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Keywords:

  • prostatitis;
  • chronic pelvic pain syndrome;
  • prevalence;
  • Italy

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

OBJECTIVE

To report a prospective, multicentre descriptive study designed to determine the prevalence of the diagnosis of prostatitis in male outpatients examined by urologists in Italy, and to further examine the diagnostic evaluation and treatment of patients identified with a clinical diagnosis of prostatitis.

PATIENTS AND METHODS

Between July 2001 and October 2001, 70 urologists, representing a cross-section of urological centres in Italy, counted and recorded the overall total of men reported in the clinic and that of patients diagnosed with prostatitis over a 5-week period. Data on demographics, previous diagnoses, symptoms, physical examination, laboratory data and therapy instituted were collected. Patients with a diagnosis of prostatitis completed questionnaires on symptom frequency and severity, and quality of life.

RESULTS

In all, 8503 patients were included in the primary outcome analysis; 1148 were identified with prostatitis (12.8%; mean age 47.1 years, range 16–83) with all age ranges equally represented, and 68% had had their first symptom within the last year. The most common presenting symptoms were severe, bothersome urinary frequency, obstructive voiding symptoms, perineal, suprapubic and penile pain or discomfort. The self-administered questionnaire confirmed that the most frequently reported and most severe symptoms at the time of evaluation were irritative voiding symptoms, perineal and suprapubic pain and discomfort. Over three-quarters of the patients were dissatisfied with their quality of life. While 98% of the patients had a digital rectal examination and expressed prostatic secretion was successfully recovered in 44%, < 3% of the patients had the traditional Meares-Stamey four-glass test. The most common treatment prescribed was drug therapy (not antibiotic).

CONCLUSION

The prevalence of a clinical diagnosis of prostatitis in urology outpatient practice in Italy was 12.8%. The prevalence, diagnosis, evaluation and treatment of prostatitis reported in this prospective study was very similar to that reported in other retrospective series from other countries.


Abbreviations
CPPS

chronic pelvic pain syndrome

EPS

expressed prostatic secretion

NIH-CPSI

National Institutes of Health Chronic Prostatitis Symptom Index.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

It has been estimated that prostatitis-like symptoms range from 2%[1,2] to as high as 6–9%[3] in men in the community; 14% of men in Finland recollect a diagnosis of prostatitis during their lifetime [4]. Of almost 32 000 health professionals in the USA without prostate cancer, 16% self-reported a history of prostatitis [5]. Billing code data shows that a diagnosis of prostatitis accounts for 5.3% of office visits to urologists (8% of male office visits) [6,7], ranking as fourth among the 10 most common principal diagnoses rendered by urologists (the most common urological diagnosis in men aged < 50 years) [7]. The Olmsted County study of Urinary Symptoms in Health Status Among Men, a prospective cohort study of the natural history of prostatism, provided an opportunity to estimate the prevalence of medically diagnosed prostatitis in the community [8]. Reviewing the medical record documentation of 2115 participants (response rate 55%) the authors reported an 11% prevalence of a physician-based diagnosis of prostatitis.

These studies all have significant limitations; those examining the prevalence of prostatitis-like symptoms used symptom scores that were designed and validated for clinical trials and not epidemiological studies [9]. Retrospective studies that rely on patients’ recollection (of a difficult diagnosis), billing data (which is notoriously inaccurate) and physicians’ chart documentation (which can be incomplete) account for differences in prevalence among the various studies. To our knowledge, no prospective study examining the prevalence of prostatitis has been published to date. We undertook a prospective, multicentre, observational study designed to determine the prevalence of the diagnosis of prostatitis in male outpatients examined by urologists in Italy. We further sought to examine the evaluation, investigation and treatment of patients identified with a clinical diagnosis of prostatitis.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

The study was prospective and multicentre, undertaken by urologists throughout Italy, between July 2001 and October 2001. During this defined period the prevalence of each urologist's diagnosis of prostatitis was noted for a 5-week interval. Each participating urologist counted and recorded the overall total of male patients reporting to the clinic and that of patients diagnosed with prostatitis. Standardized case report forms were used to document demographic data, medical history (including a previous diagnosis of prostatitis), presenting symptoms, physical examination, laboratory/radiological investigations and immediate therapeutic plans in the patients identified with a diagnosis of prostatitis. The participating urologist administered a frequency, severity and quality-of-life questionnaire to the patients. The questionnaire rated various pain and voiding symptoms on a frequency scale of 0–5 (0 never, to 5 always) and severity on a score of 0–10 (0 minimal pain, 10 maximal pain) and the quality of life on a 7-point scale (1 unsatisfied, 7 very satisfied).

