cleese — British actor
- Vincent Gallo — movie director
- Glenn Gould — pianist
- John F Kennedy — President of the United States of America
- Howard Stern — radio personality
- William Styron — author (Sophie's Choice)
- Interstitial cystitis/painful bladder syndrome — a related disease.
- Myofascial Pain Syndrome
- Myofascial Release
- Neuromuscular Therapy
- Trigger Points
- Pelvic myoneuropathy
- The Urologic Chronic Pelvic Pain Syndrome Society
- The Sex Destroyer — article from Best Life magazine gives a layman's overview of current developments
- Diagrams of the Pelvic Floor Muscles - pelvic musculature involved in causing CP/CPPS symptoms.
- Prostatitis at the Open Directory Project
- ↑ (2007). Multi-disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. NIDDK. URL accessed on 2008-01-11.
- ↑ Schaeffer AJ (2007). Epidemiology and evaluation of chronic pelvic pain syndrome in men. Int J Antimicrob Agents 31: 108.
- ↑ Luzzi GA (2002). Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management. Journal of the European Academy of Dermatology and Venereology : JEADV 16 (3): 253–6.
- ↑ 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.
- ↑ 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.
- ↑ Phillp Hannno. Defining The Urologic Chronic Pelvic Pain Syndromes: A New Beginning - An International Symposium. Urotoday. URL accessed on 2008-07-22.
- ↑ 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.
- ↑ NIH CPSI. www.ucpps.org. URL accessed on 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: 499.
- ↑ (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.
- ↑ Pontari MA, Ruggieri MR (May 2008). Mechanisms in prostatitis/chronic pelvic pain syndrome. J. Urol. 179 (5 Suppl): S61–7.
- ↑ Anderson RU, Orenberg EK, Chan CA, Morey A, Flores V (2008). Psychometric Profiles and Hypothalamic-Pituitary-Adrenal Axis Function in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Urol 179: 956.
- ↑ Dimitrakov J, Joffe HV, Soldin SJ, Bolus R, Buffington CA, Nickel JC (2008). Adrenocortical Hormone Abnormalities in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Urology 71 (2): 261–266.
- ↑ 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.
- ↑ Theoharides TC, Kalogeromitros D (2006). The critical role of mast cells in allergy and inflammation. Ann. N. Y. Acad. Sci. 1088: 78–99.
- ↑ 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.
- ↑ 17.0 17.1 17.2 Anderson RU, Wise D, Sawyer T, Chan C (2005). Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J. Urol. 174 (1): 155–60.
- ↑ 18.0 18.1 18.2 Anderson RU, Wise D, Sawyer T, Chan CA (2006). Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J. Urol. 176 (4 Pt 1): 1534–8; discussion 1538–9.
- ↑ Alexacos N, Pang X, Boucher W, Cochrane DE, Sant GR, Theoharides TC (1999). Neurotensin mediates rat bladder mast cell degranulation triggered by acute psychological stress. Urology 53 (5): 1035–40.
- ↑ Nickel JC, Roehrborn CG, O'leary MP, Bostwick DG, Somerville MC, Rittmaster RS (2007). Examination of the relationship between symptoms of prostatitis and histological inflammation: baseline data from the REDUCE chemoprevention trial. J. Urol. 178 (3 Pt 1): 896–900; discussion 900–1.
- ↑ 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.
- ↑ Schaeffer AJ (2003). Editorial: Emerging concepts in the management of prostatitis/chronic pelvic pain syndrome.. J Urol. 169 (2): 597.
- ↑ 23.0 23.1 Alexander RB, Propert KJ, Schaeffer AJ, et al. (2004). Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann. Intern. Med. 141 (8): 581–9.
- ↑ 24.0 24.1 Nickel JC, Downey J, Clark J, et al. (2003). Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial. Urology 62 (4): 614–7.
- ↑ 25.0 25.1 (2007). Multi-disciplinary Approach to the Study of Chronic Pelvic Pain. NIDDK - Department of Health and Human Services. URL accessed on 2008-02-12.
- ↑ Ullrich PM, Turner JA, Ciol M, Berger R (2005). Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine 30 (2): 112–8.
