慢性前列腺炎/慢性骨盆疼痛綜合症

慢性非細菌性前列腺炎Chronic nonbacterial prostatitis)或慢性前列腺炎/慢性骨盆疼痛綜合症chronic prostatitis/chronic pelvic pain syndrome )又稱類前列腺炎綜合徵,是會導致男性盆腔疼痛英語Pelvic pain的一種疾病,是前列腺炎中找不到致病生物體類型的總稱,涵蓋找不到致病生物體的慢性前列腺炎各類型和前列腺痛;其特徵是患者主述腰骶、會陰、外生殖器、尿道各種主觀不適難忍,遷延難愈。沒有明確的尿道感染病史。部分類前列腺炎綜合徵患者尿流率圖曲線見齒型波,最大尿流率正常;平均尿流率時間相對延長。

慢性非細菌性前列腺炎
(Chronic nonbacterial prostatitis)
類型urologic chronic pelvic pain syndrome[*]慢性前列腺炎
分類和外部資源
醫學專科泌尿外科
ICD-10N41
DiseasesDB10801
MedlinePlus000524
eMedicine437745
[編輯此條目的維基數據]

此病應與其他類型的前列腺炎區分,如慢性細菌性前列腺炎急性細菌性前列腺炎[1][2]。此外,這種疾病以前被稱為前列腺疼痛(prostatodynia)。

症狀

慢性前列腺炎/慢性骨盆疼痛綜合徵的主要特徵是骨盆或會陰疼痛,且沒有尿路感染的跡象[3],並持續超過3個月[4]——此乃關鍵症狀。它的症狀可能會時好時壞。痛楚的程度可以從輕微的,以至使人虛弱。痛楚可散發至背部和直腸,令人坐下時感到不舒服。可於會陰、睾丸、陰莖前端、恥骨或膀胱這些區域上感到痛楚[5]排尿困難關節痛肌肉痛、不明原因的乏力、腹痛、陰莖灼痛也是時常會出現的症狀。尿頻和尿急可能是暗示患者患的是間質性膀胱炎(發炎的是膀胱,而不是前列腺)。由神經和肌肉介導的射精後疼痛,仍是其一大特點[6],此特點可用以把慢性前列腺炎/慢性骨盆疼痛綜合症患者與良性前列腺增生症區分。有些患者報告說自己性慾低下、性功能障礙和勃起困難。

原因

神經、壓力和荷爾蒙

慢性前列腺炎/慢性骨盆疼痛綜合症是免疫、神經和內分泌系統與心理因素之間的相互作用導致[7]。該病背後的理論包括壓力令下丘腦-垂體-腎上腺軸功能失調,和腎上腺皮質激素(內分泌)異常[8][9],以及出現神經源性炎症英語Neurogenic inflammation[10][11][12]、肌筋膜疼痛症候群[13][14]。在後兩類,是由於過去的創傷、感染或焦慮性格導致局部神經系統的失調,慢性無意識地繃緊骨盆(受神經細胞釋放物質(如物質P英語Substance P)的調節)亦會導致炎症。前列腺(和泌尿生殖道其它部分:膀胱、尿道、睾丸)亦能因長期活化在骨盆神經端部的肥大細胞而發炎。類似壓力誘發的生殖泌尿炎症已經在其他哺乳動物實驗中發現[15]。然而,前列腺炎組織學檢查與國立衛生研究院的慢性前列腺炎症狀指數之間沒有關聯[16]

細菌感染學說曾在這一領域長時間佔居主導地位,但於2003年在華盛頓大學由李博士(Dr Lee)和理查德·伯傑(Richard Berger)教授帶領的研究顯示細菌感染並不重要。該研究發現,三分之一正常男性或患者前列腺都有類近的細菌數量[17]。這一觀點得到了西北大學泌尿外科主任和教授安東尼·謝弗博士(Dr Anthony Schaeffer)贊同,在2003年的泌尿外科雜誌中,他指出「這些數據表明,細菌在慢性骨盆疼痛綜合症的病情發展中並不扮演一個顯著角色[18] 。」;並在一年後與他的同事發表他的研究,顯示抗生素對慢性前列腺炎/慢性骨盆疼痛綜合症基本上是無用的[19][20]。由於這些研究報告的發表,UCPPS的病因研究重點已經從感染轉移到神經肌肉、行為、心理和遺傳這些方面去研究(UCPPS:慢性前列腺炎/慢性骨盆疼痛綜合症、間質性膀胱炎/膀胱疼痛綜合症),其中強調下尿路和其他生理系統之間的相互作用[21]。現在的研究把UCPPS視為一種全身性疾病[21]。為佐證這項提議,2005年的研究表明,壓力是與第三類前列腺炎慢性前列腺炎/慢性骨盆疼痛綜合症)相關的[22]

與間質性膀胱炎/膀胱疼痛綜合症重疊

一些研究人員認為,慢性骨盆疼痛綜合症是間質性膀胱炎/膀胱疼痛綜合症的一種形式。2007年,美國國立糖尿病消化與腎病研究所英語National Institute of Diabetes and Digestive and Kidney Diseases開始把間質性膀胱炎/膀胱疼痛綜合症和慢性前列腺炎/慢性骨盆疼痛綜合症組合,統稱泌尿系統慢性盆腔疼痛綜合症(Urologic Chronic Pelvic Pain Syndromes )。對間質性膀胱炎/膀胱疼痛綜合症有效的治療,如槲皮素[23],在慢性前列腺炎/慢性骨盆疼痛綜合症中同樣有一些療效[24]。最近的研究集中在基因組學蛋白質組學方面的相關條件[25]

患者可能在膀胱充盈時出現疼痛,這也是膀胱疼痛綜合症的典型症狀[26]

氣候

環境溫度在病情上也扮演一個角色。患者很多時候會報告説寒冷引起症狀加重,熱力則很多時候會被報告説改善症狀[27]。這則顯得寒冷是可以引發導致慢性前列腺炎/慢性骨盆疼痛綜合症的過程的因素之一[28]。寒冷也會導致症狀加重和復發[28][29]。一項調查表明,居住在寒冷氣候下的芬蘭北部的男性前列腺炎症狀的發生率比在世界其它地方報告的數字高[30]

食物過敏

有證據表明,食物過敏和不耐受可能在慢性前列腺炎/慢性骨盆疼痛綜合症方面起了加重病情的作用,也許是肥大細胞的介導機制所致。也有一些證據表明在一些患者的泌尿系統慢性盆腔疼痛綜合症(如間質性膀胱炎/膀胱疼痛綜合症和慢性前列腺炎/慢性骨盆疼痛綜合症)與麩質不耐英語Non-celiac_gluten_sensitivity有關[31][32][33]。因此,患者通過識別問題食品然後把其從飲食中消除可能對減輕症狀有幫助。但這方面的研究較為缺乏。

診斷

沒有確切的對慢性前列腺炎/慢性骨盆疼痛綜合症的診斷測試。這是一種所知甚少的病症。儘管它佔所有前列腺炎診斷的90%-95%[34]。它可在任何年齡的男性中被發現,35-45歲為男性發病的高峰[35]。慢性前列腺炎/慢性骨盆疼痛綜合症可以根據前列腺液分泌物中的膿細胞水平,分為炎症(分類ⅢA)或是非炎症(分類ⅢB),但這些子類別在臨床上用途有限。在分類為炎症的情況下,尿液、精液、其它從前列腺流出來的液體包含膿細胞(死去的白血細胞或白細胞);而分類為非炎症的情況下,並無發現膿細胞存在。最近的研究質疑分類Ⅲa和Ⅲb之間的區別,因為如果膿細胞和更細微的跡象(如所測量的細胞因子)被忽略,這兩類都表明是炎症[36]

2006年,中國的研究人員發現,患有Ⅲa和Ⅲb型的男性在其前列腺按摩液(EPS)均具有抗炎細胞因子TGFβ1英語TGFβ1和促炎細胞因子干擾素伽瑪的顯著升高跡象(與對照組相比)。因此,這些細胞因子的測量可用於診斷第Ⅲ型前列腺炎[37]。2010年的研究發現,神經生長因子英語Nerve growth factor也可以用作作為一種生物標誌物來測量[38]

對於慢性前列腺炎/慢性骨盆疼痛綜合症患者,尿液分析並以此表示前列腺分泌物中白細胞是有爭議的,因為確定炎性和非炎性之間的差異是沒有任何作用[39]。血清PSA測試、前列腺常規影像、沙眼衣原體和脲測試對患者並不能提供任何好處[39]

>50%慢性骨盆疼痛綜合症患者存在前列腺外腹部/骨盆壓痛,但只有7%的痛楚受到控制[40]。健康男性在其精液發現的細菌比患有慢性骨盆疼痛綜合症的男性略多[41]。在無症狀的對照人群中,白細胞和細菌培養陽性的高發病率引起了人們對臨床應用4-glass test作為慢性前列腺炎/慢性骨盆疼痛綜合症診斷工具的疑惑[41]。美國泌尿外科醫生使用4-glass test目前是十分罕見,經常使用它的只有4%[42]

患上慢性前列腺炎/慢性骨盆疼痛綜合症的男性一般人更容易患上慢性疲勞綜合症[43]大腸激躁症

有些實驗測試可能在未來有用的,包括測量精液和前列腺液的細胞因子水平的測試。各種研究已表明在慢性前列腺炎/慢性骨盆疼痛綜合症中,炎症標記物會增加,如細胞因子[44]、髓過氧化物酶[45]、趨化因子[46][47]的水平升高。

鑑別診斷

有些狀態也有與慢性前列腺炎類似的症狀,膀胱頸部肥大和尿道狹窄可能由於尿液返流引起相似的症狀,可以通過膀胱鏡和尿動力學測試排除[48][49][50]

命名法

慢性前列腺炎/慢性骨盆疼痛綜合症有時會區分做IIIa型(炎症)和IIIb型(非炎症)[51],取決於膿胞(白細胞)是否可以在患者的前列腺液分泌物(EPS)中找到。一些研究者質疑這種分類的有效性並呼籲拋棄four-glass test[52]