In all, 70 urologists participated in the study; the centres were divided into the following geographical areas: North (Vallae D’Aosta, Piedmont, Lombardy, Trentino-Alto Adige, Veneto, Friuli-Venezia Giulia, Liguria); Central (Emilia Romagna, Tuscany, Marche, Umbria, Latium, Abruzzi); South and Isles (Basilicata, Campania, Apulia, Calabria, Sicily, Sardinia).

All male patients presenting as outpatients to the participating urological centres were documented; those who were seen for a serious acute medical illness, which required immediate hospitalization, were excluded from the study. Based on the history, physical examination and laboratory testing, urologists categorized the patients with prostatitis as either acute bacterial or chronic bacterial prostatitis, chronic pelvic pain syndrome (CPPS) or suspected prostatitis, as given in the definitions in the Appendix.

ANALYSES

All case-report forms were sent to a central in-house biostatistics centre and immediately entered into a computer database. At the time of data entry each value was compared with a specific range of expected values for immediate detection of ‘implausible’ data. After the double entry of data computerized checks for consistency were used and data which failed were reviewed by a senior statistician. After validation the database was ‘frozen’ and only released for final statistical analyses. The primary outcome was the prevalence of the diagnosis of prostatitis in outpatients examined by urologists. Secondary outcomes were an evaluation of the history, diagnostic and therapeutic procedures in patients with a diagnosis of prostatitis.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

The 70 participating urologists examined a mean (sd) of 123 (73) male patients; in all, 8739 male patients were recorded, with 236 examined outside the defined period. Thus 8503 patients were included in the primary outcome population; 1148 patient data-cards of those identified with prostatitis were recorded. Seventy-four data-cards were excluded from the secondary endpoint analyses because of missing diagnosis or age, and therefore 1074 patients were included in the secondary outcome population.

Thus the prevalence of a urologist's diagnosis of prostatitis in the primary outcome population during the study period was 12.8%; Table 1 shows the distribution by geographical area. The mean (sd) age of the population was 47.1 (14) years; 23% of the men with prostatitis were < 35 years old, 23.5% were 35–45, 24.5% were 45–55 and 29.1% were > 55 years old.

Table 1.  The prevalence of prostatitis in Italy during the study period
Geographical areaNo. of patientsPrevalence, %
evaluatedwith prostatitis
Total8503108912.8
North3571 333 9.3
Central1175 23620.1
South & Isles3757 52013.8

For 68% of the men the first symptoms related to their diagnosis of prostatitis had occurred within the previous year; 38% were referred to the urologists with a diagnosis of prostatitis (16.7% by GPs and 21.3% by specialists). In these patients the diagnosis of prostatitis was based on the history and physical examination in 36.9%, some form of laboratory data in 53.4% and was unknown in 9.8%. The urological diagnoses or diseases present in > 5% of the men with prostatitis were; BPH (17.4%), recurrent UTI (11.2%), urinary calculi (11.1%), urethritis (9.5%), phimosis (7.4%), epididymo-orchitis (5.6%) and balanitis (5.3%). The concurrent diseases other than urological present in > 5% were diabetes (7.2%) and depression (6.8%). Table 2 outlines the presenting symptoms (described by patients and recorded by urologist) in the 1074 patients with a diagnosis of prostatitis.

Table 2.  Presenting symptoms (described by patients and recorded by urologists) in 1074 patients with prostatitis
SymptomN (%)
Frequency689 (64.2)
Obstructive voiding675 (62.8)
Perineal pain or discomfort630 (58.7)
Suprapubic pain or discomfort492 (45.8)
Penile pain or discomfort360 (33.5)
Premature ejaculation305 (28.4)
Malaise229 (21.3)
Urethral discharge220 (20.5)
Inguinal pain or discomfort216 (20.1)
Erectile dysfunction205 (19.1)
Haematospermia169 (15.7)
Voiding difficulties162 (15.1)
Fever159 (14.8)
Purulent urine150 (14.0)
Abnormal seminal fluid 97 (9.0)
Myalgia 64 (6.0)
Abnormal urine (mucus) 61 (5.7)
Haematuria 46 (4.3)

The data collected from those with prostatitis using a prostatitis-specific frequency/severity symptom questionnaire are presented in Table 3. Pain or discomfort in the perineum was the most prevalent pain symptom, followed by suprapubic and ejaculatory pain and discomfort. Severe bothersome urinary frequency was the most prevalent voiding symptom, followed by obstructive voiding and urgency. The highest mean symptom frequency rating (0–5) was associated with frequency, followed by perineal pain/discomfort, suprapubic pain/discomfort and obstructive voiding. The highest mean symptom severity rating (0–10) was associated with frequency, followed by perineal and suprapubic pain and discomfort. Of the men, 31% reported voiding at least eight times during the day and 51% at least twice at night. The quality-of-life assessment showed that only 8.2% of men diagnosed with prostatitis were very satisfied, satisfied or almost satisfied; 14.6% were equivocal while 77.2% were almost unsatisfied, unsatisfied and very unsatisfied.

Table 3.  Results from the frequency/severity of symptoms questionnaire in 1074 patients with prostatitis
Symptom% (n/total)Mean (sd) score
frequencyseverity
Penile pain or discomfort55.2 (386/699)1.3 (1.4)3.1 (2.7)
Perineal pain or discomfort81.6 (666/816)2.2 (1.3)4.5 (2.5)
Suprapubic pain or discomfort74.6 (561/779)2.0 (1.4)4.3 (2.5)
Ejaculatory pain or discomfort63.9 (461/721)1.4 (1.3)3.3 (2.4)
Testicular pain or discomfort43.9 (302/688)0.9 (1.2)2.5 (2.5)
Lumbar/inguinal/thigh pain35.4 (240/678)0.8 (1.3)2.3 (2.8)
or discomfort
Incomplete bladder emptying72.8 (541/743)1.8 (1.4)3.7 (2.7)
Burning during micturition81.7 (652/798)2.0 (1.3)4.2 (2.5)
Urgency72.4 (514/710)1.7 (1.4)3.9 (2.8)
Urinary frequency86.4 (717/830)2.4 (1.4)5.0 (2.7)

Table 4 outlines the physical examination, evaluations and investigations undertaken or ordered during the initial outpatient visit for the 1074 evaluable patients diagnosed with prostatitis. Urologists in the study used a DRE in 98% of men with a diagnosis of prostatitis and recorded an attempt at prostatic massage in 77%. The prostatic massage was successful at obtaining at least some expressed prostatic secretion (EPS) in 57% of the attempted cases (44% of the total prostatitis population). A variable percentage of patients had urine analysed, and various segmented urethral, urine, EPS and semen cultures, but a complete Meares-Stamey test (VB1, VB2, EPS and/or VB3) was only documented in 2.6%.

Table 4.  Evaluation of 1074 patients with prostatitis in Italy during the study period
EvaluationN (%)
  1. Urologists recorded that the evaluation was completed; for the remaining patients it was either indicated ‘not done’ or not recorded. VB1, voided bladder 1 or initial stream urine; VB2, voided bladder 2; VB3, voided bladder 3 or urine specimen after prostatic massage; the Meares-Stamey test = VB1 + VB2 + EPS ± VB3.

DRE1051 (97.9)
Prostate massage 825 (76.8)
EPS produced 473 (44.0)
VB1  48 (4.5)
MSU (VB2) 473 (44)
Urethral swab culture (bacteria) 172 (16)
Chlamydia culture 235 (21.9)
Mycoplasma/Ureaplasma culture 209 (19.5)
EPS microscopy 124 (11.5)
EPS culture 232 (21.6)
VB3 138 (12.8)
Semen culture 296 (27.6)
Meares-Stamey test  28 (2.6)
Ultrasonography 303 (28.2)
TRUS 263 (24.5)
Urography  29 (2.7)
Cystoscopy   6 (0.6)
Uroflowmetry 210 (19.6)
Urodynamics   5 (0.5)
PSA 300 (27.9)

The final clinical diagnosis in 1074 prostatitis patients was acute bacterial prostatitis in 30.2% (324), chronic bacterial prostatitis in 29.6% (318), CPPS in 19.4% (208) and suspected prostatitis (probably CPPS) in 20.9% (224).

