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Treating Chronic Prostatitis: Antibiotics No,
rostatitis is a common cause of visits to a physician. of treatment after assessing experiences reported in the lit-
The National Institutes of Health (NIH) consensus
erature (10). Finally, the lack of effect seen with ciprofloxa-
classification of prostatitis syndromes includes acute bacte-
cin plus tamsulosin merits further comment. Hypotheti-
rial prostatitis (type I), chronic bacterial prostatitis (type
cally, the combination may maximize bacterial eradication
II), chronic prostatitis/chronic pelvic pain syndrome (CP/
by improving bladder function and reducing both pain and
CPPS) (type III), and asymptomatic inflammatory pros-
voiding symptoms (10). Unfortunately, Alexander and col-
tatitis (type IV) (1). Type III, by far the most common of
leagues did not discuss possible reasons for the failure of
these syndromes, presents in 2 forms. Type III A is inflam-
matory, as shown by leukocytes in expressed prostatic se-
Of importance, approximately one third of all men
cretions, post–prostate massage urine, or semen. Type III B
with refractory CP/CPPS who undergo sequential mono-
is noninflammatory, and leukocytes are not present in
therapy experience a poor outcome (11). Multimodal ther-
these fluids. The cause of CP/CPPS is not known.
apeutic regimens may provide better results, especially in
Therapeutic strategies for patients with CP/CPPS fre-
men in whom primary therapy has failed. However, Alex-
quently include antibiotic drugs and ␣-blockers. In the
ander and colleagues’ results provide little encouragement
NIH prioritization index, both treatment categories are
for advocates of multimodal therapy. The end point of
ranked number 1 and 2 (2). Although many urologists
therapy, for individual patients and for future clinical tri-
routinely prescribe antimicrobial agents for patients pre-
als, should be an improvement in health-related quality of
senting with CP/CPPS, the emerging consensus is that an-
tibiotics do not play any role in treating patients with type
What message does Alexander and colleagues’ study
III B disease, who have no evidence of inflammation (3).
have for the clinician caring for a patient with CP/CPPS? I
Some data suggest that colonization, infection, or both oc-
believe that past research (3, 9) and Alexander and col-
cur in the prostate of patients with CP/CPPS (4). This
leagues’ study show that antibiotics aren’t useful. I don’t
finding is one rationale for the suggestion that antimicro-
think a firm conclusion can be drawn about the effective-
bial therapy ex juvantibus may be justified in patients with
ness of ␣-blockers, since 1 trial of 6 weeks of therapy and 1
inflammatory CP/CPPS (type III A) (5). ␣-Blockers re-
trial of 6 months of therapy have shown a favorable effect
lieved symptoms in men with CP/CPPS in 2 recent ran-
and the 6-week regimen used by Alexander and colleagues
domized, placebo-controlled trials (6, 7). ␣-Blockers are
showed none. Clinically, a longer trial of ␣-blockers—for
especially useful in alleviating pelvic pain, although studies
example, 3 to 6 months—is a reasonable intervention for
have indicated that prolonged treatment (14 to 24 weeks)
patients with CP/CPPS. Alexander and colleagues’ study is
is necessary to show a clinical effect (7).
an important step forward in understanding the cause and
In this issue, Alexander and colleagues (8) report the
treatment of CP/CPPS, but it is clearly not the last word
results of a large, multicenter randomized trial of treatment
in patients with CP/CPPS. The authors compared 6 weeksof therapy with ciprofloxacin, tamsulosin, both drugs, or
Wolfgang Weidner, MD
University of Giessen
placebo in men with refractory, long-standing CP/CPPS.
The primary outcome measure was the change in totalscore on the NIH Chronic Prostatitis Symptom Index
Potential Financial Conflicts of Interest:
(NIH-CPSI) from baseline to 6 weeks. The key message ofthe study is that there was no proven difference among
Requests for Single Reprints:
Wolfgang Weidner, MD, Department of
these drugs, singly or in combination, for treatment of
Urology, University of Giessen, D-35382 Giessen, Germany; e-mail,
CP/CPPS. Recently, a similar outcome was reported for
Concerning ␣-blockers, the negative outcome is disap-
Ann Intern Med.
pointing because 2 earlier randomized, double-blind,placebo-controlled clinical trials showed them to be effec-
tive (6, 7). Treatment lasted 6 weeks in 1 of these studies
1. Krieger JN, Nyberg L Jr, Nickel JC.
NIH consensus definition and classifi-
(6) and 6 months in the other (7). I agree with Alexander
cation of prostatitis [Letter]. JAMA. 1999;282:236-7. [PMID: 10422990]
and colleagues that their decision to enroll patients with
2. Nickel JC, Nyberg LM, Hennenfent M.
Research guidelines for chronic
refractory disease may have contributed to the lack of effect
prostatitis: consensus report from the first National Institutes of Health Interna-
of ␣-blockers. As suggested by the 6-month clinical trial
tional Prostatitis Collaborative Network. Urology. 1999;54:229-33. [PMID:10443716]
reported by Mehik and colleagues (7), prolonged treatment
3. Schaeffer AJ, Datta NS, Fowler JE Jr, Krieger JN, Litwin MS, Nadler RB, et
with ␣-blockers appears to be necessary to observe an ef-
Overview summary statement. Diagnosis and management of chronic pros-
fect. Alexander and colleagues decided to evaluate 6 weeks
tatitis/chronic pelvic pain syndrome (CP/CPPS). Urology. 2002;60:1-4. [PMID:
19 October 2004 Annals of Internal Medicine Volume 141 • Number 8 639
Editorial The Difficulties of Treating Chronic Prostatitis
4. Krieger JN, Ross SO, Riley DE.
Chronic prostatitis: epidemiology and role of
9. Nickel JC, Downey J, Clark J, Casey RW, Pommerville PJ, Barkin J, et al.
infection. Urology. 2002;60:8-12; discussion 13. [PMID: 12521579]
Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a ran-
5. Wagenlehner FM, Naber KG.
Prostatitis: the role of antibiotic treatment.
domized placebo-controlled multicenter trial. Urology. 2003;62:614-7. [PMID:
World J Urol. 2003;21:105-8. [PMID: 12687400]
6. Nickel JC, Narayan P, McKay J, Doyle C.
Treatment of chronic prostatitis/
10. Propert KJ, Alexander RB, Nickel JC, Kusek JW, Litwin MS, Landis JR, et
chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial.
Design of a multicenter randomized clinical trial for chronic prostatitis/
J Urol. 2004;171:1594-7. [PMID: 15017228]
chronic pelvic pain syndrome. Urology. 2002;59:870-6. [PMID: 12031372]
7. Mehik A, Alas P, Nickel JC, Sarpola A, Helstrom PJ.
Alfuzosin treatment for
11. Nickel JC, Downey J, Ardern D, Clark J, Nickel K.
Failure of a mono-
chronic prostatitis/chronic pelvic pain syndrome: a prospective, randomized, dou-
therapy strategy for difficult chronic prostatitis/chronic pelvic pain syndrome.
ble-blind, placebo-controlled, pilot study. Urology. 2003;62:425-9. [PMID:
12. McNaughton Collins M.
The impact of chronic prostatitis/chronic pelvic
8. Alexander RB, Propert KJ, Schaeffer AJ, Landis JR, Nickel JC, O’Leary MP,
pain syndrome on patients. World J Urol. 2003;21:86-9. [PMID: 12682773]
Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic
pain syndrome. A randomized, double-blind trial. Ann Intern Med. 2004;141:
19 October 2004 Annals of Internal Medicine Volume 141 • Number 8
Annu. Rev. Anthropol. 1997. 26:591–621 Copyright © 1997 by Annual Reviews Inc. All rights reserved ETHNOGRAPHY Kamala Visweswaran Department of Anthropology, The University of Texas at Austin, Austin, Texas 78712-KEY WORDS: gender analysis, feminism, women anthropologistsThis review essay illustrates how changes in the conception of gender definethe historical production of feminist ethn
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