With advancing age, the prevalence of prostate diseases increases dramatically. The three most common conditions are benign prostatic hyperplasia (BPH), prostate cancer, and prostatitis. Self-reported prostate disease affects about 3 million Americans. BPH develops in over half the men aged 65 years and older and affects the overwhelming majority of men after age 85 years. Prostate cancer is the second leading cause of cancer death in men, and many men have asymptomatic or low-grade tumors that cause few or no health problems. The prevalence of prostatitis is similar to that of ischemic heart disease or diabetes mellitus. The three common prostatic conditions are reviewed herein, with special attention to diagnosis and management.
BPH is a noncancerous enlargement of the epithelial and fibromuscular components of the prostate gland. The epithelial component normally makes up 20% to 30% of prostate volume and contributes to the seminal fluid. The fibromuscular component comprises 70% to 80% of the prostate and is responsible for expressing prostatic fluid during ejaculation. Age and long-term androgen stimulation induce BPH development. Microscopic appearance of BPH may occur as early as age 30, is present in 50% of men by age 60, and is present in 90% of men by age 85. In half of these cases, microscopic BPH develops into palpable macroscopic BPH. Of those with macroscopic BPH, only half develop into clinically significant disease brought to medical attention. BPH is one of the most common conditions in aging men; in the United States annually it accounts for more than 1.7 million office visits and 250,000 surgical procedures.
The symptoms of BPH are nonspecific; other diseases can result in identical symptoms. The pathophysiology of BPH symptoms is not completely understood, but presumably it involves the periurethral zone of the prostate gland, which results in obstructed urine flow and compensatory responses of the urinary bladder, such as hypertrophy and decreased capacity. The urethral obstruction has both mechanical (obstructing mass) and dynamic (smooth muscle contractions) components. The resulting lower urinary tract symptoms are divided into irritative (frequency, urgency, nocturia) and obstructive (hesitancy, intermittency, weak stream, incomplete emptying) manifestations. The American Urological Association developed a quantitative symptom index for severity assessment and treatment response monitoring, which was adopted by the World Health Organization and is known as the International Prostate Symptom Score (IPSS). Although tracking symptom severity is useful in the longitudinal management of patients, symptom severity has not been found to correlate with prostate size, urine flow rates, or postvoid residual volume. BPH primarily affects quality of life, although complications such as recurrent urinary tract infection, bladder stones, urinary retention, chronic renal insufficiency, and hematuria can develop.
Differential diagnosis of lower urinary tract symptoms includes endocrine disorders (especially diabetes mellitus), neurologic disorders, urinary tract infections, sexually transmitted diseases, kidney or bladder stones, and medications (especially drugs with anticholinergic and diuretic effects). Digital rectal examination (DRE) may be unremarkable or reveal an enlarged, smooth, rubbery, symmetrical gland. Urinalysis is routinely performed to evaluate for urinary tract infection, hematuria, and glycosuria. A baseline serum creatinine assesses kidney function and the possibility of obstructive uropathy or intrinsic renal disease, or both. Additional optional tests include postvoid residual urine volume, urine flow rates, and pressure flow studies. These tests may be considered when the diagnosis is uncertain or an invasive treatment is being planned.
BPH therapy is patient dependent and driven by the impact of symptoms on the patient’s quality of life (see Table 53.1). All patients should be educated regarding life-style modification: fluid adjustments (avoid caffeine) and avoidance of medications (especially anticholinergics) that aggravate symptoms. Patients with mild to moderate symptoms may be satisfied with life-style modification only. Both medical and surgical treatments are also available, with medication the usual first approach. Indications for surgical treatment include patient preference, dissatisfaction with medication, and refractory urinary retention, as well as renal dysfunction, bladder stones, recurrent urinary tract infections, or hematuria if these are clearly due to prostatic obstruction.
The two main pharmacologic approaches are α-adrenergic antagonists and 5α-reductase inhibitors.
α-Adrenergic antagonists, or α-blockers, are directed at the dynamic component of urethral obstruction. Smooth muscle of the prostate and bladder neck has a resting tone mediated by α-adrenergic innervation. α-Blockers relax the smooth muscle in the hyperplastic prostate tissue, prostate capsule, and bladder neck, thus decreasing resistance to urinary flow. Of the two major α-adrenergic receptors, α1 receptors predominate in the prostate, and the α1a subtype comprises 70% of these receptors. α-Blockade development for BPH therapy has progressed from selective α1 agents (prazosinOL, alfuzosin) to long-acting selective α1 agents (terazosin, doxazosin) and now to long-acting α1a subtype selective agents (tamsulosin). The most common adverse effects of α1 agents are dizziness, mild asthenia (fatigue or weakness), and headaches. Postural hypotension occurs infrequently and can be minimized by careful dose titration.
The enzyme 5α-reductase is required for the conversion of testosterone to the more active dihydrotestosterone. Finasteride is an inhibitor of this enzyme and reduces tissue levels of dihydrotestosterone, thus reducing prostate gland size. Improvements in symptom scores and urine flow rates may not be evident for up to 6 months. Finasteride is most effective in men with larger prostates (> 40 g, about the size of a plum). Because finasteride reduces serum prostate-specific antigen (PSA) levels an average 50%, baseline serum PSA determination is advocated for men in whom prostate cancer surveillance is planned. Subsequently, after a 6-month trial if continued finasteride therapy is desired, a PSA level on treatment is obtained and then measured annually for cancer surveillance.
When used together over years, the combination of α-adrenergic antagonists with 5α-reductase inhibitors has been shown to be safe and to reduce clinical progression of BPH better than either agent alone. In particular, a lower risk of urinary retention, urinary incontinence, renal insufficiency, and recurrent bladder infections is associated with combination therapy. Also, consistent results from a number of trials demonstrate that the herbal preparation Serenoa repens, or saw palmetto, improves urinary symptoms and flow measures in men with BPH. The improvements are similar to those associated with treatment with finasteride, and there are fewer reported adverse effects with S. repens. (See also Complementary and Alternative Medicine.)
Surgical management includes transurethral resection of the prostate, transurethral incision of the prostate, open prostatectomy, transurethral vaporization of the prostate, and device insertion such as stent placement. Surgical approaches offer the best chance for symptom improvement but also have the highest rates of complications. The benefits of surgical treatments are generally considered equivalent, but complication rates differ. Transurethral resection of the prostate is the standard of care to which other BPH treatments are compared and has an 80% likelihood of successful outcome in properly selected patients. Usually performed under spinal anesthesia, a transurethral resection of the prostate involves the passage of an endoscope through the urethra to remove surgically the inner portion of the prostate. Long-term complications may include retrograde ejaculation, urethral stricture, bladder neck contracture, incontinence, and impotence. Transurethral incision of the prostate is an endoscopic procedure via the urethra to make one to two cuts in the prostate and prostate capsule, relieving urethral constriction. Limited to small prostate glands (< 30 g), transurethral incision of the prostate offers lower rates of retrograde ejaculation, bleeding, and contractures. Open prostatectomy involves removal of the inner portion of the prostate through a retropubic or suprapubic incision. It is best used for patients with larger prostates or with complicating conditions such as bladder stones or urethral strictures. Open prostatectomy is associated with incisional morbidity, longer hospitalization, and greater risk of impotence. Transurethral vaporization of the prostate uses a high-energy electrode inserted via the urethra to vaporize the prostate. This approach has little bleeding but creates more prolonged irritative voiding. Prostatic stents are used to maintain expansion of the prostatic urethra and are employed for temporary and permanent uses.
Cancer of the prostate is the most common noncutaneous cancer and the second leading cause of cancer deaths among men in the United States. It was estimated that in 2005, 232,090 men would be diagnosed and 30,350 men would die from prostate cancer. The incidence increases with age and is rare in men younger than 40 years. In autopsy studies where the entire prostate is examined, incidental histologic evidence of cancer of the prostate is found in 30% of men over 50 and 80% of men over 80. The incidence of disease varies according to race, with American blacks having the highest risk in the world. Among black men cancer of the prostate occurs at an earlier age, has a higher mortality rate, and tends to be at a more advanced stage of disease at diagnosis. Family history is a contributing factor. Men with one first-degree relative affected have more than a twofold increased risk, and with two first-degree relatives affected, more than an eightfold increased risk. Androgens are necessary for prostate cancer pathogenesis; the disease does not occur in men castrated before puberty. Diets high in total fat consumption are associated with increased risk. The association between cancer of the prostate and early onset of sexual activity, sexually transmitted disease, or vasectomy is inconclusive.