Of the 1074 evaluable patients with a diagnosis of prostatitis, 25% were concurrently on at least one therapy at the time of the evaluation visit. Continuous antibiotic therapy was confirmed in 6.7%, antibiotic therapy was initiated in 10.6% and antibiotic therapy was documented as either not prescribed or not recorded in 82.7% of men with prostatitis. In many cases antibiotic therapy was not initially prescribed, while waiting for culture and antibiotic sensitivity results. Other ongoing drug therapy (e.g. α-blockers, anti-inflammatory agents, analgesics) was confirmed in 2.3%, modified or instituted in 54.3%, and either not prescribed or not recorded in 43.4%. Other therapies prescribed included prostatic massage in 7.2% and physical therapy in 3.0%.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

This descriptive study differs from other epidemiological surveys published previously because it does not rely on the patients’ or physicians’ self-reporting based on a recollection of a diagnosis of prostatitis [4,5,10,11], or retrospective review of billing data [6,7] and physician charts [8]. This study also differed from other prospective studies which relied on determining the prevalence of prostatitis-like symptoms using an index (National Institutes of Health Chronic Prostatitis Symptom Index, NIH-CPSI) that was only validated to follow clinically diagnosed patients [1–3]. In this study all male patients seen in 70 urology outpatient clinics during a defined period were recorded and the prevalence of a clinical diagnosis of prostatitis determined by using a predefined clinical definition of cases. Furthermore, the previous history, presenting symptoms, assessment, investigations and treatment were documented, while an objective measure of prostatitis-specific symptom frequency and severity, and quality of life, was obtained from the patients, using a standardized assessment questionnaire. The study therefore was an accurate determination of the prevalence of prostatitis (at least in that period) in outpatient urology practice in Italy, and provides an accurate picture of the assessment and management of the condition as practised in urological centres in Italy in 2001. The prevalence of prostatitis during the study period was estimated as 12.8% (10% if the category of ‘suspected prostatitis’ was eliminated). The prevalence appeared to be higher in central than in northern and southern Italy and the Isles.

The mean age of those with prostatitis was 47 years, with all age ranges equally represented. These results are compatible with those described in the Olmsted County study [8], which documented that prostatitis was not necessarily a young man's diagnosis. Over two-thirds of the patients had had their first symptoms within the previous year, while over a third had been diagnosed with prostatitis before this particular visit to the outpatient clinic. The most common presenting symptoms were severe bothersome urinary frequency, obstructive voiding symptoms, and perineal, suprapubic or penile pain or discomfort. The objective questionnaire showed that the most frequently reported symptoms present at the time of evaluation were severe bothersome urinary frequency symptoms, perineal and suprapubic pain and discomfort. These symptoms also had the highest severity ratings in the questionnaire. Over three-quarters of the patients rated their quality of life as being at best ‘dissatisfied’.

A DRE during the initial visit was recorded in 98% of the patients with prostatitis. Urologists at least attempted a prostatic massage and EPS in three-quarters of patients with prostatitis but were successful in less than half. While many patients had urethral, urine, EPS and semen culture, microscopy was used in only 10% of patients and the traditional Meares-Stamey test in < 3%. This type of investigation would indicate that Italian urologists undertake a very similar clinic visit assessment as that determined in North American surveys [10–13]. The most common treatment prescribed, drug therapy other than antibiotics (e.g. α-blockers, anti-inflammatory, analgesics), differs from North American surveys [10,11,13], which describe antibiotics as the most commonly prescribed therapy. It is very likely that more contemporary surveys would discover that other drug therapies are becoming more popular in chronic prostatitis/CPPS.

This prospective descriptive Italian outpatient survey presents a ‘snapshot’ of the prevalence, diagnosis, evaluation and treatment of prostatitis during the study period in 2001. There are limitations; there may be some practice pattern bias, as urologists interested in prostatitis may have been more inclined to participate in the survey. As the urologists were documenting their activities during this period, there also may have been a tendency to modify their routine assessment and evaluation of the patients. The NIH-CPSI was not used in this survey because an Italian version of the index was not available, the NIH-CPSI was never designed to be a diagnostic tool, and it was felt more appropriate in this study to assess the frequency and severity of each individual symptom, rather than averaging the frequency and severity score, as in the NIH-CPSI [14]. With this questionnaire it would be possible to evaluate the frequency and severity of each man's specific prostatitis symptom. In the present study there appeared to be an increased prevalence of the diagnosis of bacterial prostatitis; this particular diagnosis may have been made because patients were being treated with antibiotics at the time they were being assessed. The diagnosis and classification on this initial visit was made by a history, presenting symptoms and initial assessment, so that the true frequency of acute/chronic bacterial prostatitis may have been overestimated (but the total prevalence of a diagnosis of prostatitis would remain the same).

In conclusion, prostatitis is a very common diagnosis in urology outpatients in Italy. The prevalence of a clinical diagnosis of prostatitis in this prospectively planned urology outpatient survey was 12.8%. The prevalence, diagnosis, evaluation and treatment of prostatitis in Italy are very similar to those reported in other series from other countries.

ACKNOWLEDGEMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

Funded with a research grant from GlaxoSmithKline S.p.a Italy

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix
  • 1
    Roberts RO, Jacobson DJ, Girman CJ et al. Prevalence of prostatitis-like symptoms in a community based cohort of older men. J Urol 2002; 168: 246771
  • 2
    Tan JK, Png DJ, Lieu LC, Li MK, Wong ML. Prevalence of prostatitis-like symptoms in Singapore: a population based study. Singapore Med J 2002; 43: 18993
  • 3
    Nickel JC, Downey J, Hunter D, Clark J. Prevalence of prostatitis-like symptoms in a population-based study employing the NIH-chronic prostatitis symptom index (NIH-CPSI). J Urol 2001; 165: 8425
  • 4
    Mehik A, Hellstrom P, Lukkarinen O, Sarpola A, Jarvelin M. Epidemiology of prostatitis in Finnish men: a population-based cross-sectional study. BJU Int 2000; 86: 4438
  • 5
    McNaughton-Collins M, Meigs JB, Barry MJ et al. Prevalence and correlates of prostatitis in the Health Professionals Follow-up Study Cohort. J Urol 2002; 167: 13636
  • 6
    Schappert SM. National ambulatory medical care survey. 1991 Summary of the National Center for Health Statistics. Vital Health Stat 1994; 116: 1110
  • 7
    McNaughton-Collins M, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol 1998; 159: 12248
  • 8
    Roberts RO, Lieber MM, Rhodes T, Girman CJ, Bostwick DG, Jacobsen SJ. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology 1998; 51: 57884
  • 9
    Litwin MS, McNaughton-Collins M, Fowler FJ Jr. et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999; 162: 36975
  • 10
    Nickel JC, Nigro M, Valiquette L et al. Diagnosis and treatment of prostatitis in Canada. Urology 1998; 52: 797802
  • 11
    Moon TD. Questionnaire survey of urologists and primary care physicians’ diagnostic and treatment practices for prostatitis. Urology 1997; 50: 5437
  • 12
    Krieger JN, Nyberg L, Nickel JC. Consensus definition and classification of prostatitis. JAMA 1999; 282: 2367
  • 13
    McNaughton-Collins M, Fowler FJ, Elliott DB, Albertson PC, Barry MJ. Diagnosing and treating chronic prostatitis: Do urologists use the four-glass test? Urology 2000; 55: 4037
  • 14
    Downey JA, Ardern D, Nickel JC. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). Does it really measure frequency and intensity of specific prostatitis-like symptoms? J Urol 2001; 165 (Suppl. 5): 24 (Abstract 101)

Appendix

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGEMENTS
  8. REFERENCES
  9. Appendix

Appendix 1

The clinical definitions of prostatitis used in the prospective survey:

Acute bacterial prostatitis (Category I): acute infective process of the prostate

Patients show acute symptoms of UTI, frequently with dysuria and irritative voiding symptoms. Signs and symptoms of systemic infection can also be present. Bacteriuria and/or pyuria are present.

Chronic bacterial prostatitis (Category II): chronic infective process of the prostate

Usually associated with recurrent UTI and pain, diagnosed by detecting leukocytes and bacteria in expressed prostatic secretion and/or semen and/or urine samples after prostatic massage urine.

Chronic pelvic pain syndrome (Category III): presence of chronic pelvic pain with no confirmed infection

These patients experience pain (suprapubic, inguinal, perineal, penile) for ≥ 3 months with associated voiding problems and occasional sexual dysfunction. Patients do not have a history of recurrent UTIs. Presence of urethritis or morphological problems of the urethra, urogenital cancers, diseases of the urinary tract alone or neurological problems related to the bladder must be excluded. Leukocytes in prostatic secretion and/or semen and/or urine after prostatic massage can be present (Category IIIA) or absent (Category IIIB).

Suspected prostatitis: a clinical situation suggesting prostatitis

Patients who, in the absence of clinical or laboratory evidence, cannot be included in one of the previous definitions.