Talk:Prostatitis/Archive4

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Contents 1 Pathology Section 2 Neutrality 3 general reminders 4 New Edits 5 Edits Feb/22/2008 6 Lacking Neutral Point of View 7 Cleanup 8 Response 022508 9 Response 022608 10 Response 02/27/08 11 Better references 12 Response 030108 13 Response 030208 14 rewrite on urinary reflux 030408 15 Urinary Reflux Response 16 COI Tag — Justify or remove

Pathology Section

I'd like to get some help getting up a section on the pathology of prostatitis. My post below was reversed: The pathology of chronic prostatitis/chronic pelvic pain syndrome type III may provide clues to eventually understanding it's etiology. CPPS IIIa is by definition chronic prostatitis WITH inflammation of the prostatic fluid. In addition, a large NIH cohort study found that approximately 50% of men with CPPS III also had pus in the their urethras (urethral leukocytosis). [1] However, the NIH Cohort study failed to test for Chlamydia or any other atypical organisms that are known to cause urethritis. I quote the Wiki Pathology page here, which has already undergone consensus building, on the implications of inflammation: "Inflammation is a particularly important and complex reaction to tissue injury, and is particularly important in fighting infection. Acute inflammation is generally a non-specific response triggered by the injured tissue cells themselves, as well as specialized cells of the innate immune system and previously developed adaptive immune mechanisms. A localized acute inflammatory response triggers vascular changes in the injured area, recruits pathogen-fighting neutrophils, and begins the process of developing a new adaptive immune response. Chronic inflammation occurs when the acute response fails to entirely clear the inciting factor. While chronic inflammation can lay a positive role in containing a continuing infectious hazard, it can also lead to progressive tissue damage, as well as predisposing (in some cases) to the development of cancer.[11]" Wikipedia:Pathology

Which parts of that were not acceptable? I'm trying to trim it down to the part that is okay. Thanks. ReasonableLogicalMan 11:35, 4 November 2007 (UTC)

• Here is why the edit was reverted:

1. Wikipedia is not a crystal ball, see WP:CRYSTAL. So inserting star gazing speculation ("...may provide clues to eventually understanding...") is not on .
2. Secondly, the study Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. (PMID 12913707), done by the same group of scientists you reference above, but one year later, is more useful in this context because it went a step further and compared CPPS pts to controls, and found that "...the control population also had a high prevalence of leukocytes. Of the men with CP/CPPS 50% and 32% had 5 or more, or 10 or more white blood cells (WBCs) per high power field, respectively, in EPS compared to 40% and 20% of the control population." With such a small difference between controls and pts, the WBC count is not a useful parameter to study or monitor, which is what that study concluded: "The high prevalence of WBCs and positive bacterial cultures in the asymptomatic control population raises questions about the clinical usefulness of the standard 4-glass test as a diagnostic tool in men with CP/CPPS." WBCs were a little higher in urine for pts vs controls, but not significantly so.
3. Inflammation is not unique to infection by any means, and in CPPS is likely to arise from neuropeptide-mediated mast cell degranulation in the prostatic epithelium and prostatic urethra.   Skopp   15:25, 4 November 2007 (UTC)

Unfortunately, the abstract does not mention URETHRAL LEUKOCYTOSIS in the symptomatic patients or controls. And the study says, "Of the men with CP/CPPS 50% and 32% had 5 or more, or 10 or more white blood cells (WBCs) per high power field, respectively, in EPS compared to 40% and 20% of the control population." The trend is clear. The study may simply be underpowered. Please review the study and consider it's statistical power to find a 1% or 5% difference between patients. I would not want to miss a treatable infection in even one patient. ReasonableLogicalMan 00:06, 5 November 2007 (UTC) —Preceding unsigned comment added by Reasonablelogicalman (talk • contribs)

The study I cited is the follow-on study from the one you cited. The scientists involved decided that leukocyte measures are not useful. This was a high powered study by the premier group in the world studying prostatitis. I think we can rely on their conclusions, your concerns about urethral leukocytosis notwithstanding. Urethral leukocytosis is associated with chlamydia trachomatis, which usually yields easily to antibiotic treatment. Do you propose that the researchers in these studies completely overlooked possible chlamydial infection? If so, I'll contact the reseachers themselves and get their comments on your comment. Personally, I regard the chlamydia issue as settled and irrelevant. From Nickel's study on CPPS and infection [2]:

Although Mardh and Colleen (Mardh PA, Colleen S. Chlamydia in chronic prostatitis. Scand J Urol Nephrol. 1972;9:8-16) suggested that C trachomatis may be implicated in as many as one third of men with chronic prostatitis, their follow-up studies using cultures and serology could not confirm C trachomatis as a causative agent in idiopathic prostatitis.(Mardh PA, Ripa KT, Colleen S, et al. Role of Chlamydia trachomatis in non-acute prostatitis. Br J Vener Dis. 1978;54:330-14. Colleen S, Mardh PA. Effect of metacycline treatment on non-acute prostatitis. Scand J Urol Nephrol. 1975;9:198-204. Mardh PA, Ripa KT, Colleen S. Role of Chlamydia trachomatis in non-acute prostatitis. Br J Vener Dis. 1978;54:330-344.) Berger and colleagues (PMID 2913355) could not culture C trachomatis from the urethra in men with chronic prostatitis nor did they find a serologic or local immune response to C trachomatis in such patients. Shortliffe and co-workers (PMID 3537628) came to a similar conclusion when they evaluated antichlamydial antibody titers in prostatic fluid. Twelve percent of controls (compared with 20% of patients with nonbacterial prostatitis) had detectable antibodies. Doble and associates A search for infectious agents in chronic abacterial prostatitis using ultrasound guided biopsy(PMID 2679961) were not able to culture or detect Chlamydia by immunofluorescence in transperitoneal biopsies of abnormal areas of the prostates of men with chronic abacterial prostatitis. Although in the previous section evidence was presented that Chlamydia may be related to the development of chronic prostatitis, many of these studies had absent or inappropriate controls, did not control for urethral contamination, and employed many different techniques of variable sensitivity and specificity to detect Chlamydia. Krieger and colleagues Prokaryotic DNA sequences in patients with chronic idiopathic prostatitis (PMID 8940458) were only able to find Chlamydia in 1% of prostate tissue biopsy specimens from men with chronic prostatitis.

More recently, Chlamydia trachomatis was not found in any of the 84 CPPS pts that were part of the study Anaerobic seminal fluid micro-flora in chronic prostatitis/chronic pelvic pain syndrome patients. (PMID 16887698).

On the basis of these findings, modern research has discarded Chlamydia as a cause of Prostatitis Cat. III a&b. Now I know you feel differently, but until a proper, high powered study from a major center finds otherwise, it will not become part of Wikipedia.   Skopp   01:02, 5 November 2007 (UTC)

In the Krieger study you cite above, 1% of the patients had Chlamydia as you noted. The study also says, "Specific PCR assays detected Mycoplasma genitalium, Chlamydia trachomatis, or Trichomonas vaginalis in 10 patients (8%). Broad-spectrum PCR tests detected tetracycline resistance-encoding genes, tetM-tetO-tetS, in 25% of patients and 16S rRNA in 77% of subjects. The tetM-tetO-tetS-positive cases constituted a subset of the 16S rRNA-positive cases. Patients with 16S rRNA were more likely to have > or = 1,000 leukocytes per mm3 in their expressed prostatic secretion than men whose prostate biopsy specimens were negative for 16S rRNA (P < 0.001)." In the other study you reference, just above, of 84 patients, it says "In the CP/CPPS patients, the prevalence and/or count of some opportunistic bacteria was higher than in the control group." ReasonableLogicalMan(Talk 03:51, 5 November 2007 (UTC)

Quite so, but the Krieger study had no controls. Subsequent studies with asymptomatic controls found no significant difference on these parameters between the groups. As for the other study that found no trace of Chlamydia in any patients, but did find a higher number of "opportunistic bacteria" in semen, you'll have to weigh that up against the finding of insignificant differences in this parameter from other, better studies. The different environment is also a factor, since the average CPPS patient has usually had a lot of antimicrobial treatment, and hence an altered microflora.   Skopp   04:21, 5 November 2007 (UTC)

Please also note that the Krieger study in question provoked a follow-up study by Alexander et al (PMID 10096371) that found similar results in CPPS-free prostate cancer patients. And BTW there is no known association between CPPS and PCa.   Skopp   04:31, 5 November 2007 (UTC)

My position is that a neutral point of view allows for multiple theories of etiology based on the medical literature. The research appears to be ongoing because the disease of CPPS has not been solved. Your "subsequent studies," and "other, better studies," are not cited above. And again, the study you cited had controls, it says "In the CP/CPPS patients, the prevalence and/or count of some opportunistic bacteria was higher than in the control group." You say, "The different environment is also a factor, since the average CPPS patient has usually had a lot of antimicrobial treatment, and hence an altered microflora." A good point. Future studies should assess this. Of course, any study can be faulted. You can also say that studies that do not test all specimens including: urine, post-massage urine, prostatic fluid, prostatic biopsy, entire prostates, seminal vesicles, semen, and prostatic fluid from 4 to 10 repetitive prostatic massages are inadequate because of specimen bias. You can also say that all studies that do not test for all known infectious disease agents are inadequate because something may be missed. The very latest study on Medline on "prostatitis and infection" (1,187 articles) concludes that treating infection works on some patients, who would ordinarily be diagnosed as CPPS. The paper is entitled: "Eradication of unusual pathogens by combination pharmacological therapy is paralleled by improvement of signs and symptoms of chronic prostatitis syndrome." The study says, "Long-term improvement of signs and symptoms of prostatitis indicates that combination therapy is beneficial for symptomatic patients showing evidence of infection by unusual pathogens at the prostatic level." (PMID 17695415) Sweeping generalizations that CPPS is solved, or that studies have reached a clear consensus, and that ongoing research into etiology is not needed, or is not being done are unwarranted. Thus, I disagree with statements like this, quoting you: "modern research has discarded Chlamydia as a cause of Prostatitis Cat. III a&b." There are 224 abstracts on Medline under "prostatitis and Chlamydia" and 121 full text articles. The very first study says, "In the majority of patients C. trachomatis was demonstrated in parallel in EPS or VB3 by DNA/RNA hybridization method. Normal white blood cell count viewed per high power field <10 was found in 362 (68%) of 536 patients with symptoms of chronic prostatitis and C. trachomatis detected in EPS or VB3. These findings additionally suggest that C. trachomatis can be suspected as a causative pathogen in all categories of chronic prostatitis syndrome. Furthermore, this paper summarizes the results of five previously published clinical studies on the efficacy and tolerability of various treatment schemes for chronic chlamydial prostatitis, conducted from the beginning of 1999 until the end of 2003." (PMID 17868538). A study from the United Kingdom (Unit of Infection and Immunity, School of Medicine, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK.) is called: "Interaction of Chlamydia trachomatis serovar E with male genital tract epithelium results in secretion of proinflammatory cytokines" (PMID 17644708). It says, "From in vitro studies the suggestion that high levels of IL-6 could be a possible marker for chlamydial prostatitis is confirmed. Although not as marked a change, it is also suggested that higher IL-8 levels could be associated more with infection of the prostate than the urethra. Differential cytokine production by different male-derived epithelial cells could help determine the site of chlamydial infection and help in the study of pathogenesis." You say, "BTW there is no known association between CPPS and PCa." There is no reference for this statement. The literature leaves open the possibility of an association and suggests that more research is needed. An article on Medline says, "CONCLUSIONS: Chronic prostatitis is a common finding in radical prostatectomy specimens. Inflammation was associated with BPH and cancer but had a greater tendency to be associated with BPH." (PMID 11956490). Work on associations between clinical prostatic infection, asymptomatic prostatic infection, inflammation, and prostatic enlargement or prostate cancer appear to be ongoing. I await the neutral point of view edits of this prostatitis page, which I now understand are going to be done by the Administrator. Reasonablelogicalman(Talk 15:06, 5 November 2007 (UTC)

• Quick response, because my previous one should have been adequate:

1. You are now mostly quoting the studies from a little provincial Croatian hospital and stacking them up against the studies I used by some of the best prostatitis researchers in the world, from our top colleges and universities, using the newest equipment in sterile conditions. If you ferret around in Medline enough, you can find almost anything, as we all know. If I start a new page on CPPS, where we will have more room, you will be welcome to make a section summarising the best studies you can muster for your argument, but be prepared for me to edit in the countervailing findings.
2. The British study by Adrian Ely has to be seen in the context of his career, which has centred almost entirely around chlamydia. When one considers funding issues and how they hinge on findings, one should take cum grano salis any findings from a researcher with this single, narrow thread of interest, especially if those findings suggest that the researcher's special interest is more important than anyone has suggested thus far, and so deserves further study. Remember, several of the best scientists specializing in prostatitis, rather than chlamydia, could find little or no trace of chlamydia in CPPS pts (see above), whereas Ely and the Croatians find a high incidence. They can't all be right. And when you consider that treating CPPS pts for Chlamydia doesn't help, it is even more suggestive of no infection.
3. The "subsequent studies," and "other, better studies," refer to PMID 12544312 and PMID 12913707 inter alia.
4. While you say the research is "ongoing", I am not aware of any infection-specific study in the current NIH/NIDDK funding round. Do you have other info? Please share.
5. The Medline article count for "prostatitis and infection" (1,187 articles) is exactly why this area is deliberately de-emphasised by the NIH and researchers nowadays. There has been exhaustive research into this area, and the results are in, see studies in (3) above that reflect the findings of the Chronic Prostatitis Collaborative Research Network (CPCRN) and/or its individual members, and you are supposed to support the findings of this network, according to prostatitis.org. Yet you question them, preferring low-qual studies from obscure centres. Very puzzling ....
6. You say that I have claimed that CPPS is "solved". I never have said that, so you are using a straw man argument. But what is indisputably true is that since the landmark CPCRN studies that found against bacteria and antibiotics, the focus has changed. Just look at the areas funded in the NIDDK's lastest RFA[3].
7. You challenge my statement about a lack of association between prostate cancer and CPPS. I refer you to a study by Krieger, PMID 10569559, which found no cancer cells in CPPS pts, and the authors commented that this was unusual: "A final observation deserves comment. In our relatively large patient cohort we expected to find some incidental cancers of the prostate but none was noted ...".
8. You made a huge error by quoting the study that shows that chronic prostatitis is a common finding in radical prostatectomy specimens and using that to refer to CPPS patients. That study referred to histological inflammation of the prostate. The term "chronic prostatitis" is used there to refer to chronic tissue inflammation in the prostate, NOT to men with CPPS. I've already cited 2 good studies that show a low incidence of histological inflammation in CPPS prostates (here's one: PMID 10569559). So I think you are a little confused, about this point and more generally on the whole topic of CPPS.   Skopp   16:28, 5 November 2007 (UTC)

If confirmation of point (6) above is needed, see today's news [4]   Skopp   02:19, 6 November 2007 (UTC)

Neutrality

There are 4,503 about prostatitis on MEDLINE today. As an editor, I would present, AND ALLOW, the neutral point of view from all these studies. The Wiki prostatitis page currently says for chronic prostatitis/CPPS III that, "Theories behind the disease include autoimmunity, for which there is little published evidence, neurogenic inflammation and myofascial pain syndrome." There are 97 articles on MEDLINE under "autoimmune prostatitis" yet no references exist. There are no references in that sentence for "neurogenic inflammation" and "myofascial pain syndrome," and only a non-human study in the next sentence. A search on MEDLINE for "prostatitis neurogenic inflammation" finds 10 articles in total. A search on MEDLINE on "prostatitis and myofascial pain syndrome," finds 4 articles in total. Meanwhile a search on "prostatitis and chlamydia" reveals 225 articles. A search of "prostatitis and ureaplasma" reveals 92 articles. A search on "prostatitis and infection" reveals 1,187 articles. A search on "prostatitis and urine reflux" reveals 15 abstracts. A neutral point of view does not appear to be present on the Wiki prostatitis page. The term "pelvic myoneuropathy" which has 0 references on MEDLINE finally had to be removed by an Administrator's statement against it. The link to www.ChronicProstatitis.com was removed by an Admin. Two apparent SPAM links still exist to www.ChronicProstatitis.com - we are waiting for an Admin ruling on this at Wikipedia SPAM, or from the Administrators here. The Wiki prostatitis page says, "antibiotics are essentially useless for CP/CPPS." Only two antibiotics were studied: ciprofloxacin and levofloxacin. The studies didn't know what microbe they were treating, if any, so their use was a shot in the dark. Instead of a broad statement about all antibiotics the Wiki page should confine itself to the actual data from the studies. Indeed, antibiotics may not even penetrate the prostate adequately, as urologist Thomas Stamey published back in the 1960s, and definitive research has not been done since. Furthermore they may not be able to penetrate a chronically inflamed, infected, or obstructed prostate, or biofilms. The antibioticis studied have multiple pKa's and because of this may not be able to reach high concentrations in the prostate, especially in the chronically diseased prostate with it's own altered pH. The Wiki prostatitis page emphasizes the "Stanford Protocol" for treatment. The commercial, anonymous, website, ChronicProstatitis.com emphasizes the "Standford Protocol." The Wiki Prostatitis page says that, "Cat. III prostatitis may have no initial trigger other than anxiety, often with an element of Obsessive Compulsive Disorder or other anxiety-spectrum problem." No references are given and I do not feel that sentence reflects a neutral point of view. Prostate massage, and repetitive prostatic massage do not appear under treatment (181 articles on MEDLINE). Repetitive prostatic massage (weekly) as a therapy, can be found in Campbell's Urology all the way back to the the 1980's. Note: There is a link to the commercial, anonymous ChronicProstatitis.com website on the Wiki Prostate Massage page and the Wiki Prostate Massage page is in serious need of editing. You say, "You are now mostly quoting the studies from a little provincial Croatian hospital and stacking them up against the studies I used by some of the best prostatitis researchers in the world, from our top colleges and universities, using the newest equipment in sterile conditions." I previously posted 10 studies. You found fault in 3 of them. I am waiting for evaluation of the other 7. You say, "If you ferret around in Medline enough, you can find almost anything, as we all know." That's not true. You cannot find anything. You find hypotheses on MEDLINE that researchers study for merit, and then you find theories developed on larger bodies of medical studies. A neutral point of view would include all the working theories, and conclusions from large amounts of data. You say, "The British study by Adrian Ely has to be seen in the context of his career, which has centred almost entirely around chlamydia." So, if you're an expert, you are belittled for being an expert and discarded. I do not think that is a neutral point of view. You make a broad statement that, "... when you consider that treating CPPS pts for Chlamydia doesn't help, it is even more suggestive of no infection." It is also suggestive that antibiotics don't penetrate the prostate, as has been in the literature since the 1960s. I can find no study that demonstrates bacteriocidal concentrations of anti-chlamydial antibiotics in the prostates of men with CPPS III. It is also suggestive that obstruction, reflux, increased prostatic pressure, local immune deficiencies, or other problems might be affecting treatment trials with antibiotics. Bacterial resistance to antibiotics also needs to be taken into account. Lastly, several studies do find that treating Chlamydia helps, or turns Chlamydia tests negative, but they are belittled by you. One antibiotic therapy may be inadequate. It takes two antibiotics and a proton pump inhibitor to cure Helicobacter pylori in peptic ulcer disease. I think that a neutral point of view would include the possibility of Chlamydia, and the broader possibility of infection in general. One abstract says, "Genital Chlamydia trachomatis infection is the leading cause of bacterial sexually transmitted disease in industrialised countries, particularly among young people. The consequences of chlamydial infection may involve urethritis, cervicitis, pelvic inflammatory disease, ectopic pregnancy, tubal factor infertility, epididymitis and prostatitis. In addition, chlamydial infection increases the risk of acquisition of human immunodeficiency virus and has been associated with cervical cancer. Although screening programmes exist in a number of countries, the continuously increasing prevalence of chlamydial infections demonstrates the necessity for health authorities to establish effective screening policies, and the importance of defining a comprehensive European screening policy is emerging." (PMID 16104982). You say, "The Medline article count for "prostatitis and infection" (1,187 articles) is exactly why this area is deliberately de-emphasised by the NIH and researchers nowadays. There has been exhaustive research into this area, and the results are in." The research clearly has not been "exhaustive" and the "results are not in." Chronic prostatitis/CPPS III remains a disease of unknown etiology. A neutral point of view would look at all the research. The NIH RFA states that it wants "Studies examining infectious agents and/or biofilms as the underlying etiology for IC/PBS and/or CP/CPPS;". You say, "You challenge my statement about a lack of association between prostate cancer and CPPS." I challenged your neutral point of view. You cited a study that supported no link, I cited a study that did show a link between CPPS and prostate cancer. A neutral point of view would cite both. That's what I would do if editing the main page. You say, "You made a huge error by quoting the study that shows that chronic prostatitis is a common finding in radical prostatectomy specimens and using that to refer to CPPS patients. That study referred to histological inflammation of the prostate. The term "chronic prostatitis" is used there to refer to chronic tissue inflammation in the prostate, NOT to men with CPPS." I have reviewed the definition of CPPS and I find that CPPS Type 4 includes tissue inflammation of the prostate. "Category IV: Men in this category have no symptoms. This is also called "silent prostatitis," or asymptomatic prostatitis, and is surprisingly common. This is when significant numbers of white blood cells are seen in the prostatic fluid, the post-massage urine, the semen, or in a prostate biopsy." You cite a newspaper article to bolster your argument. I believe that Wiki Medicine articles should be based on the medical literature not on the popular press. Thousands of press articles, maybe hundreds of thousands, alleged that ulcers were cause by "stress." I would base my Wiki edits directly on the medical literature. Lastly, I am waiting for the neutral point of view editing to be done by an Administrator - take your time - I am in no hurry. Since, I'm a newbie, however, I'd like the Administrators to confirm their neutral relationships to both parties arguing here and explain a little bit about how they came to be here. Was it my "request for comment." I am not sure if that worked or not. Also, I'd like to know how more experts can be invited to edit Wiki Prostatitis. The issues of SPAM, copyright infringement, and neutral point of view also still need to be addressed. ReasonableLogicalMan(Talk 18:32, 6 November 2007 (UTC)

• I'll come back and answer in detail, but just skimming this, let me say that searches of medline for the word prostatitis is misleading because it refers to acute bacterial, chronic bacterial, Cat. III and Cat. IV prostatitis, all of which are completely different entities, and it also refers to histological prostatitis frequently referred to in papers on prostate cancer, and so any search of prostatitis will find many prostate cancer papers. Similarly, "autoimmune prostatitis" or "autoimmunity AND prostatitis" will find pages of papers on chemically-induced autoimmune prostatitis in rodents. The number of decent papers on autoimmunity and men with chronic pelvic pain is, as I said, vanishingly small. This is just another example of how your arguments sound "reasonable and logical" but really are just a jumbled conflation of poorly understood and isolated facts. Back later to wade through more of your posting.   Skopp   18:50, 6 November 2007 (UTC)

• Here's the next part of my answer. Let me firstly demolish your argument about the prostatic parenchyma and the alleged impenetrability thereof.

1. The prostates men with CPPS are well perfused with blood, in fact far better then normal men, according to doppler imaging: "The chronic prostatitis/pelvic pain syndrome was associated with increased blood flow to the prostatic capsule and diffuse flow throughout the prostatic parenchyma" PMID 10737481 Good blood flow aids antibiotic penetration. So there goes one level of support for your theory that antibiotics "may not be able to penetrate a chronically inflamed, infected, or obstructed prostate"
2. You say that "antibiotics may not even penetrate the prostate adequately, as urologist Thomas Stamey published back in the 1960s, and definitive research has not been done since". Well, that's simply wrong, as I'll show. Apparently everyone but you has moved on from the 1960s and Dr Stamey:
   1. So do antibiotics penetrate the prostate adequately? Why, yes they do. For instance, the quinolones penetrate very well. What does German prostatitis researcher Kurt Naber say about this issue? "Overall the concentrations ... of most of the fluoroquinolones should be sufficient for the treatment of chronic bacterial prostatitis and vesiculitis caused by susceptible pathogens." PMID 14535866 (Antibiotic therapy--rationale and evidence for optimal drug concentrations in prostatic and seminal fluid and in prostatic tissue).
   2. But even though the flouroquinolones achieve minimal inhibitory concentration (MIC), do they achieve minimum bactericidal concentration (MBC)? Why yes, they do! "The prostatic tissue concentrations of moxifloxacin were approximately twice as high as in corresponding serum. .... the serum and prostatic tissue concentrations of moxifloxacin were well above the MIC values of most important prostatic pathogens." PMID 17127224
   3. But that's only the quinolones, and they don't affect things like Chlamydia, do they? Why yes, they do. Ofloxacin is a great Chlamydia killer, and penetrates the prostate well. In fact, ofloxacin is better at killing Chlamydia than doxycycline, the old Chlamydia standby drug. "CONCLUSION: Ofloxacin can be recommended as the primary drug in the treatment of chlamydia-infected patients with chronic prostatitis" PMID 15474277 In vitro activity of fluoroquinolones, azithromycin and doxycycline against chlamydia trachomatis cultured from men with chronic lower urinary tract symptoms. Also see PMID 11678006 for more proof about ofloxacin achieving MIC in the prostate.
   4. That's all very well, you say, but everyone uses azithromycin these days against Chlamydia, not Ofloxacin! No wonder none of the men with CPPS (whom you say actually have hidden fastidious Chlamydial infections) ever get well, eh? And azithromycin won't penetrate the prostate anyway! You seem to make a strong case here, Reasonablelogicalman. (Forgive my use of straw men, but if you can do it, I can too). But nope, sorry Reasonablelogicalman, you are wrong again. Azithromycin, an extremely commonly prescribed antibiotic given to most men with non-BPH LUTS eventually, is actually a great penetrator of the prostate. "The mean concentration of azithromycin in human prostatic tissue (2.54 micrograms/ml) 14 h after 500 mg oral dosing (two 250 mg doses 12 h apart) was much greater than plasma concentrations (less than or equal to 0.1 micrograms/ml). Azithromycin was slowly eliminated from prostatic tissue (half-life 60 h) and a mean concentration of 0.62 micrograms/ml remained 137 h after dosing." PMID 1722460 Concentration of azithromycin in human prostatic tissue "So what!", you cry. Azithromycin is needed in higher concentrations than that to kill the Chlamydia lurking in prostates! Not so? No, wrong again, it's waaaay more than you need to wipe out Chlamydia (all strains) and similar tiny, fastidious bacteria: "All the C.t. strains tested were susceptible to the action of azithromycin (MIC range 0.125-1.0 microgram/ml)" PMID 7830100 Chlamydia trachomatis genitourinary infections: laboratory diagnosis and therapeutic aspects. Evaluation of in vitro and in vivo effectiveness of azithromycin. So is azithromycin successful against chlamydia, given that it gets into the prostate easily? Yes, about 100% successful PMID 10572491 Azithromycin and doxycycline in the treatment of non-gonococcal urethritis in males

All of the above makes your statement "I can find no study that demonstrates bacteriocidal concentrations of anti-chlamydial antibiotics in the prostates of men with CPPS III" seem a bit odd, or absurd. I'll be back to answer more of your screed later. :)   Skopp   01:06, 7 November 2007 (UTC)

1. You complain that the page does do not cover prostate massage (your personal favorite treatment, concerning which you have written two papers). But it does — look again at the page. It is mentioned, and found wanting: PMID 16566972.
2. You say that a NPOV of the Prostatitis page "would include all the working theories". That's not true. Not all details of a topic, even if verifiable, are automatically suitable for inclusion in the encyclopedia (see "What Wikipedia is Not"). However, I see no reason why we cannot expand the theories section when the page is split, and there is more space.
3. Whoops! Another big error from you above. There is no such thing as "CPPS Type 4". You do not even know the basic classification system for Prostatitis. You say "I cited a study that did show a link between CPPS and prostate cancer". No, my friend, you did not.
4. Lastly, no, I do not link to a "newspaper article" in the External Link section, but to an online (and print) mens' health periodical. Such links are well within the guidelines, your personal dislike of them notwithstanding.   Skopp   01:40, 7 November 2007 (UTC)

Oh, and BTW, the external link to chronicprostatitis.com on the Prostate massage page was inserted by another editor see diff. Perhaps it was done because that looks like a pretty good page on prostate massage at chronicprostatitis.com. And one more point: you keep referring to chronicprostatitis.com as "commercial" and "anonymous", but the owner is interviewed and named in the article linked via the External Links, and the site sells nothing. What can you buy from them? It does have a few adverts, as do almost all sites these days, including your site at prostatitis.org. The fee to join the forum is for site maintenance, according to them. So not anonymous, and not commercial.   Skopp   02:22, 7 November 2007 (UTC)

RESPONSE: 1. The study cited under number 1 above indicates that increased blood flow is a PATHOLOGICAL response. An argument has been raised that since PATHOLOGICAL blood flow is increased, antibiotics must penetrate. Antibiotics do not perfuse only according to blood flow. They must diffuse into the prostate tissue. A leading theory is that they penetrate according to ionic diffusion. Thus it is the pKa of the chronically inflamed or infected prostate that is the problem not necessarily blood flow. In addition, a study has shown increased intraprostatic pressure, (PMID 11743292) meaning important capillary blood flow could be diminished or absent. I conclude exactly what your cited abstract does, “....our knowledge is still limited concerning the mechanisms that govern the transport of antibiotic drugs into and their activity in the various prostatic compartments and how the findings can be applied clinically.” In addition, the study does not seem to be on CPPS III patients, as it says, “Studies have been carried out mainly in healthy volunteers. The results have to be interpreted with caution....” 2. The study you cite in number 2 above, according to the abstract, apparently was done in BPH patients not CPPS III patients. The abstract says, “The aim of this prospective study was to investigate the penetration of moxifloxacin into prostatic tissue in patients with benign prostatic hyperplasia.” 3. For your argument number 3, I again quote from your abstract, “The investigation of chlamydia survival in the presence of antibiotics in patients with CPS and C. trachomatis prior to treatment is recommended.” I also quote from their next study, “Chlamydia trachomatis is one of the possible aetiological agents of chronic prostatitis.” (PMID 16026425). You also quote another study that is on BPH patients having surgery and NOT on CPPS III patients, and I quote from them, “To compare the concentrations of two fluoroquinolones, ofloxacin (OFLX) and norfloxacin (NFLX), in the prostate glands of patients who underwent transurethral resection of the prostate....” 4. In number 4 above you argue about azithromycin that “No, wrong again, it's waaaay more than you need to wipe out Chlamydia (all strains) and similar tiny, fastidious bacteria." - What similar tiny, fastidious bacteria are you talking about? It is this assumption that you know that bacteria can be cured, when you don’t even know what they are, that I question. The history of the specialty of infectious disease is rife with the failure of antibiotics - see 162,730 articles on Medline under “antibiotic resistance.” 5. You say, "... seem a bit odd, or absurd. I'll be back to answer more of your screed later.” In your list, I still find no studies of men with CPPS III who have had had testing done for bacteriocidal concentrations of antibiotics in the prostatic against all the agents implicated in CPPS III. And if we do find one - great. It is research that needs to be done. I support doing such research. If such papers are done, however, antibiotic resistance will still exist. - I did however, find an article on nanobacteria [5], that performed in vitro sensitivity testing. Nanobacteria are implicated in chronic prostatitis (PMID 15643213). Your two favorite antibiotics, the quinolones and azithromycin failed miserably when tested. Besides, achieving bacterialcidal concentrations would be just the first step. There are still issues of bacterial resistance, biofilms, prostatic obstruction, calcification, inactivation of antibiotics by pKa, and polymicrobial infections, all problems to consider. - You say that there is no such thing as "CPPS Type 4". Yes, there is. Category IV CPPS: Men in this category have no symptoms. This is also called "silent prostatitis," or asymptomatic prostatitis, and is surprisingly common. This is when significant numbers of white blood cells are seen in the prostatic fluid, the post-massage urine, the semen, or in a prostate biopsy. - You mention prostatitis.org and claim that it is my site. Prostatitis.org is a 501(c)3 non-profit Prostatitis Foundation's website. Prostatitis.org, is run by a board of directors and is an all-volunteer organization. Looking back through wiki Prostatitis, I see that Prostatitis.org was the first site ever linked from the Wiki Prostatitis page. I did not link to it way back then. I did not even know this Wiki page existed then. I have not been REPEATEDLY linking to any site. Yet, ChronicProstatitis.com has REPEATEDLY ensured that it is linked to one way or another, and has gotten away with this. ChronicProstatitis.com, is the same entity that destroyed sci.med.prostate.prostatitis with SOCK PUPPETS, anonymous remailers, and it's constant spamming and flaming. I invite anyone to search that USENET group. - I’d like to repeat: I am waiting for the neutral point of view editing to be done by an Administrator. Since, I'm a newbie, however, I'd like the Administrators to confirm their neutral relationships to both parties arguing here and explain a little bit about how they came to be here. Was it my "request for comment." I am still not sure if that worked or not. Also, I'd like to know how more experts can be invited to edit Wiki Prostatitis. The issues of SPAMMING, copyright infringement, and neutral point of view still need to be addressed.ReasonableLogicalMan(Talk 21:51, 7 November 2007 (UTC)

1. The detailed results of another Finnish intraprostatic pressure study (PMID 10971269) by Aare Mehik, the same researcher you quote in (1) above, does not entertain the sort of speculation you indulge about pressure/infection. Despite ranging over all nuances and aspects of the results, Mehik, an academic researching urologist and specialist in the area of CPPS, does not even mention an enhanced micro-environment for infection. You, a retired general practitioner, know more than he does? Forgive me if I am sceptical. The no original research rules therefore make this area off limits.
2. A lot of your points above try to discredit the studies I used on the basis that they refer to antibiotic penetration into men with BPH rather than prostatitis. I, and more importantly the medical community, do not accept that there are enough physiological differences in the two groups to make any substantive difference to antibiotic penetration. Pressure rises in all areas of inflammation and edema in the body, including areas of infection, as Mehik points out in his epidemiological study linked above. Yet this does not mean antibiotics are less useful or fail to percolate into areas of reduced capillary vasodiameter. I think you are clutching at straws here.
3. You continually deride the fact that modern approaches to the etiology of CPPS mention "stress". You should therefore take note that Dr Mehik says, in his epidemiological study of men with CPPS that "Men with prostatitis have considerable psychic stress, and some degree of psychic difficulty (anxiety, depression, affect lability, weak masculine identity) has been discovered earlier in 80% of patients with chronic prostatitis, while signs of severe psychic disturbance have been reported in 20 to 50% of cases (Keltikangas-Järvinen et al. 1981, Keltikangas-Järvinen et al. 1982, Keltikangas-Järvinen et al. 1989, de la Rosette et al. 1992a, de la Rosette et al. 1993b, Berghuis et al. 1996)."
4. Referring once again to the study cited above by researcher Mehik, he mentions that none of the TURP samples taken from men with CPPS showed any signs of cancer. So there is ∴ no basis for believing CPPS and cancer are associated ? quod erat demonstratum.
5. It's quite interesting that he finds that "present results based on information given by the respondents ... showed men suffering from prostatitis to be 2 to 4 times more busy, nervous and meticulous than those without this disorder."' More support for non-microbial etiology, I guess. :)
6. Careful PCR and other advanced studies of CPPS prostate biopsies do not support the existence of some unknown strain of fastidious bacteria.
7. The nanobacteria and CPPS issue, entirely driven by just one researching urologist (who owns shares in Nanobac Pharmaceuticals Inc), is a subject that should be mentioned in the enhanced page on CPPS.
8. No, there is no such thing as "Category IV CPPS". There is Prostatitis Category III: Chronic prostatitis/CPPS and there is Prostatitis Category IV: Asymptomatic inflammatory prostatitis. Have you got that now?
9. You keep obsessively attacking chronicprostatitis.com, but that has nothing to do with this conversation or with the content that should go onto the Prostatitis page. Please keep focused on the topic and keep your personal vendettas against various sites and people under control.
10. I am removing your references to private individuals by name from this page as it is off topic and strictly not allowed on talk pages.
11. To briefly answer your other issues:

• Spam: I cannot see a spam issue on the Prostatis page or any spam issue relating to chronicprostatitis.com, since the site is not linked from the external links section. You cannot say that a site is spamming because it is linked via another link to a link. There is simply nothing in the wikipedia guidelines and rules about that. They say you cannot have links designed purely to promote a site, but if the linked site actually has useful and relevant content — and the links currently there are useful and relevant — then there is no need to be draconian. I think unless others feel that almost all external links should be removed, your singular wish to see this happen will have to remain unfulfilled.
• Copyright infringement: we have no copyrighted material on the Prostatitis page and no known infringements on linked pages.
• NPOV: I have suggested a broader approach on a new CPPS page; are you not interested in this?   Skopp   00:47, 8 November 2007 (UTC)

general reminders

I came here indirectly, from links on another page, and am a little started at the nature of the discussion, so I mention some general principles: 1. All editors at WP are equal, except for considerations of COI. 2. Any threat or even suggestion to disclose the real names of editors without their explicit permission will result in banning from WP. 3. This is a general encyclopedia. Medical articles are expected to be accessible to the general educated reader, and written in a non-technical manner. 4. This is not the place to offer advice on medical diagnosis or therapy. Such matters are often best handled by links to reliable 3rd party websites with no possible COI, such as Medline Plus. 5. This is not the place to argue the correctness of possible scientific theories. All respectable theories are to be discussed, with appropriate weight, which means only very brief consideration of fringe theories. 6. WP is not the place to publish original work. This includes one's original synthesis of the literature. The reason for this is that we do not have the structure for proper peer review. 7. Primary research articles in the journal literature are acceptable sources--if used in context. To summarize the state of knowledge, reliable review articles serve much better. To summarize the accepted consensus, recent textbooks do very well. 8. Not all peer-reviewed journals are of equal standing. The application of these to the article should be obvious. If not, I'll be back for some hints. DGG (talk) 17:38, 15 November 2007 (UTC)

New Edits

A review article states that, "Prostatitis symptoms may increase a man's risk for benign prostate hypertrophy, lower urinary tract symptoms and prostate cancer." (PMID 18164907)ReasonableLogicalMan(Talk 13:58, 14 January 2008 (UTC)

• Identify the subtype of prostatitis to which this refers. Acute bacterial prostatitis, for example, is a completely different animal to CPPS. You cannot apply that finding to 4 different entities, :) ? RATEL ? 15:28, 14 January 2008 (UTC)

Urologist Federico Guercini in a review article notes that his group searched for Chlamydia while other researchers (such as Dr. Anthony Schaeffer who is quoted below did not), and Guercini concluded that 34% of chronic “non-bacterial” prostatitis patients actually suffered from Chlamydia trachomatis infections. (PMID 17695413) Meanwhile, urologist Daniel Shoskes, has proposed an emerging pathogen, nanobacteria, as a potential cause of chronic prostatits/CPPS III, seeing patients improve from anti-nanobacteria therapy and suggesting that around 50% of CPPS III patients may be suffering from nanobacterial infection. (PMID: 15643213)ReasonableLogicalMan(Talk 13:58, 14 January 2008 (UTC)

• I moved the nanobacteria study to the section dealing with unculturable bacteria — even though it is a fringe, preliminary study that should not be on the page, since WP is not an exhaustive compendium of all research, especially not tiny preliminary studies. David should remove it if he thinks it is too arcane. I removed the Guercini study completely because it makes no reference to any such finding in the abstract (34% infected), and because several major, high powered studies have found contrary results. And I invite David to take a look at the poor quality of the Guercini abstract (PMID 17695413).? RATEL ? 15:28, 14 January 2008 (UTC)

Urologist J. Curtis Nickel, in talking about CPPS III acknowledges that, "Many researchers feel that the majority of patients with prostatitis do, in fact, have a microbial etiology for their disease, but that we are just not culturing the correct organism." And notes that new research into infection as a possible cause of chronic prostatitis of unknown etiology is ongoing based on the CPPS classification system. [6]ReasonableLogicalMan(Talk 14:32, 14 January 2008 (UTC)

• Why are you digging up 8 year old overview studies, that have no conclusion, and that have been outdated by later research? I quote the study's conclusion below:

Is chronic prostatitis an infectious disease? It can be appreciated that the etiologic basis of chronic prostatitis symptoms has been poorly understood. Unfortunately, the field still remains confusing. Evidence can be found in the research literature to support the traditional dogma (that approximately 5% of chronic prostatitis is an infectious disease), or the hypothesis that chronic prostatitis is an infectious disease (but we are just not culturing or identifying the organisms in the majority of cases), or the theory that chronic prostatitis does not represent an infectious disease at all (and any microorganisms we may identify are innocent bystanders or normal flora and are not associated with the symptomatology). Is chronic prostatitis an infectious disease? As we enter the 21st century, that question remains unanswered.

Nickel went on to co-author some landmark studies that effectively answer these questions. These landmark studies are cited in the WP page on prostatitis. In other words, RLM, why are you trying to insert all this inconsequential, low-qual and outdated material onto the page? ? RATEL ? 15:32, 14 January 2008 (UTC)

Edits Feb/22/2008

Changed to: The bacterial infection theory continues to be researched. Non-traditional uropathogens such as coagulase negative Staphylococcus species and Streptococcus species are being investigated.Nickel JC, Xiang J (2008). "Clinical Significance of Nontraditional Bacterial Uropathogens in the Management of Chronic Prostatitis". J. Urol.. doi:10.1016/j.juro.2007.11.081. PMID 18289570. ReasonableLogicalMan(Talk 03:47, 23 February 2008 (UTC) —Preceding unsigned comment added by Reasonablelogicalman (talk • contribs) 03:43, 23 February 2008 (UTC)

Changed to: and a year later with his colleagues he published studies showing that ciprofloxacin and levofloxacin are ineffective for CP/CPPS.[31][32] Prior form seems to suggest that all antibiotics were ineffective instead of only two. ReasonableLogicalMan(Talk 03:47, 23 February 2008 (UTC)

• You are all in a muddle again, RLM. Do we have to explain to you how CHRONIC BACTERIAL PROSTATITIS differs from CHRONIC PELVIC PAIN SYNDROME again? ? RATEL ? 04:18, 23 February 2008 (UTC)

The implication that I do not know the difference between chronic bacterial prostatitis and chronic pelvic pain syndrome is incorrect. You, however, are deleting posts that suggest CPPS might have an infectious etiology despite the medical literature, medical practice, and ongoing research. ReasonableLogicalMan(Talk 16:40, 23 February 2008 (UTC)

Lacking Neutral Point of View

This article lacks a neutral point of view. For starters, I will point out one section, the section entitled Category III: CP/CPPS. This article is mostly written by one editor user:Ratel also known as user:skoppensboer.

• The material on this website mirrors a commercial website called ChronicProstatitis.com and links to that site with what I suspect are defaced copyrighted medical pictures.
• Changes by other editors are mostly deleted or changed. See the last few edits as an example.
• I believe that this page needs a moderator to do a neutral point of view edit and to moderate all future changes. And, other parties, with expertise need to be brought in to edit. I will tag the page as Lacking a Neutral Point of View.
• For example, let me explain what is wrong with two statements:

The site says, "The bacterial infection theory that for so long had held sway in this field was shown to be unimportant in a 2003 study from the University of Washington." It is wrong to make a sweeping conclusion based on one flawed study. Research is ongoing. (PMID 18289570)

• Another harmful statement is this one: "and a year later with his colleagues he published studies showing that antibiotics are essentially useless for CP/CPPS.[31][32]" It is wrong to imply that all antibiotics are useless when only ciprofloxacin and levofloxacin were tested and the proper conclusion is simply that in the men studied these two antibiotics were not beneficial.
• When I edited to correct these harmful errors, my edits were deleted by user:Ratel also known as user:skoppensboer.
• There is ongoing research into whether or not chronic prostatitis/chronic pelvic pain syndrome is an infection, an occult infection, an un-culturable infection, an infection by normal flora, or an infection by some organism not yet known. What is known is that 50% of cases are associated with urethral white blood cells of the polymorphonuclear variety. And that the majority of cases are probably associated with pus in the prostatic fluid when tested via repetitive prostatic massage.
• Lastly a spam notice has been put up because of the link to the commercial website ChronicProstatitis.com under the link section which goes to (http://www.geocities.com/myoneuropathy/). The link is spam in my opinion. It is a not-so-clever attempt to promote a commercial website ChronicProstatitis.com. The link should be deleted by a moderator as user:Ratel also known as user:skoppensboer repeatedly replaces the link after it is deleted. The link also uses apparently copyrighted medical pictures without proper attribution, consent, or permission. Previously the link had the pictures defaced with huge billboards that proclaimed "ChronicProstatitis.com." One such billboard ad in smaller size is still present. The link blatantly advertises the commercial website with more links to itself and mentions the "International Prostatitis Research Foundation" which does not appear to be run by medical professionals or to exist except to advertise clickable ads.

ReasonableLogicalMan(Talk 15:56, 23 February 2008 (UTC)

• You've just been warned to desist with the personal attacks, yet you continue. ? RATEL ? 00:36, 24 February 2008 (UTC)

User:Ratel's modus operandi is to personally attack people and then to falsely accuse them of personally attacking him, or to allege that factual posts are personal attacks. It's clever, but I do not think Wikipedian's will fall for this misdirection. I invite anyone to review User:Ratel's (previously know as user:skoppensboer) history on Wikipedia and his association with a commercial website. I invite anyone to compare my edits, done with genuine neutral point of view editing, and with a love of science, with his. I also invite everyone to see how User:Ratel has stalked me all over Wikipedia. ReasonableLogicalMan(Talk 02:00, 24 February 2008 (UTC)

The lacking neutral point of view tag was deleted by user:ratel. The tag: {{POV-section}} has been replaced. It must be not be removed except by a moderator. ReasonableLogicalMan(Talk 01:38, 24 February 2008 (UTC)

The spam tag was also removed by user:ratel. The tag: {{Cleanup-spam}} has been replaced as explained above. The spam tag may not be removed except by a moderator. ReasonableLogicalMan(Talk 01:50, 24 February 2008 (UTC)

• Oh God, this is like dealing with a demented child.

1. Links marked as spam by you were already discussed (see archives) and no grounds for removal were found, so I removed the spam template. You knew this, since you were part of that discussion. Why do you ignore consensus, even when the consensus included an admin?
2. This article has had numerous editors, not just me.
3. You are the only editor claiming that there is a lack of neutrality, mainly because your wish to include low quality, fringe studies was thwarted both by me and David Ruben, and DGG hinted above that you should not try to stack the article with minor research to POV push.
4. Your constant personal attacks not only break the rules, but they are boring, so why not desist, eh?
5. Your constant referencing of chronic prostatitis.com is baffling ... what on earth has this website got to do with the article's content?
6. I am not "stalking" you, but I am monitoring what you are doing on Wikipedia, and there's nothing wrong with that, nor does it break any rules that I am aware of. ? RATEL ? 03:11, 24 February 2008 (UTC)

Cleanup

Perhaps it would help resolve things to shorten the section on Cat III, and not try to give the arguments in detail, just present the alternatives. To start, I have been cleaning up some of the references, removing some of the minor ones, without looking at who it was who inserted them. This should not have the density of an advanced medical treatise. We do not usually give

I am not happy with the external links. I would more clearly like to understand the nature of the "International Prostatitis Research Foundation" site--one the one hand, it is clearly commercial; on the other, like many commercial sites, it has a good deal of clearly useful summary material. The "Diagrams" come from a specific recent book, given on that site--do they have permission to use it there? We are not responsible for external sites, but we do not link for the purpose of showing copyright violating material. Considering the nature of the site & the book, and that the site acknowledges it, they might however have permission. The Mayo site is obviously acceptable; we need some more like it. I will add some. 3. The third site, though certainly very readable, does not appear to meet the usual criteria of WP RS, and does not give a balanced view.

PMID 18164907 referred to above is listed as unavailable. does anyone have the actual reference? DGG (talk) 02:03, 25 February 2008 (UTC)

Thanks again for this input, DGG. In answer to some of your questions above:

1. I know the contact details of the person who maintains the International Prostatitis Research Foundation site, and I'll ask him for the data you require. Please give him a few days to reply before taking action on the link. I do believe he is amenable to requests for changes, and he did previously tell me that he has permission from the authors of the A Headache on the Pelvis book to show those images. The reason I think the site is so very important as an external link is that it really is the only site on the web, the only one, that focuses on this issue in this highly detailed, graphic way, and as such is a vital resource for readers who may be interested in the topic for personal health reasons. On the other hand, editor Reasonablelogicalman (RLM) seems to want to exclude this link because the site links to or mentions another site, one with which he is apparently feuding. This reasoning has nothing to do with the quality of wikipedia and has no place here.
2. In regards to your comment on the article called The Sex Destroyer, I think you'll find it is very balanced, if you read some of the modern research (last 3 years). The author of the article is Steve Rae, a journalist and prostatitis patient who spent over a year compiling that article, personally interviewing many of the leading researchers in the field, as well as people connected (I believe) to RLM. His article truly does represent the current state of the art in this area. If you need more details, I can ask Mr Rae to contact you.
3. I cannot help with the PMID problem; that was something RLM brought up. ? RATEL ? 02:34, 25 February 2008 (UTC)

• DGG, herewith followup from the Prostatitis Diagrams website: apparently some of the images are from one of the many free medical images databases on the web, where use is allowed for noncommercial and/or educational purposes. The images from the book by Dr Wise are with permission. The images from chronicprostatitis.com are with permission. The site sells nothing and makes no money for the editor. The adverts you see are placed by Geocities or Yahoo, I'm not sure which, as part of the hosting arrangement. The site has been there for nearly a decade with no copyright complaints, I'm told. So this is not a commercial website and not infringing copyright. Now why did user RLM not first ask Dr Wise before charging copyright infringement and wasting our time? ? RATEL ? 05:55, 26 February 2008 (UTC)

Dear user:DGG Good news. The images can now be linked to directly and can bypass the offensive billboard ads to ChronicProstatitis.com, which keep getting smaller by the way as the risk grows that the spam link will be recognized for what is it is, a commercial website written by an alleged lawyer. User:Ratel can now provide us with the direct links to the pictures on free medical images databases. Thus all ads and commercial websites can be avoided.ReasonableLogicalMan(Talk 16:32, 26 February 2008 (UTC)

That's not the way wikipedia works. Wikipedia does not link to offsite images. And what billboard ads are you talking about, and at which site? I think we are talking about different sites, perhaps. Who is this lawyer you keep referring to? I am finding your comments more and more obtuse... ? RATEL ? 21:48, 26 February 2008 (UTC)

Response 022508

Thanks for taking an interest user:DGG

• First, the reference was to (PMID 18289570) which is URL

[7] and title, "Clinical Significance of Nontraditional Bacterial Uropathogens in the Management of Chronic Prostatitis."

• Second, this Wiki page on prostatitis has been owned by ChronicProstatitis.com. It mirrors the content of ChronicProstatitis.com which is a commercial website written by an alleged attorney.
• All links to the commercial website should be removed. Since the appearance of user:ratel the prostatitis page has always linked to this commercial website and anytime links are removed they are replaced and followed by personal attacks.
• ChronicProstatitis.com has a history of spamming and flaming which can be seen on sci.med.prostate.prostatitis, where physicians were spammed and flamed by ChronicProstatitis.com until the newsgroup was ruined.
• The rules on spam links are clear and unequivocal. Wikipedia says, ""Currently link spammers enjoy a lot of advantages from the lack of cohesion to the spam fighting process. It is possible to sneak links into relatively unwatched articles successfully. Such links may lay unexamined for months, gaining the appearance of legitimacy from having remained in an article so long. When spam links are reverted, there is not much communication. Spammers can return and add links when different editors are watching who do not know their history of editing-with-an-agenda. Frequently spam contributors take advantage of Wikipedia's Assume good faith policy. They may engage in straw-man or special pleading arguments for inclusion of their links under the guise that they have only the welfare of Wikipedia at heart, usually in the presence of evidence to the contrary."
• ChronicProstatitis.com is full of ads, charges $20 to be a member of a forum, sells books, advertises a Stanford treatment protocol, and spews hatred and venom at anyone with different views as can be seen on Sci.Med.Prostate.Prostatitis or here on Wikipedia.
• I have contacted Dr. David Wise about whether he gave permission to have photographs from his book used in the spam link. Irregardless of whether he has or not, there are many other medical diagrams there that appear to be taken from copyrighted medical sources without permission. And, if Dr. David Wise did give permission to use a couple of the many graphics on the site, it will only be further evidence that the site exists simply to publicize the Stanford Protocol and the theories of user:ratel. Of the 13 photos on the spam link, only two are allegedly taken from Dr. David Wise, the rest appear to be from copyrighted medical sources without attribution, and were previously defaced with huge billboards over them that said CHRONICPROSTATITIS.COM.
• When in doubt the policy of Wikipedia is to always remove spam links.
• The Prostatitis page is "owned" by user:Ratel. You can see that almost all edits by anyone else are changed or deleted by user:ratel also known as user:Skoppensboer.
• There never seems to be any consequences for user:ratel. Despite being a longtime Wiki poster, when I appeared here as a newbie, he published my alleged initials, my alleged name, and even attacked my alleged father here without being banned.
• User:ratel does not allow any posts that suggest that chronic prostatitis/chronic pelvic pain syndrome might have an infectious etiology. As a self-professed patient it appears to be in his self-interest to do so, thus the neutral point of view is not allowed.
• Here are 226 references from Medline, many of which suggest that Chlamydia may be important in this disease:

[8].

• Here are 1,198 references, many of which suggest that infection may play a role in chronic prostatitis/chronic pelvic pain syndrome:

[9]

• Urologist Federico Guercini, a well-published physician, tests all patients with chronic prostatitis/chronic pelvic pain syndrome for Chlamdyia using the latest DNA techniques and frequently find this pathogen.

[10] The response of user:Ratel to any edits about this are personal attacks on Dr. Guercini, or myself. Please review the site history.

• Nanobacteria are a possible pathogen.
• Nontraditional Bacterial Uropathogens are a possible etiological factor.
• 50% of men with CPPSIII have urethral pus according to the NIH.
• Any suggestion of articles like this one, and there is a body of similar studies, have been deleted by user:ratel:

Eur Urol. 2007 May;51(5):1385-93. Interleukin 8 and anti-chlamydia trachomatis mucosal IgA as urogenital immunologic markers in patients with C. trachomatis prostatic infection. Mazzoli S, Cai T, Rupealta V, Gavazzi A, Castricchi Pagliai R, Mondaini N, Bartoletti R. STDs Centre, Santa Maria Annunziata Hospital, Florence, Italy. "OBJECTIVE: This study evaluates the role of interleukin 8 (IL-8) and anti-Chlamydia trachomatis (CT) immunoglobulin A (IgA) in total ejaculate (TE) of patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) as potential markers in prostatic CT infection." (PMID 17107749). The entire abstract is referenced but here are some results: "RESULTS: Thirty-five patients were positive for CT plasmid DNA, but none of the controls were positive. Mucosal IgA was detected in 69.2% of patients and significant levels of IL-8 were detected in 75.6% of them. Significant correlations between IL-8 and mucosal IgA (p<0.001) and between IL-8 levels and symptom score results (p<0.001) were found. IL-8 values strongly correlated with CP/CPPS (p<0.001). Moreover, the patients with higher levels of IL-8 and higher positivity for IgA reported the worst symptoms."

• The International Prostatitis Research Foundation appears to have no valid medical credentials and exists only to propagate the spamming of ChronicProstatitis.com and to show advertisements.
• The spam link to the commercial site ChronicProstatitis.com should be banned.
• User Ratel should be banned for lacking a neutral point of view, for stalking me on Wikipedia (see his edit history as both user:ratel and user:skoppensboer, for posting my alleged initials, my alleged name, and for attacking and libeling my alleged father, all on Wikipedia. If there are never any consequences for User:Ratel's actions, when he is a longtime Wikipedia poster, who has been in many such situations before, what can I do to except respond as I have done here? I would like to see the admins clarify the rules if needed and then act.
• The spam tag was removed by user:Ratel again! It has been replaced. The spam tag must not be removed except by a moderator. Wikipedia says, "Wikipedia spam also consists of external links to websites which primarily exist to sell goods or services, use objectionable amounts of advertising, or require payment to view the relevant content."
• Wikipedia also says, "Wikipedia exists for the purpose of creating a collaboratively edited encyclopedia, not for any individual to promote a site in which they have an interest."
• Wikipedia also says, "For policy or technical reasons, editors are restricted from linking to the following, without exception: 1. Material that violates the copyrights of others per contributors' rights and obligations should not be linked."

ReasonableLogicalMan(Talk 18:46, 25 February 2008 (UTC)

1. The entire issue of the external links was discussed in the archives, if anyone is interested, and the links to both prostatitis.org (RLM's site) and chronic prostatitis.com (one of the links I have added, at least I think I did, in any event I supported its inclusion) were removed by admin David Ruben (a practising doctor), who simultaneously checked out the other links mentioned above and thought they were Ok. Given that the links have been extensively discussed and vetted by consensus, why on earth are we facing this issue again? Does PLM not respect the judgement of the admins? Is he going to go shopping for an admin who will support him? Is RLM so determined to impose his will on this page that he is going to re-raise this issue every few months? I request that admin DGG please read this page's archives in full before coming to any conclusions based on the misrepresentations above.
2. The points of medicine RLM raises above are wrong, or (more) misrepresentations, or (perhaps deliberate) misunderstandings. If DGG wants an exact description of the mistakes, I can provide them. The many lopsided interchanges I have had with RLM on this topic should suffice to prove who has the clearest intellectual grasp of this area. In general, RLM has great difficulty distinguishing the various forms of prostatitis from one another. He also relies inordinately on obscure journals and "bee in the bonnet" single-topic researchers like Mazzoli, whose work has been clearly refuted (IgA seropositivity for Chlamydia antibodies has a low correlation to infection by Chlamydia (PMID 10782395) ). Another example is his reliance on papers by Guercini, who has had all his controversial work published in the very obscure Archivio Italiano di Urologia, Andrologia and is not supported by any other significant researcher in his claims. Let me quote his latest "study" abstract, it's a classic:

Arch Ital Urol Androl. 2007 Jun;79(2):76-83. Chronic prostatitis (CP)/chronic pelvic pain syndrome (CPPS): what do we know? Guercini F. Urologic Department, Università di Perugia, Perugia, Italy. To dissertate about chronic prostatitis/chronic pelvic pain syndrome is, in the beginning of the XXI century, more difficult and complex than before. Indeed the therapeutical and pathogenetic hypothesis chase, below and often contradict each other. In this review we have tried to underline the opinions of the most accredited researcher, leaving to the reader the possibility to throw one's due conclusions. PMID: 17695413 [PubMed - indexed for MEDLINE]

As for the rest of RLM's rant, I'm not going to deny all his crazy charges and accusations again, because it's already all in the archives and I have a life. But I would really appreciate some admin demanding that RLM stop his constant littering of this page with paranoid diatribes about other people, other websites, and all issues not related to the wikipedia page. ? RATEL ? 23:52, 25 February 2008 (UTC)

Response 022608

The important point is that user:DavidRuben deleted the direct spam link to ChronicProstatitis.com, a commercial website by an alleged attorney. The link was sneaked back in under the guise of "can't live without diagrams" that were billboard defaced with ChronicProstatitis.com. Of course, these billboards and other direct links keep getting less blatant as fear arises that the spam links to ChronicProstatitis.com will finally be banned. According to User:Ratel's own findings we can now link directly to the majority of those "can't live without" pictures directly without going through the spam link. Indeed, I have recently learned that there are Spamtars of Glory. Wiki says, "The coveted Spamstar of Glory is awarded to those who show strong contributions to tracking down and stopping spammers as well as cleaning up their links." We can start calling these people in. I am placing the conflict of interest tag on this page as the "owner" of this page has a conflict of interest relationship with ChronicProstatitis.com.

• I also note that above User:Ratel belittles a medical research paper for it's poor translation of an abstract from Italian to English rather than on it's medical merits. Said author, Guercini, and his colleagues have several articles in the peer-reviewed medical literature.
• Please note that User:Ratel cites articles by urologist J. Curtis Nickel, when they agree with his point of view, but when the latest paper was placed, which suggests that chronic prostatitis/chronic pelvic pain syndrome might sometimes have an infectious etiology, the reference was quickly deleted by user:Ratel.
• See: "Clinical Significance of Nontraditional Bacterial Uropathogens in the Management of Chronic Prostatitis." (PMID 182895700).
• Any medical edits I have placed that suggest, based on the medical literature, that infection may sometimes be involved are deleted. Here is another one for a moderator to place from a study in the journal of urology: "Prevalence, incidence estimation, risk factors and characterization of chronic prostatitis/chronic pelvic pain syndrome in urological hospital outpatients in Italy: results of a multicenter case-control observational study." This study in fact says, "Urethral swabs in patients with a negative Meares and Stamey test were positive for sexually transmitted pathogens in 6%." (PMID 17937946).
• Medical clinics all around the world test for infectious diseases in these patients and often find them. They do this because of the pathology of the disease being related to pus, and because of the published medical literature. It is harmful for patients to be totally unaware of this medical literature.

ReasonableLogicalMan(Talk 17:47, 26 February 2008 (UTC)

• I presume this latest rant was directed at me, so here goes:

1. The Prostatitis Diagrams website link existed on the prostatitis page before admin David Ruben removed the link to chronicprostatitis.com (and he only did that after your persistent demands, and it was a great shame that the link was removed, given that the forum at that website — of which I am a member — is the Internet's only coherent English-language forum on this topic, and has contributing researching urologist members, including Dr Daniel Shoskes, Dr Rodney Anderson, and others, even including the self-same Dr Federico Guercini, who posted there only yesterday!). Now the fact that the pre-existence of the Prostatitis Diagrams link was carefully explained to you a few months ago makes me wonder: do you perhaps have a memory problem of which we need to be aware? Have you had some sort of head accident, or brain surgery, that may have impaired your ability to recall things? This is not an insult or cheap shot, RLM — I am genuinely curious and concerned. Please answer.
2. The paper by JC Nickel (PMID 182895700) is not a paper about CPPS, it's about chronic bacterial prostatitis ("clinical prostatitis"). If you contend otherwise, please provide proof from the text of the paper itself. Nickel is very precise in his language, and nowhere is the term "CPPS" used.
3. "sexually transmitted pathogens in 6%." (PMID 17937946) — do you know the positive rate for STD pathogens in the normal population? If not, this figure is meaningless. Excellent studies have already shown that controls have more species of bacteria and higher colony counts of bacteria living in their prostates than CPPS patients; this evidence and the study in question is on the Prostatitis page already.
4. You keep referring to "pus" (actually leukocytes), i.e. dead white cells, and they only denote inflammation, not necessarily infection. This is basic medicine. ? RATEL ? 22:17, 26 February 2008 (UTC)

Response 02/27/08

Once again Tags that can only be removed by a moderator have been removed by User:Ratel. The tags have been replaced. {{Cleanup-spam}} {{COI2|date={{{February 26, 2008}}}}} And this new one has been added. {{POV}}, User:Ratel, supporter of the commercial website, ChronicProstatitis.com, a commercial website created by an alleged lawyer, known for its flagrant spamming and flaming of the USENET newsgroup sci.med.prostatitis, where it drove off a group of collaborating physicians and patients, continues to maintain "ownership" of this page. And inappropriately removes tags calling into question his neutral point of view, conflict of interest, and spamming. He admits above that the forum he runs, which costs $20, is a key feature of ChronicProstatitis.com. Wikepdia, however, expressly forbids linking to sites that cost money. User:Ratel please see this warning [redacted]

• In addition, User:Ratel makes further personal attacks, actually writing, "do you perhaps have a memory problem of which we need to be aware? Have you had some sort of head accident, or brain surgery, that may have impaired your ability to recall things?" It is of course totally inappropriate to make personal attacks. Not to edit in good faith. And, User:Ratel was previously warned that one more personal attack and he would be banned from Wikipedia. I hope the moderators will now act according to the rules. I am perfectly willing to to debate the medical issues and to edit in an neutral point of view.

ReasonableLogicalMan(Talk 00:18, 28 February 2008 (UTC

I said I was a member of that forum; I cannot understand your references to Usenet; I have told you that DGG is monitoring this situation and that tagging is inappropriate given this and also because another admin did not find any spam links here; and your continuous attempts to "out" me as [redacted] is enough cause to have you banned forever. My question about a brain problem was based on your clear inability to remember issues discussed before, not a personal attack. After this series of insane outbursts, I call for your indefinite banning from this site. --? RATEL ? 00:48, 28 February 2008 (UTC)

both of you please

1. stop reverting tags on the article. It is fair to say the COI is a real possibility & I have placed that tag. It is fair to say the section on III is disputed. The spam tag is not really needed--discuss the individual links instead.
2. Please look for better references to replace the ones from minor journal or non-english review articles--English ones are preferrred if available & for general articles on a subject like this there should be such.
3. Find some good neutral external links to major impartial sites. An impartial site can be distinguished by discussing a balance of possibilities on disputed matters., and by avoiding commercial links. I am not happy with either www.chronicprostatitis.com or www.prostatitis.org in terms of freedom from commercial spam on their sites. Neither show the properties of a good disease-oriented information site, such as www.diabetes.org, or www.nationalmssociety.org to mention two widely known ones. I have just removed both of them.
4. Stop referring to each other at all. Talk only about the article, and the facts, and not why someone may be editing. I give a general warning here that anyone who engages in personal attacks, or gives personal information about other editors from this point forward is likely to be blocked to prevent further disruption.
5. We deal with COI by carefully examining the merits of the proposed material. People with a COI can edit, but it is better if they make any possibly COI-influenced suggestions on the talk page. Based on the nature of the edits, there is every reason to think some of the participants here do have some COI. DGG (talk) 01:43, 28 February 2008 (UTC)

I stand by my edits. see the article talk page for comments: this is not the appropriate place. If you want to see what works well for medicine, see other articles. I suggest Tuberculosis. 1/there is no need to show the "deep pelvic muscles" in this context. WP is not a how to do it for therapy. 2/if the only mass circulation article is biased, what does it say about the notability? To me, it says that the mass circulation article is likely to have been in essence a press release. Don't fight over these ELs, rather, give me a chance to guide the rewriting to get mention proportionately of the range of suggested therapies. I plan to stick around here for a while, though of course anyone else is also welcome. DGG (talk) 03:55, 28 February 2008 (UTC)

• Oh dear, where should I start?

1. Tuberculosis is a simple infection about which no controversy has existed since the 19th century, so to compare the ELs in that to a syndrome that has had a complete revolution in its understanding in the last ten years (to paraphrase a quote by leading researcher JC Nickel ) is foolhardy, to say the least.
2. Showing the neuromuscular structures generating pain has nothing to do with a "How To" for treatment, and also nothing to do with "prostate massage" as you stated above. Nothing. You clearly have little understanding of this subject and just skimmed over the page in question. And really, DGG, who are you to tell men in agony that there is "no need to show" these structures? That's an astoundingly arrogant statement when you think how this disorder destroys mens' lives. I suggest you listen to this video. You may then have some grasp of the extent of this issue. Bias: YOU have decided the Mens Health Magazine article was biased, nobody else has. Doctor Ruben read it and did not think it was biased. Please, tell me, if you can, where the bias lies? There is absolutely no bias in that article, and absolutely no good reason to delink it. Notability? Are you saying that because this disease gets little or no press, it is not notable? What is your point please? ? RATEL ? 05:37, 28 February 2008 (UTC)

Better references

I am looking for references that are in accordance with Wiki guidelines. This government source, http://www.nlm.nih.gov/medlineplus/ency/article/000523.htm, says: "Chronic prostatitis is treated with an extensive course of antibiotics. Trimethoprim-sulfamethoxazole (Bactrim) and ciprofloxacin (Cipro) are commonly used. Other antibiotics that may be used include:

   * Tetracycline
   * Carbenicillin
   * Erythromycin
   * Nitrofurantoin

The course of antibiotic therapy is long -- frequently 6 to 8 weeks -- but may be continued much longer. Most antibiotics are not able to adequately penetrate the prostate tissue. Often, infectious organisms persist despite long periods of treatment.

After antibiotic treatment has ended, recurrence of symptoms is common." ReasonableLogicalMan(Talk 15:57, 28 February 2008 (UTC)

Dear User:DGG may I post a neutral point of view edit based on this article: "Clinical Significance of Nontraditional Bacterial Uropathogens in the Management of Chronic Prostatitis." by Nickel et. al. (PMID 182895700), and have it protected from being edited or reversed by user:Ratel. ReasonableLogicalMan(Talk 19:49, 28 February 2008 (UTC)

• The Medlineplus article you cite above is clearly a page concerning chronic bacterial prostatitis (Category II). Take a look at the "Alternative Name" given on the page. So yet again, you are stumbling around, confused about the subject, trying to edit the page into oblivion. DGG, the only way to stop this is to split this page up, because the 4 conditions described on the page are all quite different. It's like having all uterus-specific disorders on one page — preposterous, cluttered and prone to confusion. ? RATEL ? 21:37, 28 February 2008 (UTC)

Dear User:DGG there are 450 articles on Medline under the term prostatitis, with the limits English language and Review. May I be free to post based on these articles without being edited and reversed by User:Ratel? ReasonableLogicalMan(Talk 23:25, 28 February 2008 (UTC)

No, you may not. The term prostatitis does not denote CPPS, and to keep editing the CPPS section with articles, often obscure articles from obscure journals, concerning conditions — such as acute or chronic bacterial prostatitis, or histological prostatitis — that have nothing to do with CPPS, will be reverted immediately. ? RATEL ? 00:14, 29 February 2008 (UTC)

Dear Admin User:DGG please confirm which tags must remain on the article. Earlier you said, "It is fair to say the COI is a real possibility & I have placed that tag. It is fair to say the section on III is disputed." If I understand the history correctly, User:Ratel has removed your COI tag. Whatever happened, can we please put the COI tag back up? Wikipedia says, "A Wikipedia conflict of interest (COI) is an incompatibility between the aim of Wikipedia, which is to produce a neutral, reliably sourced encyclopedia, and the aims of an individual editor. COI editing involves contributing to Wikipedia in order to promote your own interests or those of other individuals, companies, or groups. Where an editor must forego advancing the aims of Wikipedia in order to advance outside interests, that editor stands in a conflict of interest."ReasonableLogicalMan(Talk 04:36, 29 February 2008 (UTC)

DGG asked you to stop talking about me and waging a vendetta, and talk about the page contents. Is this beyond your capabilities? I know the answer to that question. ? RATEL ? 05:54, 29 February 2008 (UTC)

general. I am aware of the difference between type II and type III, and I am aware that a proposed alternative name for type III or at least some of it is CPPS. RLM, you say this is disputed--do you have a reference?

suitable links and sources--I'm aware of the Medline Plus page, and it should be added as an external reference. Ratel mentioned the www.prostateuk.org site--RLM do you agree it is suitable? I havent checked it in detail myself yet. In general primary case reports are inappropriate here--this is not a medical encyclopedia. The sort of articles to cite are authoritative secondary reviews from major journals, and classic or break-through primary articles. I gather there is no really evidence-based overall meta-analysis of this subject yet? also I gather hat the first substantial controlled comparative therapeutic study is just starting? It should be mentioned.

As for the drawings, an external link to them is not appropriate here--they lend excessive weight to one particular suggested therapy, and will stay off until a/another admin asks me to put them back. and b/ I am convinced they are not copyvio. In controversial medical matters we use only official sites of recognized authority, not articles in popular magazines.

COI. I replaced the COI tag and it will remain until I am convinced there is a COI-free article or another admin asks me to remove it.

I have removed the cold exposure theory as the refs very clearly do not support it being a cause, but just an influence on the disease.

Evidence, please, that Nickel is a particularly recognized authority beyond other workers on the subject? I'm not saying he isnt.

I removed excessive typographical emphasis on the Stanford therapy. I would like a ref that it is considered a major advance by unconnected centers. A method who web site says "we can only really do it here, as we're the only people who do it right" tends to arouse a desire for some actual evidence of this.

personal comments. The COI paragraph is more personal than it should have been, but the response to it is a personal attack. To avoid aggravating things, I'm passing over both for now. I never block if I can persuade people to stop causing problems and I have not given up on that yet.

there are 2 complementary ways of handling a situation where authorities disagree. One describes and gives reference to each of the views. And one tries to find an overall authoritative source. I recognize this can be tricky in a period where consensus might be changing. DGG (talk) 21:17, 29 February 2008 (UTC)

Response 030108

Dear Admin User:DGG, Thanks for what you have done so far.

• First, and sorry, it's probably not a big thing, but when you say "RLM, you say this is disputed," I am not sure which thing you are referring to. Prostatitis has been divided into 4 categories by the NIH. The site currently says:
• Classification
• According to the 1999 National Institute of Health (NIH) Classification, there are four categories of prostatitis:

1. Category I: Acute prostatitis (bacterial)
2. Category II: Chronic bacterial prostatitis
3. Category III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)

• Subdivisions of IIIa (inflammatory) and IIIb (non-inflammatory) exist based on levels of pus cells in expressed prostatic secretions, but these subcategories are of limited use clinically

1. Category IV: Asymptomatic inflammatory prostatitis

• you ask, "Regarding the www.prostateuk.org site--RLM do you agree it is suitable?" I think it is not suitable. At least not yet. They have not produced a solid medical article based on the medical literature nor have they promoted or encouraged any prostatitis research that I am aware of. They are focused on prostate cancer and BPH. Recently, however, they did invite Dr. Antonio Espinosa Feliciano, M.D., to talk at a conference on his protocol for chronic prostatitis/chronic pelvic pain syndrome, which involves repetitive prostatic massage, extensive cultures and tests to find pathogens, and then treating patients with continued massage and multiple antibiotics and antimicrobials to treat those pathogens.
• ProstateUK did do a newspaper article, which already has a note attached to it by the way, which contains the usual "Ratel information".

[11]

• As in that article, I do agree that urine reflux is a possible etiology of Type III prostatitis. I would like put something about this up, based on the available medical research, without fear of reversion by Ratel.
• You say, "I gather there is no really evidence-based overall meta-analysis of this subject yet?" That is correct. If I were to write such an article and get it published in the peer-reviewed medical literature could it be linked to here? I will refrain for now.
• Thanks for placing the COI tag.
• Thanks for cleaning up the other stuff.
• Nickel is just another physician published in the medical literature. As yet, he is no better or worse than the others published in the medical literature, but he is prolific. The researcher who will be most important will be the one who solves or cures the disease.
• May I now be allowed to delete the inaccurate and harmful edits made by User:Ratel and have you review them for NPOV and to reject or allow those changes without being edited or reverted by User:Ratel?
• Thank you. ReasonableLogicalMan(Talk 16:42, 1 March 2008 (UTC)

1. Please note, DGG, that RLM says that a major newspaper article contains "the usual Ratel information". Or is it that Ratel tries to reflect the latest thinking? Does he seriously allege that I am influencing what journalists say? Or is he setting himself up against what researchers are saying nowadays?
2. Please note, DGG, the mention of "Feliciano", "pathogens" and "prostate massage". You may remember I mentioned these items to you recently, and their COI potential.
3. Urinary reflux can cause chronic prostatitis-like symptoms, and it is due to urethral stricture, and should be wikified to this page, if mentioned. It is not CPPS.
4. The COI tag certainly does apply to another editor present.
5. Nickel is not "just another physician", he is a Professor of Urology at Queen's University, and the only man in the world to author two books on this topic, including the only medical textbook on Prostatitis:

Textbook of Prostatitis [12]

The Prostatitis Manual: A Practical Guide to Management of Prostatitis/Chronic Pelvic Pain Syndrome [13]

? RATEL ? 19:51, 1 March 2008 (UTC)

I thought I had told you both not to refer to each other, just the edits. In both cases what was said was in my opinion violations of NPA. But as things do seem to be quieting down a little, Im still not blocking this time. I warn you that one more time, regardless of provocation, will exceed even my patience. If one of you denigrates the other, please do not reply to it in kind or call attention to it. I will see it myself, and this way you wont be blocked as well as the other guy.

Try to write an article on Nickel and see if it passes AfD. It might. Full professors in the UK usually do.

RLM, just which edits do you want to revert:?

One of you try to do an sentence or two on reflux as a possible cause and go ahead and insert it and we'll look at it. DGG (talk) 23:55, 1 March 2008 (UTC)

• DGG, Prof Nickel calls himself "J. Curtis Nickel", so would the WP entry be under Curtis Nickel or J. Curtis Nickel or even JC Nickel

? ? RATEL ? 02:51, 2 March 2008 (UTC)

According to our style, it should be Jeffrey C. Nickel, with a redirect from Jeffrey Curtis Nickel and J. Curtis Nickel. When you write it, do not emphasise his role with this disorder only--he seems to be known more generally as a urologist. DGG (talk) 17:24, 2 March 2008 (UTC)

Response 030208

Dear Admin user:DGG I have placed a post on urinary reflux in the document. Please protect it from COI editing. There are several medically inaccurate and harmful statements on the page. I will delete then one at a time so that you may judge them one by one and the deletions will not be subjected to COI. I am duplicating my post here so that it won't be lost.

• Urinary reflux into the prostate has been proven to occur and has been postulated to be a cause of chronic prostatitis/chronic pelvic pain syndrome. Kirby RS, Lowe D, Bultitude MI, Shuttleworth KE (1982). "Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis". Br J Urol 54 (6): 729–31. PMID 7150931.  Another research paper proposed that, “The underlying cause of the symptoms may be an inappropriate spasm of the distal urethra/external sphincteric unit, leading to increased pressure in the prostatic urethra with a resultant reflux of urine into the prostatic ducts.” Hellstrom WJ, Schmidt RA, Lue TF, Tanagho EA (1987). "Neuromuscular dysfunction in nonbacterial prostatitis". Urology 30 (2): 183–8. PMID 3497475. . Another study says, “The link between symptomatology and immunology could rest with functional outflow obstruction causing intraprostatic reflux of urine...” Doble A, Walker MM, Harris JR, Taylor-Robinson D, Witherow RO (1990). "Intraprostatic antibody deposition in chronic abacterial prostatitis". Br J Urol 65 (6): 598–605. PMID 2196972. . Another study says, “Different causative mechanisms of the disease have been discussed, including identified and unidentified microorganisms, stone formation and psychological factors. We have demonstrated in a previous study that urinary reflux (as shown by a high creatinine concentration in prostatic fluid) occurs to a varying extent into the prostatic ducts, and this reflux has been related to prostatic pain and urate concentration in expressed prostatic secretion. Persson BE, Ronquist G (1996). "Allopurinol treatment results in elevated prostate-specific antigen levels in prostatic fluid and serum of patients with non-bacterial prostatitis". Eur. Urol. 29 (1): 111–4. PMID 8821701. . Based on the urine reflux theory one study showed that “Allopurinol has a significant, positive effect on nonbacterial prostatitis.” Persson BE, Ronquist G, Ekblom M (1996). "Ameliorative effect of allopurinol on nonbacterial prostatitis: a parallel double-blind controlled study". J. Urol. 155 (3): 961–4. PMID 8583618. . Other researchers have acknowledged that urine relux is a theory of etiology but question whether any known treatment based on the theory has worked effectively. McNaughton CO, Wilt T (2002). "Allopurinol for chronic prostatitis". Cochrane Database Syst Rev (4): CD001041. PMID 12519549. .
• Thank you, ReasonableLogicalMan(Talk 16:08, 2 March 2008 (UTC)

another editor removed it, and I agree it needs shortening. There is no need for quotes except possibly the cochrane. Cochrane conclusions are more than "other researchers"--they are considered the generally accepted synthesis as of the time published. please reduce and put it here. DGG (talk) 17:39, 2 March 2008 (UTC)

My comment is that the Cochrane Review [14] of the allopurinol study found it unconvincing, and both I and a number of other patients went on long courses of allopurinol without benefit. Urodynamic studies will find spasms of the distal urethral sphincter or strictures, so it's more a case of looking at differential diagnosis here than etiology of CP/CPPS. IOW, this should go under Diagnosis and not Etiology. ? RATEL ? 22:26, 2 March 2008 (UTC)

I will rewrite and reduce the edit and place it back here soon. ReasonableLogicalMan(Talk 02:53, 3 March 2008 (UTC)

rewrite on urinary reflux 030408

• Dear Admin user:DGG please see this rewrite.

Several studies have postulated urinary reflux into the prostate to be a cause of chronic prostatitis/chronic pelvic pain syndrome. Kirby RS, Lowe D, Bultitude MI, Shuttleworth KE (1982). "Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis". Br J Urol 54 (6): 729–31. PMID 7150931. , Doble A, Walker MM, Harris JR, Taylor-Robinson D, Witherow RO (1990). "Intraprostatic antibody deposition in chronic abacterial prostatitis". Br J Urol 65 (6): 598–605. PMID 2196972. . The Cochrane Database says, "One novel etiologic theory is that the reflux of urine into prostatic ducts causes prostatic inflammation via high concentrations of purine and pyrimidine base-containing metabolites in prostatic secretions."McNaughton CO, Wilt T (2002). "Allopurinol for chronic prostatitis". Cochrane Database Syst Rev (4): CD001041. PMID 12519549. . One research paper theorizes that the underlying cause may be inappropriate spasm of the distal urinary sphincter "leading to increased pressure in the prostatic urethra with a resultant reflux of urine into the prostatic ducts.” Hellstrom WJ, Schmidt RA, Lue TF, Tanagho EA (1987). "Neuromuscular dysfunction in nonbacterial prostatitis". Urology 30 (2): 183–8. PMID 3497475. . One group of researchers measured urinary reflux into the prostate by studying creatinine concentration in the prostatic fluid and found that the amount of reflux correlated with the amount of pain. Persson BE, Ronquist G (1996). "Evidence for a mechanistic association between nonbacterial prostatitis and levels of urate and creatinine in expressed prostatic secretion". J. Urol. 155 (3): 958–60. PMID 8583617. , Persson BE, Ronquist G (1996). "Allopurinol treatment results in elevated prostate-specific antigen levels in prostatic fluid and serum of patients with non-bacterial prostatitis". Eur. Urol. 29 (1): 111–4. PMID 8821701. , Persson BE, Ronquist G, Ekblom M (1996). "Ameliorative effect of allopurinol on nonbacterial prostatitis: a parallel double-blind controlled study". J. Urol. 155 (3): 961–4. PMID 8583618. .

1. Why even mention allopurinol and the only researcher ever to find it worthwhile (Persson)? I know of no patient who ever found benefit from using allopurinol, and there no followup studies into this rather old concept (notice how all the papers quoted above are from 70s, 80s and early to mid-90s). And the Cochrane Review basically said it was all rubbish, in the nicest possible way.
2. My recent edit on this topic in the Diagnosis section is sufficient. Reflux happens when patients have structural abnormalities (stricture) or urethral stenosis (narrowing) that can be discovered by urodynamics, and simply treated. These patients are not CP/CPPS patients, the vast majority of whom have normal urodynamics. ? RATEL ? 14:45, 4 March 2008 (UTC)

Urinary Reflux Response

Dear Admin, user:DGG, I am not sure if you are waiting for me to respond, or if I am supposed to respond or await your ruling on whether urinary reflux can be listed and discussed among the possible etiologies of chronic prostatitis/chronic pelvic pain syndrome. So, here goes: Urinary reflux definitely happens when men have clear-cut structural abnormalities. It is also suspected to occur in men who do not have measurable structural abnormalities.

• Br J Urol. 1982 Dec;54(6):729-31. "Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis." by Kirby RS, Lowe D, Bultitude MI, Shuttleworth KE. "Using a suspension of carbon particles it has been demonstrated that this can occur. It is suggested that this may be important both as a route of infection in bacterial prostatitis and as a cause of the inflammatory process in abacterial prostatitis." (PMID 7150931). ReasonableLogicalMan(Talk 15:48, 5 March 2008 (UTC)
• "There is no question that intraprostatic reflux of urine can occur." - Urologist J. Curtis Nickel. Textbook of Prostatitis. p. 350.
• "As yet unanswered, however, is why some patients should develop intraprostatic urinary reflux and others do not." - Urologist J. Curtis Nickel. Textbook of Prostatitis. p. 350.
• "There are many theories about the cause of nonbacterial prostatitis: fungi, viruses, trichomonads, and obligate anaerobic bacteria have been suspected. Irritation caused by a reflux of urine flowing into the prostate may also be a cause." [15] —Preceding unsigned comment added by Reasonablelogicalman (talk • contribs) 16:08, 5 March 2008 (UTC)

It's a well known theory that reflux plays a role in acute bacterial prostatitis: "Intraprostatic urinary reflux: This theory is the most widely accepted. Infected urine refluxes into the ejaculatory and prostatic ducts that empty into the posterior urethra. Because of the anatomy of the prostate gland, ducts that drain glands in the large peripheral zone are positioned more horizontally than other prostatic ducts and, thus, facilitate the reflux of urine into the prostate. Consequently, most infections occur in the peripheral zone." [16], which is why many believe it may be important in chronic prostatitis. The British Medical Journal, Clinical Evidence, says that "The cause of chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) is unclear" and lists "intraprostatic urinary reflux" as one of the possible etiological factors. [17] ReasonableLogicalMan(Talk 15:48, 5 March 2008 (UTC)

1. The 1982 Kirby study with carbon particles is a) ancient and 2) does not prove that "reflux" causes CPPS. It is the sort of small, outdated, isolated, hypothesizing study that has no place on wikipedia.
2. Quoting JC Nickel's 1999 textbook is not adequate for two reasons. That textbook was written before the period that Nickel himself describes (in the linked video above) as a period of amazing progress in the understanding of this disorder. And even in that textbook, he sees the issue as "unanswered", in other words he does not state that reflux is a cause. Interestingly, he has not referred to it again or authored any research into the issue since then, and nor has any other major researcher or center of which I am aware.
3. Unfortunately, the nlm.nih.gov page linked above is hopelessly inaccurate in almost everything, such as saying 65% of men with prostatitis have CPPS (it's actually about 95%), or that men with CPPS have blood in their urine (they do not), etc. That page is a disgrace and needs an urgent rewrite. It certainly should not be used as a reference for anything.
4. The theory that reflux plays a role in acute bacterial prostatitis — an entity that has nothing to do with CPPS — should perhaps be added to the relevant section, if more than just the eMedicine page's hypothesizing can be found. The phrase used above "which is why many believe it may be important in chronic prostatitis" has yet to be demonstrated, and I contend it is false.
5. The BMJ link given above is behind a firewall, so must be discounted.
6. For inclusion, this theory needs a fairly recent (last 6 years) supportive study from a major western university, from the CPCRN, or some other reputable source. Currently such support is entirely lacking. ? RATEL ? 21:32, 5 March 2008 (UTC)

1. It's a basic rule here that references can be used from any source, paid or otherwise. And BMJ is available in print in thousands of libraries.
2. eMedicine is considered reliable here as a state of the art summary--I am aware that the different eMedicine pages here are not altogether consistent with each other, so perhaps that's an approach.
3. NIH medline plus is in fact our basic standard in disputed cases for what the consensus is. If you challenge it, find a source of good authority which specifically says its wrong, and that can be added. Not just that gives another theory, that says specifically that the NIH page is in error. Alternatively, get them to change it. Anything that disagrees with it will probably be considered FRINGE around here otherwise.
4. Unpublished university studies cannot be used as sources.
5. I would prefer to use references from the last few years if possible, especially for review articles & textbooks.
6. Try to do it in two sentences, with the cochrane and one other reference. If Cochrane says its rare, include that. This, along with published consensus statements in the major journals, is one of the few sources that is accepted to supersede Medline plus.
7. Statements like "which is why many believe' are to be avoided, sourced or unsourced,per WP:WEASEL. DGG (talk) 23:31, 5 March 2008 (UTC)

• DGG, you say that anything that disagrees with a Pubmed article is regarded as "fringe". Let me point out that:

1. The author of that article is Neil D. Sherman, a complete unknown on the prostatitis and CPPS scene, and a Pubmed search for "SHERMAN AND PROSTATITIS gets no hits.
2. To demonstrate the low quality of that Pubmed page, let me take just one statement, namely that 65% of prostatitis patients have "nonbacterial prostatitis" (BTW, "nonbacterial prostatitis" is not even a term that's used anymore; it was dumped 10 years ago!), when the true figure is 95%. In a 2006 study, Professor Schaeffer, one of the biggest names in prostatitis research, said:

In contrast, chronic prostatitis/chronic pelvic pain syndrome (category III), which accounts for 90%-95% of prostatitis cases, ...(PMID 16409145)

• BMJ: the quote given from the BMJ was almost certainly derived from one of the other sources discussed, and should not be admissible unless we can see the source for the statement.
• "Unpublished studies cannot be used as sources" — absolutely agree. ? RATEL ? 03:54, 6 March 2008 (UTC)

Dear Admin, user:DGG, would it be possible for you do a neutral point of view rewrite based on the research already done? I will try return here soon, but might not be able to for a week or two.ReasonableLogicalMan(Talk 01:18, 8 March 2008 (UTC)

Obviously high authority does not apply to all articles listed in pubmed!. Medline plus, though, is [18] the NIH public health information site, and is considered along with similar government sites to be authoritative. In my experience it makes a good effort at fairness on disputed issues. But it can still be contested--the review you cite is in Ann Rev Medicine, also considered an authoritative review source , & 2006 is recent, so I will go read the whole review in context--& check whether there is one in the 2007. If sources of such very high authority disagree, we give them both. It will however take me till the middle of next week until I can get to it. DGG (talk) 05:24, 9 March 2008 (UTC)

COI Tag — Justify or remove

That COI tag is completely indefensible unless it can be pointed out how this article is slanted in one way or another. The other editor's contention that I have weighted scientific evidence in one direction has yet to be supported by even ONE review paper from the literature. I suggest the tag be removed unless cause can be shown. ? RATEL ? 22:13, 25 March 2008 (UTC)

as far as I can tell, at least two of the major contributors here have COI, though not in the same direction. the tag will remain.

I have changed back the reference formatting, which did not come out right.

and the Mayo ref is considered more authoritative than the personal opinion of any contributor here; if you can find a source saying specifically it is wrong, that is of equal or greater authority, you can add it. DGG (talk) 04:06, 26 March 2008 (UTC)

1. The COI tag states that "It may require cleanup to comply with Wikipedia's content policies". Please justify this. Where is the required cleanup? Where is the bias? On which review study do you base your conclusion? That COI tag was added by another editor who has tried to insert numerous incorrect and outdated snippets of data, and when blocked, added the tag. If you support it, please show where it is justified.
2. The Mayo ref contains blatantly unsupported "facts", such as the theory that massaging the prostate will "unplug the ducts". There is no scientific basis for this. I should add that I was the person who originally added the Mayo link.
3. The footnote formatting works fine for me, and is used on the Fibromyalgia page too, where I got it. ? RATEL ? 04:15, 26 March 2008 (UTC)

I see it there, so, please restore it and I'll check. As for the Mayo, let me think about it another day--perhaps it is outdated. As for COI there have been COI accusations against almost every editor on this page. As for splitting the article, I'd rather keep the topictogether and condense it here. I dont see any real consensus on how closely related the conditions are. DGG (talk) 23:11, 27 March 2008 (UTC)

1. Restored as requested.
2. If you think we need some external link (with Mayo gone), I can add in a DMOZ search on the term "chronic prostatitis" (WP guidelines suggest using DMOZ.org for this purpose). But then, this is only one of the disorders on the page — another reason to put these separate entities on their own pages. External links for one have nothing to do with external links for another, which is confusing for readers.
3. Splitting vs condensing: if we condense the page, it'll become less and less informative. Do we really want that? Is that suggestion due to the conflicts here? Because if it is, it's a pity (and a form of defeat) to let editorial disputes contract the topic and its usefulness. I truly believe that some of these conflicts will evaporate when the subjects are disentangled to their own pages, thus helping editors to focus their edits logically. The only place these disparate disorders are ever conflated is in the NIH categorisation, which is itself a work in progress, and probably due to change soon (see "UCPPS" references on the page). 99% of research treats these disorders separately. There is no consensus anywhere that these conditions are related. Even the two seemingly related categories of acute bacterial prostatitis and chronic bacterial prostatitis (Cat I and Cat. II) are not related in most cases, and research treats them separately.

Thanks for giving your time to this page, David. ? RATEL ? 00:04, 28 March 2008 (UTC)