Correspondence

Chronic Prostatitis

N Engl J Med 2007; 356:423-424January 25, 2007

Article

To the Editor:

In his Clinical Practice article, Schaeffer (Oct. 19 issue)1 recommends the use of the Meares–Stamey 4-glass urine test in the diagnosis of chronic bacterial prostatitis. This investigation seems hard to justify since, as the author states, its accuracy and reliability have not been established.

The 4-glass test was shown to be of no value in the diagnosis of the chronic pelvic pain syndrome (category III prostatitis).2-4 Moreover, by today's standards, there have been no appropriate evaluations of this test in patients with chronic bacterial prostatitis. Specifically, this test and the 2-glass modification have not been compared with a diagnostic gold standard; therefore the sensitivities, specificities, and predictive values of these tests in the diagnosis of chronic bacterial prostatitis are unknown.

The 4-glass test is an undignified and often unpleasant procedure that involves prostatic massage, and like any investigation, it should not be undertaken without good reason. As Schaeffer points out, it is not widely used, even by urologists. I believe that the 4-glass test should currently be confined to research settings in which it is being evaluated.5

Graz Luzzi, M.D.
Buckinghamshire Hospitals, High Wycombe HP11 2TT, United Kingdom

5 References

1
Schaeffer AJ. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med 2006;355:1690-1698
Full Text | Web of Science | Medline

2
McNaughton Collins M, MacDonald R, Wilt TJ. Diagnosis and treatment of chronic abacterial prostatitis: a systematic review. Ann Intern Med 2000;133:367-381
Web of Science | Medline

3
Schaeffer AJ, Knauss JS, Landis JR, et al. Leukocyte and bacterial counts do not correlate with severity of symptoms in men with chronic prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study. J Urol 2002;168:1048-1053
CrossRef | Web of Science | Medline

4
Nickel JC, Alexander RB, Schaeffer AJ, Landis JR, Knauss JS, Propert KJ. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol 2003;170:818-822
CrossRef | Web of Science | Medline

5
Luzzi GA. Whither “chronic prostatitis”? Sex Transm Infect 2005;81:96-97
CrossRef | Web of Science | Medline

Author/Editor Response

In men with recurring urinary tract infections who have normal results on imaging and endoscopic evaluation, the prostate is a likely source of bacterial persistence, and the patient is likely to have chronic bacterial prostatitis. The only way to determine whether the prostate is the source of bacterial persistence is to perform a 2- or 4-glass test. This test has not been compared with a diagnostic gold standard because no diagnostic gold standard exists. Numerous clinical trials have used this test to diagnose chronic bacterial prostatitis and to evaluate antimicrobial therapy. The alternative would be to treat patients empirically with extended courses of antimicrobial therapy; this would appear to be injudicious, considering the potential side effects.

The 4-glass test has not been shown to be valuable in the management of the chronic pelvic pain syndrome, as noted, but it is being used in research settings in an effort to determine the causes of this condition.

Anthony J. Schaeffer, M.D.
Northwestern University Feinberg School of Medicine, Chicago, IL 60611
ajschaeffer@northwestern.edu

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