- ↑ Nickel JC, Forrest JB, Tomera K, et al. (April 2005). Pentosan polysulfate sodium therapy for men with chronic pelvic pain syndrome: a multicenter, randomized, placebo controlled study. J. Urol. 173 (4): 1252–5.
- ↑ 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.
- ↑ Rempe S, Hayden JM, Robbins RA, Hoyt JC (December 2007). Tetracyclines and pulmonary inflammation. Endocr Metab Immune Disord Drug Targets 7 (4): 232–6.
- ↑ Urbano P, Urbano F (2007). Nanobacteria: facts or fancies?. PLoS Pathogens 3 (5): e55.
- ↑ Urbano P, Urbano F (2007). Nanobacteria: Facts or Fancies?. PLoS Pathogens. URL accessed on 2008-01-15.
- ↑ Michael Hopkin (2008). Nanobacteria theory takes a hit. Nature. URL accessed on 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.
- ↑ 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.
- ↑ Benson PJ, Smith CS (1992). Cytomegalovirus prostatitis. Urology 40 (2): 165–7.
- ↑ Mastroianni A, Coronado O, Manfredi R, Chiodo F, Scarani P (1996). Acute cytomegalovirus prostatitis in AIDS. Genitourinary medicine 72 (6): 447–8.
- ↑ 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.
- ↑ Doble A, Harris JR, Taylor-Robinson D (1991). Prostatodynia and herpes simplex virus infection. Urology 38 (3): 247–8.
- ↑ Hedelin H, Jonsson K (2007). Chronic prostatitis/chronic pelvic pain syndrome: symptoms are aggravated by cold and become less distressing with age and time. Scand. J. Urol. Nephrol. 41 (6): 516–20.
- ↑ 40.0 40.1 Hedelin H, Jonsson K (2007). Chronic abacterial prostatitis and cold exposure: an explorative study. Scand. J. Urol. Nephrol. 41 (5): 430–5.
- ↑ Gao DJ, Guo YS, Yu HY, Wang YJ, Cui WG (December 2007). [Prevalence and related factors of prostatitis-like symptoms in young men]. Zhonghua Nan Ke Xue 13 (12): 1087–90.
- ↑ Mehik A, Hellström P, Lukkarinen O, Sarpola A, Järvelin M (September 2000). Epidemiology of prostatitis in Finnish men: a population-based cross-sectional study. BJU Int. 86 (4): 443–8.
- ↑ Habermacher GM, Chason JT, Schaeffer AJ (2006). Prostatitis/chronic pelvic pain syndrome. Annu. Rev. Med. 57: 195–206.
- ↑ (Dec 2002). Inflammation and anti-inflammatory therapy in chronic prostatitis.. Urology 60 (6 Suppl): 29-33; discussion 33-4.
- ↑ 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 12 (11): 982–4.
- ↑ 46.0 46.1 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: 91.
- ↑ 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.
- ↑ 48.0 48.1 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.
- ↑ (Mar 2000). Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?. Urology 55 (3): 403-7.
- ↑ Leslie A Aaron et al. (2001). Comorbid Clinical Conditions in Chronic Fatigue, A Co-Twin Control Study. J Gen Intern Med. 16 (1).
- ↑ (Dec 2009). Clinical Significance of IL-2, IL-10, and TNF-alpha in Prostatic Secretion of Patients With Chronic Prostatitis.. Urology.
- ↑ (Jun 2000). Seminal oxidative stress in patients with chronic prostatitis.. Urology 55 (6): 881-5.
- ↑ (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.
- ↑ (May 2006). Interleukin-8 levels in seminal plasma in chronic prostatitis/chronic pelvic pain syndrome and nonspecific urethritis.. BJU Int 97 (5): 1043-6.
- ↑ Chiari R (1983). Urethral obstruction and prostatitis. Int Urol Nephrol 15 (3): 245–55.
- ↑ 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.
- ↑ Romero Pérez P, Mira Llinares A (1996). [Complications of the lower urinary tract secondary to urethral stenosis]. Actas Urol Esp 20 (9): 786–93.
- ↑ 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): S63–71.
- ↑ Giubilei G, Mondaini N, Minervini A, et al. (2007). Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments--could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study. J. Urol. 177 (1): 159–65.
