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대한요로생식기감염학회지 : 제 6 권제 1 호 2011년 4월 Korean J UTII Vol. 6, No. 1, April 2011 종설 급성세균성전립선염에대한최신지견 서울대학교보라매병원비뇨기과 최우석 손환철 [Abstract] Update of Acute Bacterial Prostatitis Woosuk Choi, Hwancheol Son From the Department of Urology, Seoul National University Boramae Hospital, Seoul, Korea Acute bacterial prostatitis is defined as acute infection of prostate. It is classified into category I according to the National Institutes of Health (NIH) consensus classification. Patients with acute bacterial prostatitis present with acute symptoms of urinary tract infection, including urinary frequency, dysuria and symptoms suggestive of systemic infection, such as malaise, fever and myalgia. The prostate may be swollen and tender on digital rectal examination, butprostatic massage is contraindicated. The most common pathogen is Escherichia coli. For initial therapy, high doses of bactericidal antibiotics, such as abroad-spectrum penicillin, a third-generation cephalosporin or a fluoroquinolone may be administered parentally and these regimens may be combined with an aminoglycoside. After defeverescence and normalization of infection parameters, oral antibiotic therapy can be continued for 2 to 4weeks. We should bear in mind that acute bacterial prostatitis secondary to manipulation of the lower urinary tract, such as transrectal prostatic needle biopsy,has more aggressive clinical course. (Korean J UTII 2011;6:8-17) Key Words: Prostatitis, Urinary tract infections 서 론 급성세균성전립선염은비뇨기계병원균에의해전립선의전부위에발생하는급성감염으로, 1,2 교신저자 : 손환철, 보라매병원비뇨기과서울시동작구신대방 2 동우 156-707 Tel: 02-870-2391, Fax: 02-870-3863 E-mail: volley@snu.ac.kr Received: February 25, 2011 Accepted: March 25, 2011 8 1999년 National Institute of Health (NIH) 에서제시한전립선염의분류에따라 category I에속한다 (Table 1). 3 전립선염은미국남성의경우일생동안 11% 에서 16% 가겪는매우흔한질환이지만 category I 전립선염은전체전립선염의 0.02 5% 정도로전립선염중가장드문질환이다. 4,5 하지만급성세균성전립선염은만약치료하지않고방치된다면생명을위협할정도의패혈증이나전립선농양등의합병증을유발하거나사망에이르게할수있는비뇨기과적응급질환으로임상적의미는적지않다. 6-8

최우석외 : 급성세균성전립선염에대한최신지견 9 Table 1. National Institute of Health (NIH) Consensus classification of prostatitis 6 Category I. Acute bacterial prostatitis is acute infection of prostate. Category II. Chronic bacterial prostatitis is a recurrent infection of the prostate. Category III. Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CPPS), where there is no demonstrable infection. Subgroups of this class are: Category IIIa. Inflammatory chronic pelvic pain syndrome, where white cells are found in the semen, expressed prostatic secretions (EPS) or voided bladder urine-3 (VB-3). Category IIIb. Non-inflammatory chronic pelvic pain syndrome, where white cells are NOT found in the semen, EPS, and VB-3. Category IV. Asymptomatic inflammatory prostatitis (AIP), where there are no subjective symptoms but white cells are found in prostate secretions or in prostate tissue during an evaluation for other disorders. 하지만대부분의전립선염에대한연구가만성비세균성전립선염 (category III) 에초점을맞추고있어급성세균성전립선염에초점을둔보고는많지않다. 이에현재까지밝혀진급성세균성전립선염의역학, 증상, 치료등에대하여살펴보고자한다. 본론 I. 역학및병인급성세균성전립선염의호발연령은 20 40세와 60세이후로두구간에서정점을보이는형태를이룬다. 9,10 최근급성전립선염에대한후향적연구들에따르면발병연령의중앙값은 53.3세였고 11,12 국내의다기관분석에서도급성세균성전립선염환자의평균연령은 54.9세였다. 13 이들연구에서급성세균성전립선염에이환된환자의 15 33% 는이전에급성세균성전립선염의병력이있었고, 8 12% 의환자는전립선생검이나경요도시술을받은병력이있었으며 13 15% 는비뇨기과적수술을받은이후발생한경우였다. 11,12 이중전립선생검이후급성전립선염이발생하는경우를살펴보면항생제사용없이전립선생검을시행한경우급성세균성전립선염의발생률은 44% 까지높게보고되었다. 하지만적절한항생제를사용한경우처음으로시행한전립선생검에서급성세균성전립선염의발생률은 0.5 2% 로보고되었고두번이상의 전립선재생검 (re-biopsy) 을시행한경우발병률은 4.7% 까지상승하는것으로보고되었다. 13-15 생검시도뇨관이삽입되어있는경우와생검시세균뇨가있는경우급성전립선염의위험도가증가하는것으로알려져있다. 15,16 급성세균성전립선염은대부분역행성감염으로감염된소변이사정관이나전립선관내로역류되어발생한다. 이러한역행성감염은성교, 경요도시술, 도뇨관거치등에의해발생한다. 그밖의감염경로로전립선생검시직접균이이식되는경우와항문주위감염이임파액을통한감염되는경우그리고혈관을통한혈행성감염이있다. 17 II. 증상및진단급성세균성전립선염은뚜렷한하부요로감염증상이주된증상이며감염에따른전신증상과통증이수반된다. 뚜렷한하부요로감염증상으로배뇨통, 빈뇨, 급박뇨등이나타나며감염에따른전신증상으로오한, 발열, 근육통, 구역, 구토등의증상이나타나며, 치골상부통증과항문주위통증이수반될수있다. 6,8,18 발열과배뇨통이가장흔한증상으로 80% 이상의환자에서나타나며오한및통증이 50% 에서나타난다. 요저류가발생하는경우는 20% 정도이다. 11 급성세균성전립선염이균혈증이나패혈증으로발전하면의식저하, 고열, 발한, 저혈압등의증상이발생할수있다. 이렇듯급성세균성전립선염은배뇨통, 빈뇨, 급

10 대한요로생식기감염학회지 : 제 6 권제 1 호 2011 년 4 월 Table 2. Evaluation of acute prostatitis History taking Lower urinary tract symptoms, sexual history, history of sexually transmitted diseases/urethritis, coexisting medical problems, history of prior inguinal or pelvic surgery Physical examination Abdominal, genital, perineal examination and gentle digital rectal examination Laboratory examination Complete blood count Urinalysis and urine culture Blood culture: in case of immunosuppressed patient, suspected hematogenous source, complications such as sepsis, abscess formation Imaging study Transrectal ultrasonography (TRUS): diagnosis of prostatitis and abscess, abscess drainage Computed tomography (CT): diagnosis and drainage of prostatic/pelvic abscess, ruling out other pelvicpathology mimicking prostatitis 박뇨등의뚜렷한하부요로감염증상및징후를보이기때문에증상만으로어렵지않게진단이가능하다. 6 급성세균성전립선염의진단을위한접근은병력청취와신체검사에서시작한다 (Table 2). 병력청취는하부요로증상에대한질문이우선되어야하며발기및사정에관한성적병력, 성병및요도염의병력, 당뇨등의내과적병력, 비뇨기과적수술병력등에대한조사가필요하다. 19 신체검사에는복부, 회음부촉진및부드러운직장수지검사가포함된다. 하복부통증및방광팽만이흔히관찰되고양측또는단측의부고환의압통이있을수도있으며항문주위근육의연축이촉진될수도있다. 직장수지검사는부드럽고조심스럽게시행할수있으며, 90% 이상에서압통을동반한팽만된전립선이특징적으로촉지된다. 12 하지만전립선마사지는균혈증이나패혈증을유발할수있기때문에시행하여서는안된다. 18 요검사와요배양검사는모든환자에서반드시시행되어야한다. 19 일반요검사에서대부분단백뇨, 농뇨, 혈뇨가관찰되며현미경적요검사에서적혈구및백혈구가다수관찰되며, 고배율시야당 5 10개의백혈구는요로감염을강력히시사한다. Leukocyte esterase와 nitrite 검사에서모두양성을보이는경우의민감도는 68 88% 이다. 소변배양검사는 원인균을밝히는데유용하며그람염색은처음투여할항생제의선택에도움을줄수있다. 급성세균성전립선염은증상만으로대부분진단이가능하기때문에전립선액검사 (expressed prostatic secretion; EPS) 나 4부분요배양검사 (voided bladder urine-3; VB3) 는필수적인검사는아니다. 20-22 급성세균성전립선염환자의일반혈액검사는진단에큰도움을주진않지만다른질환의감별에도움을줄수있으며, 환자가정상면역력을가진경우보통비성숙호중구의숫자의증가가관찰된다. 이상의검진으로급성전립선염이의심되는경우전립선농양이의심되는경우가아니라면더이상의검사는필요치않으며치료를바로시작해야한다. 혈액배양검사는면역능력이저하된환자이거나혈행성감염이의심되거나합병증이발생한경우에서만권장된다. 338 명의환자를대상으로시행한요로감염에대한한역행성연구에서요배양검사에서확인되지않은균이혈액배양검사에서양성으로확인된경우는오직 1례에서있었다고밝혀져있다. 23 전립선특이항원 (prostate specific antigen; PSA) 검사는진단의지표는아니지만대부분의급성전립선염에서상승되어있다. 20-22 국내의보고에서급성전립선염환자의평균전립선특이항원수치는 24.6±30.2ng/ml 였다. 24 상승

최우석외 : 급성세균성전립선염에대한최신지견 11 된전립선특이항원수치는항생제치료를시작하면 3 14일사이에떨어지기시작한다. 25,26 급성전립선염이후전립선특이항원이정상화되는데걸리는기간에대한정확한보고는없지만급성전립선염이발생한이후 2 3개월까지도전립선특이항원의상승이관찰되는경우가보고되어있어 21,27,28 전립선특이항원에대한재검사는이기간이후에이루어지는것이추천된다. 29 전립선농양이의심되는환자에서는전산화단층촬영술을사용하거나항생제를투여한이후경직장초음파검사를이용하면요로패혈증의위험을증가시키지않으면서전립선농양을감별할수있다. 30,31 부로침투하는데에중요한역할을하는것으로알려졌다. 36-39 최근두연구에따르면세균성전립선염을일으키는 E. coli는방광염이나신우신염을일으키는 E. coli 균주보다생체필름을형성을더욱잘하며이는전립선염의치료가어려운이유로생각한다. 