2007年,美國國立糖尿病消化與腎病研究所英語National Institute of Diabetes and Digestive and Kidney Diseases以研究為目的,開始使用「泌尿系統慢性盆腔疼痛綜合症」此一傘式術語,指與膀胱(即間質性膀胱炎/膀胱疼痛綜合症)和前列腺(即慢性前列腺炎/慢性骨盆疼痛綜合症)有關的疼痛綜合症[53]

此疾病的舊版術語是前列腺痛和非細菌性前列腺炎。

治療

慢性骨盆疼痛綜合症是很難治療的[54]

心理治療和物理治療

第三類前列腺炎可能除了焦慮情緒外,並沒有任何的觸發因素。且患者經常伴有強迫症恐慌症或其他焦慮光譜的問題[55][56][57]。這理論上會令骨盆區域出現敏化狀態,令肌肉循環性地緊張,並提高神經反饋。目前的治療方案在很大程度上集中於使緊張的盆腔或肛門部位(通常被稱為激痛點)放鬆,方法包括直腸按摩、對該區域進行物理治療和放鬆療法,以減少致病的壓力。


有氧運動可以幫助那些沒患上慢性疲勞綜合症或不會由運動加劇痛苦症狀的慢性前列腺炎/慢性骨盆疼痛綜合症患者[58]。據報告,針灸也對一些患者有幫助[59]。慢性非細菌性前列腺炎(第III類),也被稱為慢性前列腺炎/慢性骨盆疼痛綜合症,這使得大多數男性被診斷為「前列腺炎」。一最近已經公佈了個稱為「斯坦福大學治療方案英語Wise–Anderson Protocol[13][14][60]的治療方案,其包括:

  • 藥物治療(使用三環類抗抑鬱藥苯二氮卓
  • 心理治療(矛盾放鬆(paradoxical relaxation)訓練,專門針對盆腔疼痛,早在20世紀期間由埃德蒙·雅各布森發展的一種漸進式放鬆技術)
  • 物理療法(盆底和腹部肌肉的激痛點釋放療法,而且進行瑜伽式的練習,以放鬆盆底和腹部肌肉為目的)[13][14]

生物反饋理療對學習如何控制盆底肌肉可能是有幫助的[61][62][63][64]。生物反饋對青春期的慢性前列腺炎治療是良好的療法(主要是治療排尿問題)[65]

藥理治療

許多藥物可用於治療這種疾病。α-受體阻滯劑英語Alpha blocker或抗生素似乎是最有效的。非甾體抗炎藥如布洛芬,提供的益處則較少[66]

  • 抗生素治療是有爭議的。有些抗生素已發現對病情有好處[66];但有些人質疑抗生素的效用[67]。抗生素已知具有抗炎特性,因此這被認為說明了它們的部分功效並建議用於治療慢性骨盆疼痛綜合症[18]。抗生素如喹諾酮類,四環素類和大環內酯類缺乏沒有感染的直接抗炎性質。阻斷細胞因子如白細胞介素1族白細胞介素-8腫瘤壞死因子,都在男性慢性前列腺炎患者的精液和列腺按摩液中發現升高的現象[68]
  • α-受體阻滯劑(坦索羅辛阿夫唑嗪)對慢性骨盆疼痛綜合症的有效性備受質疑,2006年的一項薈萃分析發現,他們在持續至少3個月的治療中度有益[69]
  • 雌激素再吸收抑製劑,例如美帕曲星英語Mepartricin,能改善排尿、減少神經疼痛,提高慢性非細菌性前列腺炎患者的生活質量[70]
  • 還沒有在臨床試驗中經妥善評價,但有軼事證據支持的藥物包括:加巴噴丁苯二氮䓬類阿米替林[71]

外科手術

經尿道針切除前列腺英語Transurethral needle ablation of the prostate已在實驗被證明無效[72]

流行病學

慢性骨盆疼痛綜合症的每年人口患病率為0.5%[73]。38%初級衛生保健提供者表示他們從來沒有見過慢性前列腺炎/慢性骨盆疼痛綜合症患者[74]。然而,暗示慢性前列腺炎/慢性骨盆疼痛綜合症的總患病率為6.3%[75]

預後

近年來,慢性前列腺炎/慢性骨盆疼痛綜合症的預後出現改善,歸因於多峰治療、植物療法,旨在通過激痛點釋放和控制焦慮,使骨盆神經平靜下來,還有治療慢性疼痛[76][77][78]