Cancer usually arises in the peripheral zone of the prostate. The majority of patients, especially those with early-stage, potentially curable disease, are asymptomatic. Cancer of the prostate spreads by three routes: direct extension, the lymphatics, and the blood stream. Direct invasion of the urethra and bladder can lead to irritative voiding symptoms, urinary incontinence, and hematuria. Extension of disease to adjacent nerves may cause impotence and pelvic pain. Nodal metastasis may cause extrinsic ureteral obstruction. Leg edema may develop from lymphatic obstruction. Hematogenous metastasis to bone may cause severe local pain, normochromic normocytic anemia, pathologic fractures, and spinal cord compression. Less commonly, hematogenous metastasis involves viscera—namely, the lung, liver, and adrenal glands.
The benefit of early detection and the best approach to treatment of prostate cancer are controversial. At the heart of the screening debate is the fact that no direct evidence exists to show that early detection decreases prostate cancer mortality rates. There is a large reservoir of cancer of the prostate that does not need to be diagnosed because the majority of men with prostate cancer die with the disease, not from it. The well-recognized burden of progressive cancer of the prostate is the impetus for early detection and management. The American Urological Association and the American Cancer Society advocate annual screening, recommending the PSA test and DRE beginning at age 50 for men with at least a 10-year life expectancy and earlier (age 40) for men at high risk (black men, first-degree relative affected). Groups that use explicit criteria to develop evidence-based practice guidelines (U.S. Preventive Services Task Force, American College of Physicians, and Canadian Task Force on the Periodic Health Examination) have recommended against routine PSA screening for cancer of the prostate. Guidelines are in agreement that the controversy surrounding screening should be discussed with patients in order to achieve individualized, informed courses of action. The effectiveness of PSA screening is particularly questionable in elderly men.
DRE of the prostate allows palpation of the posterior surfaces of the lateral lobes, where cancer most often begins. Cancer characteristically is hard, nodular, and irregular. DRE enhances screening efforts by detecting some cancers with a normal PSA level. DRE is inherently inaccurate because parts of the prostate gland cannot be reached. About half of the cancers thought to be “confined” to the prostate on the basis of DRE are found during surgery to have already spread. DRE produces many false-positive results; about one third of positive DRE tests are shown to be cancer by biopsy. Local extension of cancer of the prostate into the seminal vesicles can often be detected by DRE. Despite its limitations, DRE remains important for screening and staging.
The serum PSA test is not specific for cancer of the prostate. PSA elevations occur in benign conditions of the prostate, namely, hypertrophy and prostatitis, and in transient response to conditions such as ejaculation and prostatic massage. The sensitivity of the PSA test is also imperfect. Declines in PSA values have been associated with acute hospitalization and use of medications such as finasteride and saw palmetto. Normal PSA levels are found in 30% to 40% of men with cancer confined to the prostate (false-negative tests). The reported positive predictive value of PSA in screening studies is 28% to 35%: about one third of men with elevated PSA levels have cancer of the prostate demonstrated by fine-needle biopsy.
Several approaches to improve the accuracy of PSA testing have been developed. PSA density is derived from the PSA concentration divided by the volume of the gland (measured by ultrasound). Cancer of the prostate produces higher PSA levels per unit volume than BPH and should therefore yield a higher PSA density. The PSA rate of change or velocity is more specific for cancer of the prostate than a single PSA measurement. Using a PSA velocity value of ≥ 0.75 ng/mL/year achieves 90% specificity, whereas using a single PSA level > 4 ng/mL achieves 60% specificity. This high specificity for PSA velocity is realized even in normal-range serum PSA levels (< 4 ng/mL). Another approach involves age-adjusted PSA reference ranges because PSA values increase with age. Finally, one can measure the ratio of free to complexed PSA, recognizing that PSA bound to α1-antichymotrypsin accounts for a larger proportion of total PSA with cancer of the prostate than with BPH.
Abnormal DRE or PSA tests lead to transrectal ultrasound–guided biopsy of the prostate for pathologic diagnosis. Cancer may appear as a hypoechoic density, but ultrasound is not specific enough to be used as a screening tool. Spring-loaded core needle biopsies are routinely taken from the base, middle, and apex of each lobe (six samples total). Biopsies may also be taken from specific palpable nodules.
The Gleason grading system is the most commonly used system that is based on the histologic appearance of prostate cancer. The Gleason grade ranges from 1, or well differentiated, to 5, or poorly differentiated. The Gleason score is the sum of the most common Gleason grade observed plus the next most common Gleason grade seen. The Gleason score ranges from 2 to 10. Gleason scores are sometimes grouped as 2–4, well differentiated; 5–7, moderately differentiated; 8–10, poorly differentiated. Well-differentiated tumors have a favorable prognosis; poorly differentiated tumors, an unfavorable prognosis. Most clinically detected tumors are moderately differentiated.
Staging of cancer of the prostate is necessary for planning disease management. Two classification systems are used: the tumor, regional node, metastasis (TNM) system and the Jewett-Whitmore (ABCD) system (Table 53.2). Usually detected by transurethral resection of the prostate, incidentally discovered cancers are staged according to the amount of tissue involved (T1 or A). Stage T1c reflects the growing number of tumors detected because of an elevated PSA level. Tumors detectable by DRE and confined to the prostate (T2 or B) are subdivided on the basis of the amount of tumor that is palpable. The degree of extension and invasion of surrounding structures stage tumors that extend beyond the prostatic capsule (T3 to T4 or C). Advanced disease (M1 or D) has metastasized.
The initial staging evaluation includes PSA level, DRE findings, and transrectal ultrasonography results. Bone scans may be performed on patients with PSA values greater than 10 ng/mL or complaints of bone pain. For patients electing active treatment, surgical assessment of lymph node involvement (pelvic lymphadenectomy) is performed by itself or in conjunction with prostate surgery or implantation of radioactive seeds. Computed tomography (CT) scans are often employed for active treatment planning.
In the past, CT scans, magnetic resonance imaging scans, pedal lymphangiography, and pelvic lymph node dissection were routinely employed in various combinations to evaluate the extent of cancer of the prostate. These tests should be eliminated in the initial staging evaluation of prostate cancer patients because they have been associated with unacceptably high false-negative and false-positive results. A subset of patients appears to benefit from CT scans combined with fine-needle aspiration. Patients who have a PSA > 25 ng/mL, a Gleason score > 6, and a palpable abnormality on DRE are currently recommended to undergo a CT scan with fine-needle aspiration if a lymph node larger than 6 mm is present. Many of these patients will be diagnosed with nodal metastasis and thus spared the need for bilateral pelvic lymph-node dissection and its associated morbidity.
The serum PSA level should be used to eliminate the staging radionuclide bone scan. In the asymptomatic, newly diagnosed, previously untreated prostate cancer patient, a PSA concentration ≤ 10 ng/mL has been associated with rare (0% to 0.8%) findings of skeletal metastases. Adopting recommendations to eliminate the staging radionuclide bone scan in this population will substantially reduce testing, because 50% to 60% of men with newly diagnosed cancer of the prostate have a serum PSA concentration in this range.
Localized cancer lends itself to cure, but the prevalence of men dying with cancer of the prostate (often asymptomatic) but not from the disease questions the necessity of treatment. No trials have shown that treatment prolongs life when treatment is compared with watchful waiting. Thus, three approaches to localized prostate cancer are routinely advocated: watchful waiting, radical prostatectomy, and radiation therapy (see Table 53.3).
Watchful waiting (also called expectant or conservative management; surveillance) is the approach offered most commonly to men with less than a 10-year life expectancy, who have significant medical comorbidities, or whose tumor is small and well to moderately differentiated. Conservative management studies have shown that 10-year disease-specific survival is 89% to 96% for Gleason score 2–5 tumors, 70% to 82% for Gleason score 6 tumors, 30% to 58% for Gleason score 7 tumors, and 13% to 40% for Gleason score 8–10 tumors. Because most men with cancer of the prostate are asymptomatic, watchful waiting attempts to spare men the burden of unnecessary treatment. However, awaiting symptoms in men with prostate cancer before initiating treatment means sacrificing the opportunity for cure. Patients are offered palliation if and when symptoms develop.
Radical prostatectomy involves the surgical removal of the entire prostate gland and the seminal vesicles. It can be performed through a perineal (incision near the rectum) or retropubic (lower abdominal incision) approach. The perineal approach allows an easier vesicourethral anastomosis and less bleeding, whereas the retropubic approach allows access to the pelvic lymph nodes and spares the neurovascular supply to the corpora cavernosa (with improved potency). The major morbidities of this treatment are urinary incontinence and erectile dysfunction. Surgery is thought to have the highest incidence of post-treatment sexual dysfunction. A population-based study of 1291 men undergoing radical prostatectomy for clinically localized prostate cancer found that 18 months later, 59.9% reported erections not firm enough for sexual intercourse and 8.4% were incontinent. Patients following radical prostatectomy are more likely to experience stress incontinence, with symptoms ranging from occasional leakage to no urinary control. Bladder neck contractures also occur, resulting in obstructive voiding symptoms and urinary retention. Both sexual dysfunction and urinary symptoms have a negative impact on quality of life. The relationship between these morbidities and sense of bother is not direct; for example, those with the most leakage may have little bother while those with minimal leakage may report substantial bother. The goal of surgery is cure. Biochemical progression (PSA ≥ 0.4 ng/mL) has been reported in 40% of men 10 years after radical prostatectomy for localized disease. Actuarial metastasis-free survival at 15 years is 82%. Thus, this treatment can be offered to men with locally confined disease, with greater than a 10-year life expectancy, and without contraindications to operative therapy.
Radiation therapy is provided through external beam radiation or through implantation of radioactive sources (known as brachytherapy). The standard regimen of external beam radiation delivers a total of 6000 to 7000 rads over a 7-week period. Pelvic lymph nodes can be radiated as well. Proctitis and urethritis are common acute side effects. Chronic complications include erectile dysfunction, urinary incontinence, and chronic proctitis. The incidence of urinary stress incontinence after radiation therapy is significantly less than with surgery, but the presence of irritative voiding dysfunction is greater. Bowel dysfunction, uncommon after surgery, affects more than half of patients after radiation. Bowel symptoms include diarrhea, rectal urgency, and fecal soiling. The majority of patients classify these bowel symptoms as minor with little to no effect on quality of life. Local control and cancer survival rates are comparable to those of radical prostatectomy. Conformal radiation therapy is a mode of high-precision external-beam radiation that uses high-resolution CT scan data and advanced computer technology to conform the radiation dose to the three-dimensional configuration of the tumor. This new technology shows promise in reducing complications and adverse effects.
Brachytherapy involves retropubic or perineal implantation of radioactive seeds, usually iridium or palladium. Improvements in three-dimensional imaging of the prostate through CT scan or ultrasound guidance have allowed more uniform distribution of seeds throughout the prostate and overcome many of the past limitations of brachytherapy. Potency is better preserved with seed implants. Urinary symptoms include frequency, dysuria, and urge incontinence. Bowel symptoms include rectal urgency and rectal bleeding. The morbidity of seed implants appears to improve over time following the initial seed placement. Currently no evidence suggests that brachytherapy is more effective than external beam radiation or prostatectomy.
Locally advanced prostate cancer extends beyond the capsule or invades the seminal vesicle, without evidence of distant or nodal metastasis. Radiation therapy is the recommended treatment, and adjuvant androgen deprivation provides additional benefit toward increased survival and freedom from metastases. However, controversy exists as to when androgen deprivation should be initiated. Patients may have a prolonged asymptomatic cancer period, while significant negative quality-of-life changes from long-term androgen deprivation occur, including loss of stamina, increased fatigue, hot flashes, diminished muscle mass, and premature osteoporosis. Patients should therefore be given the choice of early versus delayed androgen deprivation.
Advanced disease is treated with androgen ablation and symptom-specific approaches, such as focal radiation therapy to painful bone metastasis. Androgen ablation aims to eliminate prostate cancer growth stimulation and includes orchiectomy or luteinizing hormone-releasing hormone (LHRH) agonists with antiandrogens. Orchiectomy and LHRH agonists are equally effective at reducing androgens to castration levels. Orchiectomy is the oldest, safest, least expensive approach but is rejected by nearly half of U.S. men. LHRH agonists such as leuprolide and goserelin produce castration levels about a month after an initial increase in serum testosterone levels. Antiandrogens (eg, flutamide) are often given before initiation of LHRH agonists to blunt the effects of the initial testosterone increase. Antiandrogens inhibit the binding of androgen to its receptor. After castration a small amount of adrenal androgen exists and may allow continued stimulation of prostate cancer growth. Antiandrogens may be combined with chemical or surgical castration, a practice called complete androgen ablation. Survival rates for antiandrogens alone are inferior to those for chemical or surgical castration alone; complete androgen ablation offers slight improvement in survival over that offered by castration only.
Radiation therapy is useful for relieving the pain of isolated bone metastasis and reducing the risk of fracture of bones with significant destruction. Diffuse bone metastases require alternative approaches. Bone-seeking radiopharmaceuticals such as strontium can be beneficial for pain control. Androgen deprivation decreases bone pain in two thirds of symptomatic patients.
Prostatitis is an inflammatory condition of the prostate that may represent acute bacterial, chronic bacterial, or nonbacterial causes. The most common sources of acute or chronic infection are ascending urethral infection or reflux of infected urine into the prostatic ducts, or both. Direct extension or lymphatic spread from the rectum or hematogenous spread also occurs. Acute prostatitis is an infectious process that is more common in young men. Pathogens in men 35 years and younger often include Neisseria gonorrhea and Chlamydia trachomatis. In older men acute prostatitis is associated with indwelling urethral catheter use, and coliforms are the suspected bacterial cause. More than 80% of patients with prostatitis have no identifiable infectious agent.
Acute bacterial prostatitis is characterized by fever, chills, dysuria, and a tense or boggy, extremely tender prostate. Because bacteremia may result from manipulation of the inflamed gland, minimal rectal examination is indicated. Gram’s stain and culture of the urine can identify the causative agent.
Chronic bacterial prostatitis presents classically as recurrent bacteriuria caused by the same organism, although most patients will not have this presentation. Patients have varying degrees of obstructive or irritative voiding symptoms and perineal pain. The prostate often feels normal. First-void or midstream urine is compared with expressed prostatic secretion or urine collected postmassage. The expressed sample should reveal leukocytosis and the causative agent. Sterile expressant with leukocytosis suggests nonbacterial prostatitis.
Acute bacterial prostatitis is treated with antibiotics and may require hospitalization. The severe inflammation allows antibiotics to penetrate the prostate, and prompt response to empiric therapy is expected. CT or magnetic resonance imaging should be considered to evaluate for an abscess if recovery is delayed. Antibiotic selection should be based initially on urine Gram’s stain results, with subsequent consideration of sensitivity profiles. Fluoroquinolones are highly effective in most cases.
Antibiotics are less effective for chronic bacterial prostatitis because of the poor penetration of the prostate by most of these drugs. Prolonged therapy of 6 to 16 weeks offers a cure rate of 30% to 40%. Continuous low-dose antibiotic suppression therapy can be offered for those with frequent symptomatic relapse. Total prostatectomy offers cure but at a high risk-to-benefit ratio. Transurethral resection of the prostate is safer but cures only one third of patients.
Nonbacterial prostatitis is treated symptomatically. A small percentage of cases may involve occult infections, and empiric antibiotic therapy is often used. Efforts to reduce pain and discomfort include anti-inflammatory agents, sitz baths, fluid adjustments (avoid caffeine), anticholinergic agents, and α-adrenergic antagonists.
■ AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol. 2003;170(2 Pt 1):530–547.
This article provides a review of the diagnostic and therapeutic approaches to benign prostatic hyperplasia with a section on emerging therapies. The American Urological Association panel of experts noted that the Agency for Health Care Policy and Research 1994 guideline is still valid with five minor adjustments.
■ Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(11):917–929.
This article reports the U.S. Preventive Services Task Force updated review of the evidence of benefits and harms of screening and earlier treatment for prostate cancer patients. The task force concluded that the data are insufficient to recommend for or against routine screening for prostate cancer.
■ Penson DF, Litwin MS. The physical burden of prostate cancer. Urol Clin North Am. 2003;30(2):305–313.
This article provides a comprehensive description of the physical burden of prostate cancer and its treatments, covering both metastatic and localized disease. This information may be useful for patients and their physicians as they discuss treatment alternatives.
■ Schaeffer AJ, Datta NS, Fowler JE, et al. Advances in the diagnosis and treatment of prostatitis: overview summary statement. Urology. 2000; 60(Suppl 6):1–4.
This is the lead article of an entire supplement on chronic prostatitis. The authors review the diagnostic criteria and then review recommendations for the initial assessment of patients presenting with symptoms of chronic prostatitis. There is a helpful overview of treatment options along with references to other articles in the supplement that provide additional details.
Lisa J. Granville, MD