36,37 또한전립선염을일으키는 E. coli가다른요로감염을일으키는 E. coli에비하여병원성이강한이유가용혈소 (hemolysin) 와세포독성괴사인자 (cytotoxic necrotizing factor) 때문이라는보고도있다. 35,37 이러한연구들은전립선이혈관분포가다른기관에비해잘발달된기관이지만전립선염의치료가비교적어려운이유로설명되고있다. III. 세균학 IV. 치료 급성전립선염을일으키는원인균은 Escherichia coli (E. coli) 가 55 80% 로가장많으며, 그다음으로 Pseudomonas (10 15%), Proteus, Klebsiella 순으로나타난다. 11,12 그밖에흔하지않은원인균으로 Streptococcus, Anaerobes, Ureaplasma, Mycoplasma genitalium, Trichomonas vaginalis, Chlamydia trachomatis, Candida 등이있다. 특히 Pseudomonas는하부요로시술을시행한후발생한급성전립선염에서 10배정도더많이관찰된다. 12 Enterococci에의한감염은보통전체감염의 5 10% 로보고되고있다. 32 Nesseria gonorrhoeae는성적활동이왕성한 35세이하에서주로관찰되며 35세이하에서는반드시의심해야하는원인균이다. 33 HIV 감염으로면역기능이저하된환자에서는 Mycobacterium tuberculosis, Serratia, Salmonella, Fungi (Candida, Histoplsma, Aspergillus, Cryptococcus) 등이발견된다. 34 세균성전립선염을일으키는원인균의병원성에대하여 E. coli가가장잘연구되어있다. 최근연구들은단순요로감염이나신우신염을일으키는 E. coli 균주에비하여전립선염을일으키는 E. coli의병원성이강하다는증거를제시하고있다. 35-37 박테리아들이군집하여서로강하게붙어끈적끈적한기질 (gelatinous matrix) 로주변을봉인하여면역체계나항생제의공격을방어하는것을생체필름 (biofilm) 이라고하는데이것이 E. coli가전립선내 급성전립선염의적절한치료는항생제의경정맥투여와증상완화치료로이루어진다. 28 항생제치료는요배양검사와필요한경우혈액배양검사이후즉시시행한다. 항생제의선택은환자의상태와요검사에서그람염색결과에따라결정한다 (Table 3). 전신증상이없는환자에게는외래환자처럼처음부터경구항생제투여를시행할수도있지만보통의경우경정맥투여가추천된다. 최근 2010년유럽비뇨기과학회진료지침에따르면경험적항생제로페니실린계, 3세대세팔로스포린, 플로오로퀴놀론을사용하며모두아미노글라코사이드계항생제와병용투여를고려하도록권고하고있다. 40 초기치료에성공적인반응을보이면플로오로퀴놀론계항생제같은경구항생제로의전환이가능하며치료기간에대하여는연구마다다르지만일반적으로 2 4주가적절하며 41 유럽비뇨기과학회진료지침에서도경정맥항생제를체온이정상화되고염증지표들이호전될때가지사용한이후경구용항생제로전환하여전체기간이 2 4주가될때까지지속하도록권고하고있다. 40 증상이심하지않은경우플로오로퀴놀론경구투여 10일요법도가능하다. 42 장기간치료후의성적은잘알려져있지않으나치료성공율은 90% 정도로보고되고있다. 43 하지만한전향적연구에서급성전립선염에대하여 6주간의항생제투여후 3개월에추적

12 대한요로생식기감염학회지 : 제 6 권제 1 호 2011 년 4 월 Table 3. Antibiotics used in acute bacterial prostatitis Parenteral agents Ampicillin Gentamicin Amikacin Ciprofloxacin Levofloxacin Ceftriaxone Aztreonam Ticarcillin-clavulanate Imipenem-cilastin Oral agents Ampicillin Amoxicillin/clavulanate Trimethoprim-sulfamethoxazole Doxycycline Cefuroxime (2nd) Cefixime (3rd) Cefpodoxime (3rd) Ciprofloxacin Levofloxacin Norfloxacin Ofloxacin Standard dosage 1g IV every 6hrs. 1mg/kg IV every 8hrs. 7.5mg/kg IV every 12hrs. 400mg IV every 12hrs. 500mg IV daily 1~2g IV daily 