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Les prostatites chroniques: Microbiologie; Thérapeutique

Chronic prostatitis: microbiology and treatment

Resume

La prostatite chronique est une pathologie qui englobe un groupe hétérogène de pathologies infectieuses et non infectieuses, la plupart étant insuffisamment explorés pour déterminer l’étiologie. C’est la cause urologique de consultation la plus commune chez les moins de 50 ans et la troisième chez les plus de 50 ans. Le système de classification pour les syndromes de prostatite a été mis à jour récemment afin de faciliter une classification de référence concernant les affections prostatiques sans adopter une méthodologie diagnostique claire concernant les moyens d’identification d’un éventuel agent microbien.

II existe actuellement plusieurs outils diagnostiques microbiologiques peu utilisés par les urologues dans cette indication. L’analyse du premier jet d’urine et des sécrétions prostatiques avant et après massage prostatique dans le cadre de l’épreuve de Meares Stamey reste le meilleur outil diagnostique pour retrouver les bactéries à croissance facile.

Le développement de la recherche de matériel génétique (biologie moléculaire) apporte aujourd’hui une aide considérable, en cas d’épreuve de Meares Stamey négative, pour la recherche des bactéries à développement intracellulaire. Les bactéries les plus fréquemment en cause restent les entérobactéries,Escherichia coli en premier, mais selon l’histoire de la maladie d’autres bactéries sont retrouvées. Les bactéries intra-cellulaires (Chlamydia, Mycoplasma,...) sont retrouvées grâce aux nouvelles méthodes diagnostiques sans pouvoir les incriminer de façon certaine dans la physiopathologie du syndrôme prostatique chronique.

L’association Sulfamethoxazole/Triméthoprime, les fluoroquinolones, en particulier les nouvelles ayant une activité anti-streptocoque et anti-anaérobies, les macrolides, ainsi bien sur que les β-lactamines à bonne diffusion intra-prostatique donnent des bons résultats dans cette entité nosologique.

Au vu de l’histoire clinique, de la documentation bactériologique ou en son absence et en faisant intervenir les paramètres pharmacodynamiques et pharmacocinétiques, un de ces antibiotiques sera retenu pour un traitement prolongé (10 à 12 semaines). C’est pourquoi et afin d’optimiser le choix entre ces différentes molécules, il est très important d’associer à la décision thérapeutique un microbiologiste.

Abstract

Chronic prostatitis/Chronic pelvic pain syndrome (CP/CPPS) represents an important health problem resulting in considerable morbidity and of health care expenditure. CP/CPPS is a multifactorial problem affecting men of all ages and all demographic characteristics. Over recent years, progress has been made in the epidemiology and diagnosis of CP/CPPS. A new universally accepted classification system has become the gold standard in the contemporary literature.

Men with CP/CPPS have significantly higher leukocyte counts in all segmented urine samples and expressed prostatic secretion (EPS) but not in semen. In segmented cultures, the urethral culture (first 10 ml of urine), EPS and first 10 ml of urine avoided immediately after prostatic massage are the “optimal” samples to detect the microbial agent.

According to the four-glass test with polymerase chain reaction testing (PCR), Chlamydia and/or Ureaplasma infection can be suspected in several cases, but their role in the pathogenesis of prostatitis remains speculative. However, testing for these infections is highly recommended in non-documented infections. Quantification, speed and specificity make real-time PCR a promising approach for the quantitative detection and identification of prostatic bacteria from CP/CPPS patients. Several antibiotics have a good correlation between pharmacokinetic/pharmacodynamic parameters and efficacy for antibiotics in the treatment of chronic prostatitis. Fluoroquinolones, cotrimoxazole and ceftriaxone have a bactericidal concentration to the main pathogens in the prostatic fluid of patients with subacute and chronic prostatitis and in prostatic tissue.

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Correspondence to Adel Ben Ali.

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Communication au XXo Congrès de la Société d’Andrologie de Langue Française, Orléans, 11–13 décembre 2003.

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Ben Ali, A. Les prostatites chroniques: Microbiologie; Thérapeutique. Androl. 14, 312–316 (2004). https://doi.org/10.1007/BF03034918

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Mots clés

  • prostatite chronique
  • syndrome prostatique
  • épreuve de Meares Stamey
  • Chlamydia
  • Mycoplasma
  • fluoroquinolones

Key words

  • chronic prostatitis
  • prostatic syndrome
  • Meares Stamey test
  • Chlamydia
  • Mycoplasma
  • fluoroquinolones