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Prospective Identification Of National Institutes Of Health Category IV Prostatitis In Men With Elevated Prostate Specific Antigen

Jeannette M. Potts
From the Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
THE JOURNAL OF UROLOGY 2000;164:1550-1553
Purpose: Plain-English notes (provided by webmaster to aid understanding)
Although prostatitis may cause elevated prostate specific antigen (PSA), asymptomatic patients are not routinely screened for this diagnosis before transrectal biopsy is performed to rule out cancer. Many negative biopsies reveal evidence of prostatitis classified as National Institutes of Health (NIH) category IV prostatitis or asymptomatic inflammation. To our knowledge this report represents the initial study of the incidence of NIH category IV prostatitis in men before biopsy and its clinical significance. A large number of patients get biopsies for cancer just because their PSA is high. Usually they aren't checked first to see if they have prostatitis. But the tissues removed in the biopsy often show prostatitis. Nobody has ever looked at the issue of prostatitis before biopsy and its effect on how effective the biopsy is in determining whether the patient has cancer.
Materials and Methods:
From 1996 to 1998 asymptomatic men with elevated PSA levels were evaluated for laboratory signs of prostatitis. Patients with expressed prostatic secretions or post-prostate massage urine (voiding bottle 3 [VB3]) positive for greater than 20 and greater than 10 white blood cells per high power field, respectively, received antibiotics for 4 weeks and were reevaluated after 6 to 8 weeks. Men without these clinical signs promptly underwent biopsy. Those with acute urinary tract infection and PSA greater than 30 ng./ml., without a rectum or who refused biopsy were excluded from study. The study looked at men who did not have any symptoms of prostatitis, but did have raised PSA. (For more background on PSA click here.) The patients who had raised white blood cells in EPS or in the 4-jar test (indicating possible prostatitis) were given antibiotics for 4 weeks and new PSA tests after 6 to 8 weeks. The men who showed no signs of prostatitis were given biopsies right away. Men who clearly had an infection or who had had colon surgery or who would not submit to a biopsy were not included in the study.
Of the 187 study patients 122 were evaluable with a mean PSA of 9.35 ng./ml., including 51 (42%) with laboratory signs of prostatitis. After treatment PSA was normal in 22 cases and remained elevated in 29, including 9 in which biopsy revealed cancer. The change or improvement in PSA was significantly greater in men with benign results than in those with prostate cancer (–21.32 versus –1.33%, p = 0.001). In the cohort with negative expressed prostatic secretion and VB3 results transrectal ultrasound guided biopsy was done promptly. Screening decreased the number of biopsies by 18% (22 of 122 cases). The positive predictive value of PSA for detecting biopsy proved cancer improved with screening for prostatitis (45 of 122 cases or 37% versus 36 of 71 or 51%). Long-term followup revealed continued normal or stable PSA in the prostatitis cohort. That left 122 men in the study. Of these, 51 men had signs of prostatitis. Of these, 22 had their PSA go down to normal for their age, but 29 had their PSA scores stay high. Of these 29, nine indeed had cancer shown by biopsy. Of the men treated with antibiotics, the ones with cancer had their PSA go down only a little, but the ones with prostatitis and no cancer had their PSA go down a lot. As mentioned above, the men who didn't have any sign of prostatitis (but high PSA) had immediate biopsies. The net effect of using prostatitis diagnosis and treatment to forstall biopsy decreased the total number of biopsied by 22, or 18 per cent. When screening for prostatitis was included, to help focus who really needed a biopsy, the value of biopsy for detecting prostate cancer improved.
Screening for NIH category IV prostatitis should be considered in men with elevated PSA. Although patients may be asymptomatic, anxiety caused by prostate cancer and diagnostic procedures contributes to the clinical significance of this disorder.

Key Words: prostate; prostatitis; prostate-specific antigen; biopsy
J Urol 2000 November;164(5):1550-1553
If the conclusion of this paper becomes widely accepted, the number of unnecessary biopsies given to men with prostatitis, but no cancer, will decrease. And the biopsies given to the remaining men will be much more effective at detecting cancer. This paper, if confirmed by other studies, may transform the field of urology.

This information is forwarded to you by the Prostatitis Foundation. We do not provide medical advice. We distribute literature and information relevant to prostatitis. While we encourage all research we do not endorse any doctor, medicine or treatment protocol. Consult with your own physician.
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