1~2g IV daily 3.1 giv every 6hrs. 250~500 mg IV every 6~8hrs. Standard dosage 500mg p.o. every 6hrs. 500mg p.o. twice a day 1 dosage (160/800mg) tablet p.o. twice a day 100mg p.o. twice a day 250mg p.o. twice a day 100mg p.o. twice a day 100mg p.o. twice a day 500mg p.o. twice a day 500mg p.o. daily 400mg p.o twice a day 400mg p.o twice a day IV: intravenous, p.o.: per oral 관찰하였을때전립선액에세균이잔존하는경우가 33% 까지보고된바가있어플로오로퀴놀론을 6 주간사용한이후에다시평가하는것을추천하는학자도있다. 28 모든항생제는전립선염의급성기에는전립선의심한염증때문에전립선내로쉽게침투한다. 44 플로오로퀴놀론은전립선및정낭액에서높은농도를유지하며 8,45 요로감염을일으키는균들에서플로오로퀴놀론내성은비교적드물다. 46 플로오로퀴놀론은위장관에서잘흡수되며전립선내로잘침투하며약동학적특성이좋고안전성이높으며 Pseudomonas를포함한그람음성균에광범위한효과를보인다. 플로오로퀴놀론의부작용으로광독성, 약물상호작용, 발적, 황달, 건염, 건파열, 말초신경병증, 중추신경계이상등이있어장기간의치료시에는모니터링이필요하다. 레보플록사신 (levofloxacin) 은사이프로플록사신 (ciprofloxacin) 에 비하여장점이있어전립선액에는더높은농도를보이지만사정관, 정충 (spermatozoa), 정낭에서는낮은농도를유지하며 8,45 Chlamydia와 Mycoplasma 등의그람양성균에도효과적이다. 플로오로퀴놀론에대하여내성을보이는경우가외국에서는 5% 내외로보고되지만국내에서는 15.2 23.4% 로더높은내성을보이고있어항생제선택에지역적특성을고려하여야한다. 국내의조사에서요로감염을일으키는 E. coli의경우사이프로플록사신, 레보플록사신, 겐타마이신, 토브라마이신에각각 24.7%, 20.7%, 23.5%, 7.8% 로외국에비해높은내성을보인반면아미카신, 3세대세팔로스포린계항생제에각각 0.6%, 1.8 15% 로비교적낮은내성을보이고있다. 47 지역사회감염이아닌병원내감염에서는더높은내성이보고되어경험적처방으로플로오로퀴놀론항생제를처방할경우장점은많지만치료에실패할확률이외국의빈도보다는

최우석외 : 급성세균성전립선염에대한최신지견 13 높음을고려하여야한다. 증상완화치료에는요로폐색에대한치료가포함된다. 전립선의심한염증에따라요로폐색이발생할수있기때문에잔뇨측정이반드시필요하다. 잔뇨측정은가능하다면비침습적인초음파를통하여확인하는것이바람직하다고판단된다. 알파차단제의병용에대하여는이견이있지만통증과배뇨에대한증상을개선하고만성전립선염으로의이행을예방하는효과가있다는보고가있다. 48 요로폐색이있는경우예상되는도뇨관거치기간에따라서거치기간이짧을것으로예상되는경우얇은요도도뇨관을사용할수있으며거치기간이길것으로예상되면치골상부방광루를설치하여야한다. 8 전립선농양및패혈증의위험이큰환자에서는치골상부방광루가추천된다. 49 진통소염제와대변완화제의투여도증상완화에도움을줄수있다. 18 입원치료는전신증상이호전되고통증조절이잘되며충분한배뇨가가능하면서전립선농양등의합병증이없음이확인될때까지시행한다. 49 V. 전립선생검후발생한급성전립선염전립선생검의심각한합병증으로급성전립선염과패혈증이있다. 이러한합병증은빈도는작지만심각한증상을유발하여입원치료가필요한경우가많고광범위항생제의사용이필요하다. 앞서언급한바와같이항생제사용없이전립선생검을시행한경우 44% 까지세균혈증이보고되어있고 15 플로오로퀴놀론 1회투여등의적절한예방적항생제사용을시행한경우 1 2% 에서만감염이발견된다. 16 국내의보고에서도예방적항생제로플로오로퀴놀론을사용하고전립선생검을시행했을때 2% 에서급성전립선염이발생하였다. 13 전립선생검후전립선염의위험을증가시키는요인은도뇨관거치상태와생검시세균뇨이다. 16 항생제의투여시기는일반적으로생검전에투여하는것을추천하지만한연구에서는필요한경우전립선생검후에항생제를투여하여도염증성합병증을예방하는효과가있다고보고하였다. 15 생검전관장의 효과에대하여는정립되어있지않다. 연구마다견해가다르지만적절한예방적항생제투여를한경우생검전관장이전립선염예방에도움을주지않는다는견해가우세하다. 