著名病例

參考資料

  1. ^ Schaeffer, A. J.; Datta, N. S.; Fowler Jr, J. E.; Krieger, J. N.; Litwin, M. S.; Nadler, R. B.; Nickel, J. C.; Pontari, M. A.; Shoskes, D. A.; Zeitlin, S. I.; Hart, C.; Chronic Prostatitis Collaborative Research Network. Overview summary statement. Diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Urology. 2002, 60 (6 Suppl): 1–4. PMID 12521576. doi:10.1016/S0090-4295(02)01979-9. 
  2. ^ Holt JD1 et al. Common Questions About Chronic Prostatitis. Am Fam Physician. 2016 Feb 15;93(4):290-6. PMID 26926816
  3. ^ Schaeffer AJ. Epidemiology and evaluation of chronic pelvic pain syndrome in men. Int J Antimicrob Agents. 2007, 31: S108–11. PMID 18164597. doi:10.1016/j.ijantimicag.2007.08.027. 
  4. ^ Luzzi GA. Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management. Journal of the European Academy of Dermatology and Venereology : JEADV. 2002, 16 (3): 253–6. PMID 12195565. doi:10.1046/j.1468-3083.2002.00481.x. 
  5. ^ Clemens, J Quentin; Meenan, Richard T; O'Keeffe Rosetti, Maureen C; Gao, Sara Y; Calhoun, Elizabeth A. Incidence and clinical characteristics of National Institutes of Health type III prostatitis in the community. J Urol. Dec 2005, 174 (6): 2319–22. PMID 16280832. doi:10.1097/01.ju.0000182152.28519.e7. 
  6. ^ Shoskes DA, Landis JR, Wang Y, Nickel JC, Zeitlin SI, Nadler R; Landis; Wang; Nickel; Zeitlin; Nadler; Chronic Prostatitis Collaborative Research Network Study Group. Impact of post-ejaculatory pain in men with category III chronic prostatitis/chronic pelvic pain syndrome. J. Urol. August 2004, 172 (2): 542–7. PMID 15247725. doi:10.1097/01.ju.0000132798.48067.23. 
  7. ^ Pontari MA, Ruggieri MR; Ruggieri. Mechanisms in prostatitis/chronic pelvic pain syndrome. J. Urol. May 2008, 179 (5 Suppl): S61–7. PMID 18405756. doi:10.1016/j.juro.2008.03.139. 
  8. ^ Anderson RU, Orenberg EK, Chan CA, Morey A, Flores V; Orenberg; Chan; Morey; Flores. Psychometric Profiles and Hypothalamic-Pituitary-Adrenal Axis Function in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome. J Urol. 2008, 179 (3): 956–60. PMC 2694575 . PMID 18207189. doi:10.1016/j.juro.2007.10.084. 
  9. ^ Dimitrakov J, Joffe HV, Soldin SJ, Bolus R, Buffington CA, Nickel JC; Joffe; Soldin; Bolus; Buffington; Nickel. Adrenocortical Hormone Abnormalities in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Urology. 2008, 71 (2): 261–266. PMC 2390769 . PMID 18308097. doi:10.1016/j.urology.2007.09.025. 
  10. ^ Theoharides TC, Cochrane DE; Cochrane. Critical role of mast cells in inflammatory diseases and the effect of acute stress. J. Neuroimmunol. 2004, 146 (1–2): 1–12. PMID 14698841. doi:10.1016/j.jneuroim.2003.10.041. 
  11. ^ Theoharides TC, Kalogeromitros D; Kalogeromitros. The critical role of mast cells in allergy and inflammation. Ann. N. Y. Acad. Sci. 2006, 1088: 78–99. Bibcode:2006NYASA1088...78T. PMID 17192558. doi:10.1196/annals.1366.025. 
  12. ^ Sant GR, Kempuraj D, Marchand JE, Theoharides TC; Kempuraj; Marchand; Theoharides. The mast cell in interstitial cystitis: role in pathophysiology and pathogenesis. Urology. 2007, 69 (4 Suppl): 34–40. PMID 17462477. doi:10.1016/j.urology.2006.08.1109. 
  13. ^ 13.0 13.1 13.2 Anderson RU, Wise D, Sawyer T, Chan C; Wise; Sawyer; Chan. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J. Urol. 2005, 174 (1): 155–60. PMID 15947608. doi:10.1097/01.ju.0000161609.31185.d5. 
  14. ^ 14.0 14.1 14.2 Anderson RU, Wise D, Sawyer T, Chan CA; Wise; Sawyer; Chan. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J. Urol. 2006, 176 (4 Pt 1): 1534–8; discussion 1538–9. PMID 16952676. doi:10.1016/j.juro.2006.06.010. 
  15. ^ Alexacos N, Pang X, Boucher W, Cochrane DE, Sant GR, Theoharides TC; Pang; Boucher; Cochrane; Sant; Theoharides. Neurotensin mediates rat bladder mast cell degranulation triggered by acute psychological stress. Urology. 1999, 53 (5): 1035–40. PMID 10223502. doi:10.1016/S0090-4295(98)00627-X. 
