The Association Of Chronic Pelvic Pain Symptoms And Prostate Inflammation Among Chinese Population

Background: Chronic prostatitis/chronic pelvic pain syndrome(CP/CPPS) is a common and intractable medical condition encounteredby urologists and patients，and commonly manifests as pain in areasincluding the perineum, rectum, prostate, penis, testicles, and abdomen（chronic pelvic pain symptoms）. The failure of traditional treatmentmethods resulting clinicians and researchers to explore new ideas. Recentstudies question the role of the prostate as the key factor in thepathogenesis of chronic pelvic pain symptoms. The chronic pelvic painsymptoms appear to result from an interplay between psychologicalfactors and dysfunction in the immune, neurological and endocrinesystems. New perspectives has let researchers to the awareness thatpatients with CP/CPPS are individuals with different and variedetiologies, progression pathways and response to therapy. Thenon-bacterial chronic prostatitis was divided into NIH-ⅢA (NationalInstitutes of Health,NIH) type and NIH-ⅢB type according to thepresence or absence of prostate inflammation may not have practicalvalue. If the prostate not the key factor in the pathogenesis of CP/CPPS,whether the female population has a similar prevalence of chronic pelvicpain symptoms? If the presence or absence of prostate inflammation is not meaningful for chronic pelvic pain symptoms, how the prevalence ofprostate inflammation in the population? All these contributed to ourresearch to provide better clues of CP/CPPS in clinical and research tofuture.Purpose:(1) To compare chronic pelvic pain symptoms in bothsexes by using a sex-neutral questionnaire in a large group of men andwomen participating in a health survey.(2) To describe the prevalenceand proportion of NIH-ⅢA, NIH-ⅢB and NIH-IV chronic prostatitisamong Chinese male population, and to explore the clinical significanceof cytokines in expressed prostatic secretions of patients with differenttypes of chronic prostatitis.(3) To describe the prevalence of and riskfactors for NIH-IV prostatitis among a large male population.Methods: The study male population comprised5,988men at secondphase recruitment of a population-based cohort in China (theFangchenggang Area Male Health Examination Survey, FAMHES).Female population uses the same method to collect from July to August2013. Data collection was conducted in Fangchenggang First People’sHospital Medical examination Centre. During the physical examination,trained physicians administered a standard questionnaire includingquestions on demographic information (age, education and occupation),history of disease, and lifestyle risk factors. Patients with chronic pelvicpain symptoms were defined by the NIH Chronic Prostatitis SymptomIndex (NIH-CPSI), with the female homolog of each male anatomicalterm use on questionnaires for female participants. We enrolled5,296 men and1106women in the present study according to the exclusioncriteria.(1) First, to compare chronic pelvic pain symptoms in male andfemale populations.(2) Exclude of men who refused digital rectalexamination or no expressed prostatic secretion (EPS) specimen could beobtained，remaining2,887men. The populations were divided into fourparts: NIH-ⅢA, NIH-ⅢB, NIH-IV chronic prostatitis and healthycontrols according to EPS white blood cell count and NIH-CPSI. Thenrandomly selected30cases of each group to analyze48cytokine levels inEPS.(3) Exclude of men with any complaints of chronic pelvic pain ordiscomfort and abnormal mid void urine, acute urinary tract infection,remaining1,868men. To describe the prevalence of and Risk Factors forNIH-IV Prostatitis among a large male population.Results:（1）The prevalence of chronic pelvic pain symptoms in ourpopulation was3.9%%in males and7.5%%in females, resulting in a2-fold higher prevalence in women. Our study found that male voidingsymptom score and quality of life scores increased with increasing age,and women were not similar to these trends. We also found that that thefemale population have a higher prevalence of chronic pelvic painsymptoms and higher pain score comparison with men.（2） Theprevalence of prostate inflammation (NIH-ⅢA or Type-IV CP) betweenthe symptomatic (chronic pelvic pain symptoms) men (NIH-ⅢA╱NIH-ⅢA+ⅢB,19.20%) and asymptomatic men (NIH-IV╱NIH-IV+Health,20.62%) is similar. In addition, the NIH-ⅢA and NIH-IV CPpatients have the concomitant increase or decrease of several cytokines, while the NIH-ⅢB CP patients have the different levels of cytokines.(3)NIH-IV prostatitis is prevalent in China. Age, smoking, drinking andlower education levels were associated with an increased risk of NIH-IVprostatitis.Conclusions:.(1) CPPS should not just be employed as a diagnostic for men.CPPS and painful bladder syndrome (PBS) have a lot of similarities.Because gender issues led doctors have suffered the inertia of thinking,women tend to be diagnosed as PBS while men are diagnosed with CPPS.We also observed that the female population have a higher prevalence ofchronic pelvic pain symptoms and higher pain score comparison withmen indicating that the role of CPPS is not limited to males but is evenmore apparent in females.(2) NIH-IIIA and NIH-IV prostatitis may have a similarpathogenesis.Studies have reported quite similar microbiologic findings betweenNIH-IIIA and NIH-IV prostatitis. The high prevalence of prostateinflammation (NIH-IIIA or NIH-IV prostatitis) between the symptomaticmen (chronic pelvic pain symptoms)(19.20%; NIH-IIIA╱NIH-IIIA+IIIB) and asymptomatic men (20.62%; NIH-IV╱NIH-IV+Health) issimilar. In addition, the NIH-IIIA and NIH-IV prostatitis patients have theconcomitant increase or decrease of several cytokines, while theNIH-IIIB prostatitis patients have the different levels of cytokines. Thisobservation led us to the idea that symptomatic (NIH-IIIA) andasymptomatic (NIH-IV) inflammatory prostatitis could have similarnature, but NIH-IIIB prostatitis may be a different disease with different pathogenesis.(3) The high prevalence of prostate inflammation brings our doubts.The chronic prostate inflammation may be involved in thedevelopment and progression of chronic prostatic disease, such asBPH(Benign Prostatic Hyperplasia) and Pca(Prostate Cancer), althoughthere is still no evidence of a causal relation. In addition, NIH-IVprostatitis has also been associated with elevated PSA levels，and it mayalso be a risk factor for subsequent male infertility. Although our studyfound that age, smoking, drinking and lower education levels wereassociated with an increased risk of NIH-IV prostatitis, the outcome ofthis asymptomatic disease is unknown.(4) Questioning the NIH-Ⅲ prostatitis typing.First of all, there was not any linear correlation between theleukocyte in EPS and the severity symptom of prostatitis. Secondly, Ourfindings suggest that NIH-IV prostatitis is prevalent among asymptomaticpopulation, symptomatic (NIH-IIIA) and asymptomatic (NIH-IV)inflammatory prostatitis could have similar nature, but NIH-IIIBprostatitis may be a different disease with different pathogenesis. Inaddition, NIH-Ⅲ A prostatitis in patients with chronic pelvic painsymptoms accounts for only19.20%, and its prevalence rate in thepopulation is only1.49%. NIH-ⅢA prostatitis may not be a separatesubtype of prostatitis, but “prostate inflammation”(NIH-IV prostatitis)in patients complicated with " symptoms "(NIH-IIIB prostatitis).Therefore, we question the NIH-ⅢA prostatitis as a separate subtypedifferent from NIH-ⅢB. The diagnosis and observation of the curativeeffect of prostatitis in clinic should be given priority to clinical symptoms, and the classification of NIH-ⅢA and NIH-ⅢB may be meaningless,only mislead clinicians to determine the therapeutic effect of CP/CPPSdepend on the severity of inflammation.