- ↑ Rosted P (2007). Chronic prostatitis/chronic pelvic pain syndrome and acupuncture - a case report. Acupunct Med 25 (4): 198–9.
- ↑ (2005). The Stanford Protocol. URL accessed on 2006-12-09.
- ↑ Cornel EB, van Haarst EP, Schaarsberg RW, Geels J (2005). The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III. Eur. Urol. 47 (5): 607–11.
- ↑ PMID 11113739 (PMID 11113739)
- ↑ PMID 9146624 (PMID 9146624)
- ↑ Prostatitis and Wheat. www.chronicprostatitis.com. URL accessed on 2009-11-05.
- ↑ (2006). Pharmacological treatment options for prostatitis/chronic pelvic pain syndrome. URL accessed on 2006-12-11.
- ↑ Shoskes DA, Zeitlin SI, Shahed A, Rajfer J (1999). Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology 54 (6): 960–3.
- ↑ Oxidative stress in prostatic fluid of patients with chronic pelvic pain syndrome: correlation with gram positive bacterial growth and treatment response.. J Androl 21 (5): 669-75.
- ↑ (Jul 2002). Cytokine polymorphisms in men with chronic prostatitis/chronic pelvic pain syndrome: association with diagnosis and treatment response.. J Urol 168 (1): 331-5.
- ↑ Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brähler E, Weidner W (June 2009). 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..
- ↑ Elist J (2006). Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized, double-blind, placebo-controlled study. Urology 67 (1): 60–3.
- ↑ Potts JM (2005). Therapeutic options for chronic prostatitis/chronic pelvic pain syndrome. Current urology reports 6 (4): 313–7.
- ↑ Management of Men Diagnosed With Chronic Prostatitis/Chronic Pelvic Pain Syndrome Who Have Failed Traditional Management. www.ncbi.nlm.nih.gov. URL accessed on 2009-12-13.
- ↑ Hua VN, Williams DH, Schaeffer AJ (2005). Role of bacteria in chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep 6 (4): 300–6.
- ↑ 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.
- ↑ Nickel JC, Krieger JN, McNaughton-Collins M, et al. (December 2008). Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome. N. Engl. J. Med. 359 (25): 2663–73.
- ↑ Nickel JC (2007). Treatment of chronic prostatitis/chronic pelvic pain syndrome. Int J Antimicrob Agents 31: 112.
- ↑ (Aug 2007). Current treatment options in the management of chronic prostatitis.. Ther Clin Risk Manag 3 (4): 507-12.
- ↑ Anderson goes. Australian Broadcasting Corporation Transcript. URL accessed on 2008-05-12.
- ↑ Allison Reitz (2009). John Cleese tour pays the 'Alimony' with West Coast comedy shows. tickenews.com. URL accessed on 2009-07-28.
- ↑ Roger Ebert. The whole truth from Vincent Gallour Flies. Chicago Sun Times. URL accessed on 2008-05-30.
- ↑ Glenn Gould as Patient. URL accessed on 2008-05-12.
- ↑ Dallek, Robert (2003). An Unfinished Life: John F. Kennedy 1917-1963, 123, Boston: Little, Brown.
- ↑ The Howard Stern Show for September 4, 2007. Howard Stern. URL accessed on 2008-05-12.
- ↑ The Howard Stern Show for September 5, 2007, PULLING OUT A PLUM. Howard Stern. URL accessed on 2008-05-12.
- ↑ Styron’s Choices. NY Times. URL accessed on 2008-05-12.
Diseases of the pelvis, genitals and breasts (N40-N99, 600-629)
|Diseases of male genital organs|
|Disorders of breast|
| Inflammatory diseases|
of female pelvic organs
| Noninflammatory disorders|
of female genital tract
Endometriosis (Adenomyosis) - Vaginal prolapse (Cystocele, Rectocele) - obstetric fistulae (Vesicovaginal fistula, Rectovaginal fistula) - Ovarian cyst - Endometrial polyp - Retroverted uterus - Hematometra - Leukorrhea - menstruation (Amenorrhoea, Oligomenorrhea, Menorrhagia, Menometrorrhagia, Metrorrhagia, Dysmenorrhea) - intercourse (Dyspareunia, Vaginismus) - Mittelschmerz
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