Discussion and Summary

Discussion

A lively discussion highlighted important aspects in managing bacterial prostatitis, with Prof. Naber stressing the need to identify pathogens and never using empiric therapy for a chronic disease. He noted that levofloxacin is extremely useful in this setting, as it possesses broad-spectrum bacterial coverage against both common and atypical uropathogens as well as exceptional PK/PD features, all of which make it the agent of choice for managing urogenital infections.

Difficulties in carrying out the 4-glass test on every patient were raised, and whether testing of expressed prostatic secretions (EPS) should be performed at every follow-up. Prof. Naber commented that, while the 4-glass test is useful for identifying patients requiring antimicrobials, the newly proposed 3-glass test may be an easier screening procedure, reducing the need for prostatic massage in 30% of patients (1).

With fluoroquinolones being the antibiotics of choice for treatment of chronic bacterial prostatitis, the issue of safety, particularly cardiotoxicity and influence on glucose homeostasis was raised. Prof. Naber emphasized that 500 mg and 750 mg doses of levofloxacin have a well-documented safety profile, with levofloxacin less likely to be associated with significant toxicity than other fluoroquinolones.

Prof. Naber noted that while bacterial prostatitis requires antibiotic therapy, some also advocate additional α-blockers. Prof. Nickel agreed, reporting results from 2 studies suggesting that α-blockers and antibiotics together are superior to antibiotics alone for chronic bacterial prostatitis.

When using α-blockers, the presenters were asked why 8 mg silodosin was less successful than 4 mg. Prof. Nickel believed it was because CP/CPPS is different from BPH, which does have a dose response. CP/CPPS occurs in younger patients presenting with pain and voiding symptoms, and the reduction in successful outcome with the 8 mg dose is probably related to a higher incidence of retrograde ejaculation resulting in a reduced QOL.

A discussion about potential differences between the currently available α-blockers ensued. Silodosin was noted as a more specific, highly selective α_1A-adrenergic receptor antagonist. As a third generation agent, it exhibits clinical efficacy along with an improved safety profile. However, it is not possible currently to differentiate between individual agents as the patient numbers in studies are too small to produce a subset analysis, although Prof. Nickel stressed that silodosin has shown in clinical studies to be effective and safe in prostatitis.

Reference
(1) Kulchavenya E, et al. Minerva Urol Nefrol 2012; 64: 273-8.

Summary

In summary, the following consensus was arrived at Prof. Naber and Prof. Nickel, and the Discussion session: