The role of Chlamydia trachomatis in prostatitis

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1 International Journal of Antimicrobial Agents 19 (2002) 466/470 The role of Chlamydia trachomatis in prostatitis W. Weidner *, Th. Diemer, P. Huwe, H. Rainer, M. Ludwig Department of Urology, Universitätsklinikum Giessen, Rudolf-Buchheim-Straße 7, D Giessen, Germany Abstract Ascending chlamydial infections have been thought to be an infective cause of prostatitis for the last three decades. Unfortunately, the definitive association between isolation of an infective agent and its prostatic origin is limited by various factors, although modern techniques of molecular biology for identification of the microorganisms are available. Two major problems are: (1) diagnostic material passing the urethra may reflect only urethral contamination, (2) prostatic biopsy specimens from the gland may also contain urethral material. The ejaculate has the same limitations, and an ideal test for detection of Chlamydia species in ejaculate specimens is not available yet. Investigations for local chlamydial IgA-antibodies may be useful; the overlap with Chlamydia pneumoniae and Chlamydia psittaci means a clear differentiation on an type-specific basis is necessary, which is normally provided by the elaborate microimmunofluorescence test. Modern p-elisas using major outer membrane protein parts as antigens may deliver identical results in the future. In the follow-up of standardized prostatitis patients, a combination of such urological tests in EPS and seminal plasma combined with genital chlamydial DNA material, may further elucidate the chlamydial aetiology of prostate infection. # 2002 Elsevier Science B.V. and International Society of Chemotherapy. All rights reserved. Keywords: Chlamydia trachomatis ; Polymerase chain reaction; ELISA; Chlamydial antibodies; Microimmunofluorescence test 1. Introduction Genital Chlamydia trachomatis infections in men are among the most frequently encountered sexually transmitted diseases worldwide. Epididymitis and urethritis have a proven chlamydial aetiology using specific DNA identification. Molecular investigation techniques of genital chlamydia have been accepted as the gold standard [1]. For three decades ascending chlamydial infections of the prostate have been under debate. The chlamydial origin of the so called urethro-prostatitis has been discussed especially for post-urethritis patients [2,3] and also for acute prostatitis [4] and in all other types of prostatitis but without positive common findings on culture [5]. Unfortunately, any association between isolation and the prostatic origin of C. trachomatis in the typical diagnostic material deriving from the prostate (expressed prostatic secretions, urethral swabs and/ or urine after prostatic massage) has always been limited by the passage of all these specimens through the * Corresponding author. Tel.: / ; fax: / address: wolfgang.weidner@chiru.med.uni-giessen.de (W. Weidner). urethra with a potential urethral contamination as the major problem of these techniques [6]. 2. Evidence that C. trachomatis in urethral specimens might represent prostatic material Table 1 summarizes data of several studies [7 /12] using material (expressed prostatic secretions, urine after prostatic massage, seminal plasma) obtained after passage down the urethra post prostatic massage. In up to 25% of the cases, chlamydial isolation has been associated with infections to the prostate. It must be stated that all these findings cannot be strictly classified according to the new NIH definition of prostatitis [13]. However, these data are very similar to urethral isolation results of our group carried out 10 years ago that indicated an astonishingly high percentage of positive chlamydial isolation in 27% of patients with nonbacterial prostatitis (now NIH IIIa) [14]. Our data (Table 2) suggests that C. trachomatis may originate in the prostate in an unknown percentage of patients with prostatitis symptoms [14]. Nevertheless, we are convinced, that especially after urethritis a real discrimination between urethral colonization and prostatic /02/$ - see front matter # 2002 Elsevier Science B.V. and International Society of Chemotherapy. All rights reserved. PII: S ( 0 2 )

2 W. Weidner et al. / International Journal of Antimicrobial Agents 19 (2002) 466/ Table 1 Evidence for Chlamydial Prostatitis Study Technique Comment Positive results Weidner et al. [7] Culture EPS, VB3 43 of 233 Bruce and Reid [8] IF-staining (elementary bodies) EPS 6 cases Gümüs et al. [9] In situ hybridization EPS 18 of 78 Heqing et al. [10] PCR, culture EPS 6 of 30 Mutlu et al. [11] LPS-antigen EPS, VB3 14 of 55 Mazzoli et al. [12] PCR, EM (reticular bodies) EPS, seminal plasma 10 cases EPS, expressed prostatic secretions; VB3, urine after prostatic massage. Table 2 Search for C. trachomatis (culture, urethral swabs). Prostatitis n656 C. trachomatis n (%) CBP 46 / NIH IIIa (27) Prostato-Urethritis (25) NIH IIIb (13.4) Controls (6.6) Patients of the Giessen Prostatitis Cohort Study (according to Ref. [14]) infection remains impossible with this methodological approach. To fulfil one of Koch s postulates, several authors [15 /21] have tried to detect chlamydial infection of prostatic epithelial cells directly in prostatic tissue obtained under sterile conditions from patients with different types of prostatitis. The results are displayed in Table 3. One reason for the apparent discrepancies in these findings may be due to different techniques used for retrieving prostatic material. Via transrectal aspiration biopsy, open operation and transurethral resection of the prostate, tissue is available both from the peripheral gland and from the prostatic urethra. In perineal biopsies with negative findings, as have been performed in our study [20] and by Doble et al. [18], tissue was only taken from the peripheral prostatic lobes thus excluding urethral contamination. In other words, tissue from transrectal biopsy, transurethral resection or open surgery of the prostate apparently contains epithelial cells of the prostatic urethra, which could have been infected in the course of urethral infection. The dilemma is therefore similar to direct chlamydial investigation of expressed prostatic secretions, a fact that already has been debated by our group in 1985 [6]. 3. Search for C. trachomatis in biopsy studies of the prostate 4. Indirect evidence for a role of C. trachomatis for prostatitis*/the value of semen analysis Prostatic secretions contribute in up to 80% to the ejaculate volume and it is reasonable to look also for C. trachomatis in this specimen. Unfortunately, the ideal chlamydial diagnostic test for semen analysis has not been established yet, although modern DNA recombination techniques are available for specific analyses [22]. Polymerase chain reaction (PCR) and the ligase chain reaction are especially useful for the examination of Table 3 Search for C. trachomatis in prostatic biopsies Study Patients (n ) Prostatic urethra (n) Prostate (n ) Type of operation Chlamydial detection Poletti et al. [15] 30 Not done 10 Transrectal biopsy Culture Pust et al. [16] Urethral and perineal biopsy Immuno-fluorescense Shurbaji et al. 16 Not done 5 TUR-P, open surgery Immuno-histochemistry [17] Doble et al. [18] 50 Not done None Perineal ultrasonically guided Culture, immuno-fluorescense biopsy Abdelatif et al. 23 Not done 7 TUR-P In situ hybridization [19] Weidner et al None Perineal ultrasonically guided Culture [20] biopsy Corradi et al. [21] 64 Not done 9 TUR-P, open surgery In situ hybridization, transmission electron microscopy

3 468 W. Weidner et al. / International Journal of Antimicrobial Agents 19 (2002) 466/470 urethral swabs and first voided urine specimens, respectively. Several investigators detected C. trachomatis in ejaculate specimens especially in fertility clinic patients in significant numbers whilst using amplified DNA methods. The figures were 10.8% in asymptomatic partners of infertile couples prior to in vitro fertilization [23], 39.3% of infertile men [24], 10% in male partners of infertile couples [25] and only 1.8% in male infertility patients [26]. Furthermore, it is accepted that chlamydia may adhere to human spermatozoa [27], may enter spermatozoa [28], may ascend to the epididymis via the seminal pathway and contribute significantly to disturbed male reproduction [29]. On the other hand, we have learned that especially in semen samples analyzed for andrological reasons about 70% of the specimens are contaminated with microorganisms of any kind [30]. This figure may be still increased [31] using modern universal eubacterial primers. Unfortunately it would appear the problem is the same as for material derived from the prostate*/the ejaculate has to pass the urethra, so contamination or infection of this compartment hampers the definite diagnosis of the infection and especially the origin of the microorganisms detected (overview in [30]). 5. Chlamydial antibodies in expressed prostatic secretions and seminal plasma It is generally accepted that in contrast to women, in men serum antibody investigations are not useful in the detection of chlamydial genital infections [22]. This is mainly due to the wide overlap between antibodies directed towards C. trachomatis with those of C. pneumoniae and C. psittacii [32]. Two methods have been recommended to circumvent this dilemma: (a) antibody tests that clearly differentiate between the different Chlamydia species [22,32], (b) tests for IgAantibodies in the local secretions only [22,33]. The microimmunofluorescence test (MIF) is presently thought to be able to evaluate local antibodies on an original type-specified basis [22,32]; only this test uses elementary bodies as antigen thus excluding crossreactivity between the species. Using such specific MIF, only 7% of andrological patients had seminal antibodies against C. trachomatis alone and 16% had antibodies versus both C. trachomatis and C. pneumoniae [33]. Unfortunately this test is time consuming and elaborate and is not convenient for clinical use. Modern C. trachomatis p-elisas using a synthetic peptide from the immuno-dominant region of the major outer membrane protein may be able to discriminate C. trachomatis-specific antibodies better and initial data suggest elevated titres of C. trachomatis specific secretory IgA in acute genital infections [34]. Local secretory IgA-antibodies against C. trachomatis have been evaluated in prostatic secretions and seminal plasma in patients with prostatitis, epididymitis, male accessary gland infections and infertility by different authors using different tests. Table 4 summarizes some of these studies [25,33,35 /40]. The data clearly demonstrate the occurrence of IgA-antibodies in semen as an indicator of local chlamydial infections within the different anatomical compartments. Unfortunately, only some of the IgA-positive specimens are positive in PCR-investigations (overview in [36]), findings that accord with current literature elucidating the problems of the difficult interpretation of chlamydial antibody findings in this context. 6. Suggestions for future studies Sensitive molecular techniques for specific DNA identification of genital chlamydia are necessary for all further investigations [22]. For prostatitis, a correct classification of urethral and prostatic inflammation is required [41,42]. In well defined cases, a sterile biopsy of the gland using modern prokaryotic DNA sequences for identification of the microorganisms, may identify some chlamydial infections under standardized conditions [43]. On the other hand, there is no absolute diagnostic test for chronic abacterial prostatitis at the moment, and with some exclusions the methodological quality of most studies mentioned is low [44]. Nevertheless, our group is convinced that the future diagnostic regimes will have to Table 4 IgA chlamydial antibody findings in prostatic secretions (EPS) and seminal fluid (SF) Study Clinical diagnosis Test Material Positive IgA-findings Tsunekawa and Kumamoto [39] Prostatitis MIF EPS Koroku et al. [40] Prostatitis Elisa EPS 29% Kojima et al. [37] Epididymitis MIF SF Mazzoli et al. [38] Prostatitis Elisa SF 90% (!) Ludwig et al. [35] Male urological patients MIF SF 7% Bollmann et al. [33] Infertile patients MIF SF 7% Weidner et al. [36] Asymptomatic andrological patients Elisa SF 19% Dieterle et al. [25] Male partners of infertile couples Elisa SF 16%

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