The Prostatitis Foundation

Causes of Prostatitis
Do Bacteria cause Chronic Prostatits?


The virulence of E-coli is partly explained by its ability to absorb and use bits of DNA from other cells and organisms, a new study shows

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Bacteria, antibiotics, causes, Staphylococcus, Streptococcus, E coli, Cipro, Bactrim, gram-positive, gram-negative, culture, sensitivity, resistance, biofilm, corynebacteria

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A Dec. 1999 Symposium discusses bacteria
Recommendations for patients

Your prostatitis could be caused by bacteria. If you ever had acute prostatitis with fever, it was probably bacterial (and most likely quickly brought under control with antibiotics).

In the beginning....there was bacterial infection.

That is to say, the original theory about the cause of prostatitis was that it is caused by bacterial infection. Now, of course, we know that some prostatitis has nothing, or little, to do with bacteria. Exactly how important bacterial infection is in causing prostatitis is a subject of great debate on every level, from patient discussion to scientific research.

The reason there can be any controversy is because of the logic of how one tests for bacteria. Generally speaking, a negative test for bacteria just means the test did not find any. They may be there, hiding from the testing method, the wrong test may have been used, the testing method may not have been sensitive enough, or the test may not have been read properly. Also, until the advent of multiple-drug-resistant bacteria, antibiotics have been so effective that after a long course of antibiotics, many doctors presume that there cannot be any bacteria left.

Then there's the next question: if bacteria are shown to be present, does that mean that they are causing your symptoms? Will eliminating your bacteria mean the end of your problems, and your pain and other symptoms?

Which leads to another big question. How does one get rid of bacteria? Are there antibiotics that work on your bacteria? Do the antibiotics cause serious side effects? Are your bacteria resistant to antibiotics? Or as a recent study suggests, do some bacteria have mechanisms to survive antibiotics?

In the last 30 years, with the wide availability of powerful antibiotics, doctors in many clinical settings have not honed their ability to diagnosis specific bacterial infections. Why bother? Just prescribe a powerful broad-spectrum antibiotic and watch the patient get better. This reliance on antibiotics goes to such an extent that doctors will prescribe antibiotics, which themselves have risks, even though the doctor doesn't think your problem is caused by bacteria.

A full color printout of the December, 1999 symposium report, Current Management of Prostatitis can be ordered from The Prostatitis Foundation.(click)

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In a symposium sponsored by Contemporary Urology, three Urology researchers discussed the role of bacteria. Dr. Culley Carson of UNC Chapel Hill said that it is "widely known" that E. coli "is the predominant cause of bacterial prostatitis." Dr. Carson is referring to acute prostatitis.

Dr. Stacy J Childs of the University of Colorado Medical Center agreed, adding that he also sees " Klebsiella or Proteus mirabilis." Hospitalized patients with catheters have prostatitis involving staphylococci or gram negative pathogens, "Pseudomonas in particular. " Gram-positive bacteria cause prostatitis, particularly Staphylococcus aureus.enterococci, Childs added.

Dr. Carson added Staphylococcus saprophyticus to the list. "A big controversy centers on the issue of whether nonbacterial prostatitis from the old schema is caused by Chlamydia trachomatis, Ureaplasma urealyticum, and Mycoplasma hominis," Carson contributed.

Dr. Childs disagreed, saying Chlamydia, Ureaplasma and Mycoplasma "do not play a major role in bacterial disease. Yet, if a patient presents with prostatitis symptoms — bothersome urethritis, in particular — and tells me his partner has a documented chlamydial infection, I insist he be treated, even though I'm not sure one disease has anything to do with the other."

Dr John Krieger of the University of Washington in Seattle suggested that patients "should be treated regardless of whether they are symptomatic or symptom free. Many asymptomatic women have persistent long-term colonization with genital Mycoplasma species. "
Dr. John Krieger

"Another formidable issue concerns fastidious or nonculturable organisms," Dr. Krieger noted. "I prescribe antibiotics to patients with these pathogens, and some of them get better. Their improvement may not last for long, although it's not uncommon for men to note that when they're taking x, y, or z drug, they feel better, even if their cultures are negative."

Dr. Krieger also said that flora in patients' prostates can be identified using molecular technology or careful culturing. He said evidence of bacteria can be found in 50% or more of chronic prostatitis patients. Dr. Krieger said that identifying these flora requires cloning and sequencing RNA, and then conducting extensive database comparisons.

Dr Childs commented that researchers have "cultured out " certain gram-positive organisms, for example, streptococci, in addition to coagulase-negative staphylococci. But he asked whether these were "true pathogens?" Many patients get better following 30 days of treatment, Childs said, "which leads some clinicians to believe that if these men have Staphylococcus epididymus in their expressed prostatic secretions [EPS], these organisms must be deep inside the prostate."

"I bought into that philosophy for a while," Dr Childs admitted. But he said further research showing the normal flora in the urethra makes him doubt they act as pathogens.

Dr. Krieger countered that UCLA researchers found " a tenfold increase in Corynebacterium species," which does not meet some definitions of causing disease, but certainly points in a direction for further research.

In the symposium, Dr. Krieger spoke out about the difficulty most doctors have in getting good lab results. "Even in our well-known microbiology department, it took me a year to get our clinical lab to do what I wanted," Dr. Krieger recounted. " That all changed the day I asked if I could run the tests myself in our research lab. Such testing requires careful microbiology, which will uncover organisms in many normal patients. If your lab tests only patients with symptoms, and if your facility runs these tests only occasionally, your laboratorians' work won't be the same as that of those who do it on a regular basis."

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Recommendations for Patients
Medical Doctors
: Please write to the webmaster with your recommendations for what patients should ask their doctors to do in diagnosing and treating prostatitis.

Dr. Daniel Shoskes
The role of bacteria in chronic pelvic pain syndrome (CPPS, NIH category III prostatitis) is controversial. Many doctors do not perform cultures on men with CPPS under the rationale that 1) most cultures are negative; 2) positive or negative the only treatment they offer is antibiotics and 3) that conventional cultures may miss many pathogens anyway.

In my practice we always perform extensive cultures as part of our academic interest in this disorder but it important to realize that no-one has proven that treatment based upon these cultures vs empiric treatment offers any improvement in response rate. Furthermore it is ESSENTIAL to understand that the presence of bacteria in urine or prostatic fluid is NOT equivalent to having an infection. By analogy, if somebody had rectal pain and cultured a swab of the the rectum they would find billions of bacteria. That does not prove that these bacteria are causing the pain. Similarly men without symptoms of prostatitis or history of infection will often have low counts of gram positive bacteria found in the prostate fluid and successful treatment of these bacteria in men with CPPS does not always lead to any change in symptoms.

The following specimens should be an absolute minimum for culture:

  • Urethral swab
  • Voided urine
  • Expressed prostatic secretions (preferable) or post prostate massage urine ("VB3")

In addition, in men with post ejaculatory pain and/or visual changes in the semen we culture the semen.

For bacterial cultures, we ask that all counts of all bacteria be reported. The cutoff that many labs use of 10E5/ml for "significant growth" is based on urine cultures of asymptomatic females and has no bearing on cultures in symptomatic patients, especially in prostatic fluid. We also ask our lab to culture for at least 5 days, although the relevance of positive cultures discovered in this manner has not been confirmed.

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The mission of the Prostatitis Foundation is to educate the public about the prevalence of prostatitis
and encourage and support research to find the cause and a cure for prostatitis.

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