  16. ^ Nickel JC, Roehrborn CG, O'leary MP, Bostwick DG, Somerville MC, Rittmaster RS; Roehrborn; O'Leary; Bostwick; Somerville; Rittmaster. Examination of the relationship between symptoms of prostatitis and histological inflammation: baseline data from the REDUCE chemoprevention trial. J. Urol. 2007, 178 (3 Pt 1): 896–900; discussion 900–1. PMID 17632164. doi:10.1016/j.juro.2007.05.041. 
  17. ^ Lee JC; Muller CH; Rothman I; et al. Prostate biopsy culture findings of men with chronic pelvic pain syndrome do not differ from those of healthy controls. J. Urol. February 2003, 169 (2): 584–7; discussion 587–8. PMID 12544312. doi:10.1097/01.ju.0000045673.02542.7a (不活躍 2015-01-11). 
  18. ^ 18.0 18.1 Schaeffer AJ. Editorial: Emerging concepts in the management of prostatitis/chronic pelvic pain syndrome. J Urol. 2003, 169 (2): 597–598. PMID 12544315. doi:10.1016/S0022-5347(05)63961-4. 
  19. ^ Alexander RB; Propert KJ; Schaeffer AJ; et al. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann. Intern. Med. 2004, 141 (8): 581–9. PMID 15492337. doi:10.7326/0003-4819-141-8-200410190-00005. 
  20. ^ Nickel JC; Downey J; Clark J; et al. Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial. Urology. 2003, 62 (4): 614–7. PMID 14550427. doi:10.1016/S0090-4295(03)00583-1. 
  21. ^ 21.0 21.1 Multi-disciplinary Approach to the Study of Chronic Pelvic Pain. NIDDK—Department of Health and Human Services. 2007 [2008-02-12]. (原始內容存檔於2018-07-15). 
  22. ^ Ullrich PM, Turner JA, Ciol M, Berger R; Turner; Ciol; Berger. Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain. Annals of Behavioral Medicine. 2005, 30 (2): 112–8. PMID 16173907. doi:10.1207/s15324796abm3002_3. 
  23. ^ Theoharides, TC.; Whitmore, K.; Stanford, E.; Moldwin, R.; O'Leary, MP. Interstitial cystitis: bladder pain and beyond. Expert Opin Pharmacother. Dec 2008, 9 (17): 2979–94. PMID 19006474. doi:10.1517/14656560802519845. 
  24. ^ Murphy, AB.; Macejko, A.; Taylor, A.; Nadler, RB. Chronic prostatitis: management strategies. Drugs. 2009, 69 (1): 71–84. PMID 19192937. doi:10.2165/00003495-200969010-00005. 
  25. ^ Dimitrakov, J.; Dimitrakova, E. Urologic chronic pelvic pain syndrome—looking back and looking forward. Folia Med (Plovdiv). 2009, 51 (3): 42–4. PMID 19957562. 
  26. ^ Rourke W, Khan SA, Ahmed K, Masood S, Dasgupta P, Khan MS; Khan; Ahmed; Masood; Dasgupta; Khan. Painful bladder syndrome/interstitial cystitis: aetiology, evaluation and management. Arch Ital Urol Androl. June 2014, 86 (2): 126–31. PMID 25017594. doi:10.4081/aiua.2014.2.126. 
  27. ^ Hedelin H, Jonsson K; Jonsson. Chronic prostatitis/chronic pelvic pain syndrome: symptoms are aggravated by cold and become less distressing with age and time. Scand. J. Urol. Nephrol. 2007, 41 (6): 516–20. PMID 17853027. doi:10.1080/00365590701428517. 
  28. ^ 28.0 28.1 Hedelin H, Jonsson K; Jonsson. Chronic abacterial prostatitis and cold exposure: an explorative study. Scand. J. Urol. Nephrol. 2007, 41 (5): 430–5. PMID 17853032. doi:10.1080/00365590701365123. 
  29. ^ Gao DJ, Guo YS, Yu HY, Wang YJ, Cui WG; Guo; Yu; Wang; Cui. [Prevalence and related factors of prostatitis-like symptoms in young men]. Zhonghua Nan Ke Xue. December 2007, 13 (12): 1087–90. PMID 18284056 (中文). 
  30. ^ Mehik A, Hellström P, Lukkarinen O, Sarpola A, Järvelin M; Hellström; Lukkarinen; Sarpola; Järvelin. Epidemiology of prostatitis in Finnish men: a population-based cross-sectional study. BJU Int. September 2000, 86 (4): 443–8. PMID 10971269. doi:10.1046/j.1464-410X.2000.00836.x. 
  31. ^ Catassi C. Gluten Sensitivity. Ann Nutr Metab (Review). 2015,. 67 Suppl 2: 16–26 [2016-08-01]. PMID 26605537. doi:10.1159/000440990. (原始內容存檔於2016-03-16). 
  32. ^ Rostami K, Hogg-Kollars S. A Patient's Journey. Non-coeliac gluten sensitivity. BMJ. 2012, 345: e7982. PMID 23204003. 
  33. ^ Gluten and CP/CPPS. Prostatitis Network. [2016-03-16]. (原始內容存檔於2016-03-27). 
  34. ^ Habermacher GM, Chason JT, Schaeffer AJ; Chason; Schaeffer. Prostatitis/chronic pelvic pain syndrome. Annu. Rev. Med. 2006, 57: 195–206. PMID 16409145. doi:10.1146/annurev.med.57.011205.135654. 
  35. ^ Daniel Shoskes. Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Humana Press. 2008: 171. ISBN 1-934115-27-4. 
  36. ^ A Pontari, M. Inflammation and anti-inflammatory therapy in chronic prostatitis. Urology. Dec 2002, 60 (6 Suppl): 29–33; discussion 33–4. PMID 12521589. doi:10.1016/S0090-4295(02)02381-6. 
  37. ^ Ding XG, Li SW, Zheng XM, Hu LQ; Li; Zheng; Hu. [IFN-gamma and TGF-beta1, levels in the EPS of patients with chronic abacterial prostatitis]. Zhonghua Nan Ke Xue. 2006, 12 (11): 982–4. PMID 17146921 (中文). 
  38. ^ Watanabe, T.; Inoue, M.; Sasaki, K.; Araki, M.; Uehara, S.; Monden, K.; Saika, T.; Nasu, Y.; Kumon, H.; Chancellor, Michael B. Nerve growth factor level in the prostatic fluid of patients with chronic prostatitis/chronic pelvic pain syndrome is correlated with symptom severity and response to treatment. BJU Int. Sep 2010, 108 (2): 248–51. PMID 20883485. doi:10.1111/j.1464-410X.2010.09716.x. 
  39. ^ 39.0 39.1 Weidner W, Anderson RU; Anderson. Evaluation of acute and chronic bacterial prostatitis and diagnostic management of chronic prostatitis/chronic pelvic pain syndrome with special reference to infection/inflammation. Int J Antimicrob Agents. 2007, 31 (2): S91–5. PMID 18162376. doi:10.1016/j.ijantimicag.2007.07.044. 
  40. ^ Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S; Berger; Elmi; Landis; Propert; Zeitlin; Chronic Prostatitis Collaborative Research Network Study Group. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J. Urol. 2008, 179 (2): 556–60. PMC 2664648 . PMID 18082223. doi:10.1016/j.juro.2007.09.088. 
  41. ^ 41.0 41.1 Nickel JC, Alexander RB, Schaeffer AJ, Landis JR, Knauss JS, Propert KJ; Alexander; Schaeffer; Landis; Knauss; Propert; Chronic Prostatitis Collaborative Research Network Study Group. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J. Urol. 2003, 170 (3): 818–22. PMID 12913707. doi:10.1097/01.ju.0000082252.49374.e9. 
  42. ^ McNaughton Collins, M.; Fowler, FJ.; Elliott, DB.; Albertsen, PC.; Barry, MJ. Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?. Urology. Mar 2000, 55 (3): 403–7. PMID 10699621. doi:10.1016/S0090-4295(99)00536-1. 
  43. ^ Leslie A Aaron; et al. Comorbid Clinical Conditions in Chronic Fatigue: A Co-Twin Control Study. J Gen Intern Med. 2001, 16 (1): 24–31. PMC 1495162 . PMID 11251747. doi:10.1111/j.1525-1497.2001.03419.x. 
  44. ^ He, L.; Wang, Y.; Long, Z.; Jiang, C. Clinical Significance of IL-2, IL-10, and TNF-alpha in Prostatic Secretion of Patients With Chronic Prostatitis. Urology. Dec 2009, 75 (3): 654–7. PMID 19963254. doi:10.1016/j.urology.2009.09.061. 
  45. ^ Pasqualotto, FF.; Sharma, RK.; Potts, JM.; Nelson, DR.; Thomas, AJ.; Agarwal, A. Seminal oxidative stress in patients with chronic prostatitis. Urology. Jun 2000, 55 (6): 881–5. PMID 10840100. doi:10.1016/S0090-4295(99)00613-5. 
  46. ^ Penna, G.; Mondaini, N.; Amuchastegui, S.; Degli Innocenti, S.; Carini, M.; Giubilei, G.; Fibbi, B.; Colli, E.; et al. Seminal plasma cytokines and chemokines in prostate inflammation: interleukin 8 as a predictive biomarker in chronic prostatitis/chronic pelvic pain syndrome and benign prostatic hyperplasia. Eur Urol. Feb 2007, 51 (2): 524–33; discussion 533. PMID 16905241. doi:10.1016/j.eururo.2006.07.016. 
  47. ^ Khadra, A.; Fletcher, P.; Luzzi, G.; Shattock, R.; Hay, P. Interleukin-8 levels in seminal plasma in chronic prostatitis/chronic pelvic pain syndrome and nonspecific urethritis. BJU Int. May 2006, 97 (5): 1043–6. PMID 16643489. doi:10.1111/j.1464-410X.2006.06133.x. 
  48. ^ Chiari R. Urethral obstruction and prostatitis. Int Urol Nephrol. 1983, 15 (3): 245–55. PMID 6654631. doi:10.1007/BF02083011. 
  49. ^ Hruz P, Danuser H, Studer UE, Hochreiter WW; Danuser; Studer; Hochreiter. Non-inflammatory chronic pelvic pain syndrome can be caused by bladder neck hypertrophy. Eur. Urol. 2003, 44 (1): 106–10; discussion 110. PMID 12814683. doi:10.1016/S0302-2838(03)00203-3. 
  50. ^ Romero Pérez P, Mira Llinares A; Mira Llinares. [Complications of the lower urinary tract secondary to urethral stenosis]. Actas Urol Esp. 1996, 20 (9): 786–93. PMID 9065088 (西班牙語). 
  51. ^ Prostatitis: Benign Prostate Disease: Merck Manual Professional. [2010-04-17]. (原始內容存檔於2010-04-28). 
  52. ^ Treatment of Chronic Prostatitis. www.medscape.com. [2010-04-18]. (原始內容存檔於2017-04-27). 
  53. ^ Multi-disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. NIDDK. 2007 [2008-01-11]. (原始內容存檔於2018-07-15). 
  54. ^ Potts J, Payne RE; Payne. Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key. Cleveland Clinic journal of medicine. May 2007, 74 (Suppl 3): S63–71. PMID 17549825. doi:10.3949/ccjm.74.Suppl_3.S63. 
  55. ^ Anderson, RU.; Orenberg, EK.; Morey, A.; Chavez, N.; Chan, CA. Stress induced hypothalamus-pituitary-adrenal axis responses and disturbances in psychological profiles in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol. Nov 2009, 182 (5): 2319–24. PMID 19762053. doi:10.1016/j.juro.2009.07.042. 
  56. ^ Li, HC.; Wang, ZL.; Li, HL.; Zhang, N.; Chen, HW.; Zhang, P.; Gan, WM.; Chong, T.; Wang, ZM. [Correlation of the prognosis of chronic prostatitis/chronic pelvic pain syndrome with psychological and other factors: a Cox regression analysis]. Zhonghua Nan Ke Xue. Aug 2008, 14 (8): 723–7. PMID 18817346. 
  57. ^ Clemens, JQ.; Brown, SO.; Calhoun, EA. Mental health diagnoses in patients with interstitial cystitis/painful bladder syndrome and chronic prostatitis/chronic pelvic pain syndrome: a case/control study. J Urol. Oct 2008, 180 (4): 1378–82. PMC 2569829 . PMID 18707716. doi:10.1016/j.juro.2008.06.032. 
  58. ^ Giubilei G; Mondaini N; Minervini A; et al. Physical activity of men with chronic prostatitis/chronic pelvic pain syndrome not satisfied with conventional treatments—could it represent a valid option? The physical activity and male pelvic pain trial: a double-blind, randomized study. J. Urol. 2007, 177 (1): 159–65. PMID 17162029. doi:10.1016/j.juro.2006.08.107. 
  59. ^ Rosted P. Chronic prostatitis/chronic pelvic pain syndrome and acupuncture—a case report. Acupunct Med. 2007, 25 (4): 198–9. PMID 18160930. doi:10.1136/aim.25.4.198. 
  60. ^ The Stanford Protocol. 2005 [2006-12-09]. (原始內容存檔於2021-03-07). 
  61. ^ Cornel EB, van Haarst EP, Schaarsberg RW, Geels J; Van Haarst; Schaarsberg; Geels. The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III. Eur. Urol. 2005, 47 (5): 607–11. PMID 15826751. doi:10.1016/j.eururo.2004.12.014. 
  62. ^ Clemens, J. Q.; Nadler, R. B.; Schaeffer, A. J.; Belani, J.; Albaugh, J.; Bushman, W. Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology. 2000, 56 (6): 951–955. PMID 11113739. doi:10.1016/S0090-4295(00)00796-2. 
  63. ^ Kaplan, S. A.; Santarosa, R. P.; D'alisera, P. M.; Fay, B. J.; Ikeguchi, E. F.; Hendricks, J.; Klein, L.; Te, A. E. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. The Journal of Urology. 1997, 157 (6): 2234–2237. PMID 9146624. doi:10.1016/S0022-5347(01)64727-X. 
  64. ^ He, W.; Chen, M.; Zu, X.; Li, Y.; Ning, K.; Qi, L. Chronic prostatitis presenting with dysfunctional voiding and effects of pelvic floor biofeedback treatment. BJU international. 2009, 105 (7): 975–977. PMID 19751259. doi:10.1111/j.1464-410X.2009.08850.x. 
  65. ^ Li, Y.; Qi, L.; Wen, J.; Zu, X.; Chen, Z. Chronic prostatitis during puberty. BJU international. 2006, 98 (4): 818–821. PMID 16978277. doi:10.1111/j.1464-410X.2006.06386.x. 
  66. ^ 66.0 66.1 Anothaisintawee, T; Attia, J; Nickel, JC; Thammakraisorn, S; Numthavaj, P; McEvoy, M; Thakkinstian, A. Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis.. JAMA: The Journal of the American Medical Association. Jan 5, 2011, 305 (1): 78–86. PMID 21205969. doi:10.1001/jama.2010.1913. 
  67. ^ Wagenlehner, FM.; Naber, KG.; Bschleipfer, T.; Brähler, E.; Weidner, W. Prostatitis and male pelvic pain syndrome: diagnosis and treatment. Dtsch Arztebl Int. Mar 2009, 106 (11): 175–83. PMC 2695374 . PMID 19568373. doi:10.3238/arztebl.2009.0175 (不活躍 2015-01-11). 
  68. ^ Shoskes DA. Use of antibiotics in chronic prostatitis syndromes. Can J Urol. June 2001,. 8 Suppl 1: 24–8. PMID 11442994. 
  69. ^ Yang G, Wei Q, Li H, Yang Y, Zhang S, Dong Q; Wei; Li; Yang; Zhang; Dong. The effect of alpha-adrenergic antagonists in chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis of randomized controlled trials. J. Androl. 2006, 27 (6): 847–52. PMID 16870951. doi:10.2164/jandrol.106.000661. ...treatment duration should be long enough (more than 3 months) 
  70. ^ Cohen JM, Fagin AP, Hariton E, Niska JR, Pierce MW, Kuriyama A, Whelan JS, Jackson JL, Dimitrakoff JD. Therapeutic Intervention for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/ CPPS): A Systematic Review and Meta-Analysis. PLOS ONE. 2012, 7 (8): e41941. Bibcode:2012PLoSO...741941C. PMID 22870266. doi:10.1371/journal.pone.0041941. 
  71. ^ Curtis Nickel, J; Baranowski, AP; Pontari, M; Berger, RE; Tripp, DA. Management of Men Diagnosed With Chronic Prostatitis/Chronic Pelvic Pain Syndrome Who Have Failed Traditional Management. Reviews in urology. 2007, 9 (2): 63–72. PMC 1892625 . PMID 17592539. 
  72. ^ Leskinen, MJ.; Kilponen, A.; Lukkarinen, O.; Tammela, TL. Transurethral needle ablation for the treatment of chronic pelvic pain syndrome (category III prostatitis): a randomized, sham-controlled study. Urology. Aug 2002, 60 (2): 300–4. PMID 12137830. doi:10.1016/S0090-4295(02)01704-1. 
  73. ^ Taylor BC; Noorbaloochi S; McNaughton-Collins M; et al. Excessive antibiotic use in men with prostatitis. Am. J. Med. May 2008, 121 (5): 444–9. PMC 2409146 . PMID 18456041. doi:10.1016/j.amjmed.2008.01.043. 
  74. ^ Phillp Hannno. Defining The Urologic Chronic Pelvic Pain Syndromes: A New Beginning—An International Symposium. Urotoday. [2008-07-22]. (原始內容存檔於2015-02-22). 
  75. ^ Daniels NA, Link CL, Barry MJ, McKinlay JB; Link; Barry; McKinlay. Association between past urinary tract infections and current symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome. J Natl Med Assoc. May 2007, 99 (5): 509–16. PMC 2576075 . PMID 17534008. 
  76. ^ Duclos, AJ.; Lee, CT.; Shoskes, DA. Current treatment options in the management of chronic prostatitis. Ther Clin Risk Manag. Aug 2007, 3 (4): 507–12. PMC 2374945 . PMID 18472971. 
  77. ^ Shoskes, DA.; Katz, E. Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep. Jul 2005, 6 (4): 296–9. PMID 15978233. doi:10.1007/s11934-005-027-0 (不活躍 2015-01-11). 
  78. ^ Bergman, J.; Zeitlin, SI. Prostatitis and chronic prostatitis/chronic pelvic pain syndrome. Expert Rev Neurother. Mar 2007, 7 (3): 301–7. PMID 17341178. doi:10.1586/14737175.7.3.301. 
  79. ^ Anderson goes. Australian Broadcasting Corporation Transcript. [2008-05-12]. (原始內容存檔於2016-10-28). 
  80. ^ The Intimate Sex Lives of Famous People. Doubleday. 2008 [2010-12-21]. ISBN 9781932595291. 
  81. ^ Allison Reitz. John Cleese tour pays the 'Alimony' with West Coast comedy shows. tickenews.com. July 2009 [2009-07-28]. (原始內容存檔於2009-07-28). The star of Monty Python and "A Fish Called Wanda" has been diagnosed with prostatitis, the inflammation of the prostate gland and is undergoing treatment. 
  82. ^ Roger Ebert. The whole truth from Vincent Gallour Flies. Chicago Sun Times. [2008-05-30]. (原始內容存檔於2008-05-13). 
  83. ^ Glenn Gould as Patient. [2008-05-12]. (原始內容存檔於2008-06-07). 
  84. ^ Dallek, Robert. An Unfinished Life: John F. Kennedy 1917-1963. Boston: Little, Brown. 2003: 123 [2016-08-02]. ISBN 0-316-17238-3. (原始內容存檔於2010-03-26). 
  85. ^ The Howard Stern Show for September 4, 2007. Howard Stern. [2008-05-12]. (原始內容存檔於2013-03-21). 
  86. ^ The Howard Stern Show for September 5, 2007, PULLING OUT A PLUM. Howard Stern. [2008-05-12]. (原始內容存檔於2013-03-21). 
  87. ^ Leavitt, David. Styron’s Choices. NY Times. 2008-05-11 [2008-05-12]. (原始內容存檔於2018-11-18). 

外部連結