50 전립선생검의금기가없는환자를선별하여적절한예방적항생제를사용하였음에도불구하고생검후전립선염이발생한경우항생제내성균이원인으로지목되고있다. 최근다약제내성 E. coli 가전통적인퀴놀론계항생제치료에내성을획득하면서그중요성이더해지고있다. 다약제내성 E. coli 획득의위험인자는나이, 후진국으로의여행, 그리고퀴놀론계항생제에노출된병력이다. 51 최근전립선생검등의하부요로조작이후발생한급성전립선염은보통의전립선염보다농양의발생이더많고 E. coli 이외의흔하지않은원인균에의한감염이많아일반적인전립선보다나쁜예후를지닌다고보고되고있다. 12 따라서생검후급성전립선염환자를치료할때에는더나쁜예후를염두에두어야하며당뇨등고위험군환자에게는생검단계부터적극적인예방적항생제를투여하는것이바람직하다고판단된다. VI. 전립선농양전립선농양은흔하지않지만치료하지않을경우농양이주변의방광및직장주변으로파급되어심한합병증을일으킬수있어적절한치료를요구한다. 전립선농양은면역기능이저하된환자나당뇨환자에서더흔히발생하며그증상은일반전립선염환자와비슷하게나타나지만발기지속증과같은비전형적인증상이동반되기도한다. 52 대부분의급성세균성전립선염이 36 48시간이내에체온이정상화되는데 48시간이상고열이지속되는경우전립선농양에대한검사를지체없이시행하여야한다. 28 콤프터단층촬영과자기공명영상 (magnetic resonance imaging; MRI) 이전립선농양의진단에효과적이기는하지만최근경직장초음파검사가가장민감도가높고, 비용효과적이며진단과동시에치료를시행할수있다는점에서가장선호되는검사이다. 콤프터단층촬영은임상적으로농양

14 대한요로생식기감염학회지 : 제 6 권제 1 호 2011 년 4 월 이의심되나경직장초음파검사에서나타나지않거나, 농양이아주심하게파급된경우, 그리고농양의정확한크기와주변조직과의관계를알고자하는경우에추천된다. 31,53,54 전립선농양의치료는이전에는경요도절개술 (transurethral unroofing) 을통한수술적치료가주된치료였지만합병증발생가능성이있어, 최근에는경직장초음파유도하흡인술 (transrectal ultra-sound guided aspiration) 을먼저고려하는경우도많다. 53,54 전립선농양환자에게적절한농양배출과함께치골상부방광루를함께시행하기를권장하는학자들도있다. 55,56 전립선농양에서가장많이배양되는원인균은 E. coli와 Staphylococcus이다. 그밖에 Mycobacterium tuberculosis, Actinomycoces, Citrobacter, Bacterioides fragilis, Aeromonas aerophyla, Klebsiella pneumonia 등이보고되어있다. 52-54 VII. 면역기능저하환자에서의급성전립선염인간면역결핍바이러스 (human immunodeficiency virus/acquired immune deficiency syndrome; HIV/AIDS) 에감염되어면역기능이저하된환자에서급성세균성전립선염과전립선농양이더잘발생하는것으로알려져있다. 57 조절이잘되고있는 HIV 환자에서는급성전립선염의발병률이일반인과비슷하지만 HIV 감염초기환자에서는급성전립선염의발병률이 14% 까지증가하는것으로보고되었다. 57 하지만이러한자료는 1989년이전의자료들로최근면역저하환자에서의급성전립선염과전립선농양의발병률이더떨어진다고판단되지만정확한자료는보고되지않았다. 34 결론급성세균성전립선염은고열과배뇨통을주증상으로하는전립선의급성염증을의미한다. 증상만으로진단이가능하며직장수지검사는부드럽게시행할수있지만전립선마사지는금기이다. 치료는플로오로퀴놀론, 광범위페니실린, 3세대세팔로스포린계항생제를경정맥투여하며아미노글라 코사이드계항생제를병용투여할수있다. 증상이호전된후경구용항생제를사용하며전체치료기간이 2 4주가되도록사용하는것이권장된다. 항생제치료후에도 48시간이상고열이지속되는경우전립선농양에대한경직장초음파검사를시행하여야하며전립선농양이발견되면경직장초음파유도하흡인술을고려하여야한다. REFERENCES 1. Vahlensieck W Jr, Hofstetter AG. Acute prostatitis and prostatic abscess. In: Weider W, Madsen PO, Schiefer HG, editors. Prostatitis. 1st ed. Berlin: Springer-Verlag; 1994;133-48 2. Neal DE Jr. Acute bacterial prostatitis. In: Nicket JC, editor. Textbook of prostatitis. 1st ed. