Chronic bacterial prostatitis (NIH type II): diagnosis, therapy and influence on the fertility status F. M. E. Wagenlehner 1 , T. Diemer 1 , K. G. Naber 2 & W. Weidner 1 1 Clinic for Urology and Paediatric Urology, Justus Liebig University, Gießen, Germany; 2 Technical University, Munich, Germany Introduction The prostatitis syndrome is one of the most common enti- ties encountered in urologic practice. Classification of the prostatitis syndrome is based on the clinical presentation of the patient, the presence or absence of white blood cells in the expressed prostatic secretion (EPS), and the presence or absence of bacteria in the EPS (Schaeffer, 1999). Prosta- titis is described as chronic where symptoms are present for at least 3 months. The classification of the prostatitis syndrome is best performed by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)/ National Institutes of Health (NIH; Krieger et al., 1999). Category II chronic bacterial prostatitis is caused by chronic bacterial infection of the prostate with or without prostatitis symptoms and usually with recurrent urinary tract infection (UTI) caused by the same bacterial strain. Chronic bacterial prostatitis is the most frequent cause for recurrent UTI in young and middle-aged men. Epidemiology The incidence of bacterial prostatitis in a managed care population may be higher than previously reported. One study evaluated new physician-diagnosed prostatitis cases in a managed care population over a 2-year interval (Clemens et al., 2005). The incidence of bacterial prostati- tis in this study was 1.26 cases per 1000 men per year. Pathogenesis The bacteriology of chronic bacterial prostatitis has been described in carefully investigated patients from tertiary care institutions (Krieger & McGonagle, 1989; Weidner et al., 1991a). These series report that Gram-negative bacilli (especially Escherichia coli) were responsible for the great majority of cases (Table 1). Clinical series of patients used to support approval of antibiotics for treat- ment of chronic bacterial prostatitis have reported a Keywords Bacterial prostatitis—fluoroquinolones— infertility—management—NIH classification Correspondence Dr Florian M. E. Wagenlehner, Clinic for Urology and Paediatric Urology, Justus Liebig University, Rudolf-Buchheim-St. 7, 35385 Gießen, Germany. Tel.: +49 641 994 4518; Fax: +49 641 994 4509; E-mail: wagenlehner@aol.com Summary In only approximately 10% of men with symptoms of chronic prostatitis/ chronic pelvic pain syndrome bacterial infection of the prostate can be demon- strated by the Meares and Stamey 4-glass or the pre- and post-prostate massage (PPM) two-glass test. Chronic bacterial prostatitis is mainly caused by Gram- negative uropathogens. The role of Gram-positives, atypicals and anaerobes is still debatable. For treatment, fluoroquinolones are considered the drugs of choice because of their favourable pharmacokinetic properties and their antimi- crobial spectrum. As relapse and re-infection are a major problem in chronic bacterial prostatitis, only the results of studies with a follow up period of at least 6 months are meaningful. Analysing the concentrations of various fluoro- quinolones in prostatic and seminal fluid as well as in prostatic tissue, it becomes, however, obvious that fluoroquinolones differ not only in plasma concentrations, but also in their penetration ability to these sites. Nevertheless, the concentrations at the site of infection of most fluoroquinolones with this indication should be sufficient for the treatment of chronic bacterial prostatitis caused by susceptible pathogens. On the other hand, male accessory gland infection has been linked to male infertility. However, there is still a lack of evidence showing that bacterial prostatitis would have a negative impact on sperm quality. ª 2008 The Authors 100 Journal Compilation ª 2008 Blackwell Publishing Ltd Æ Andrologia 40, 100–104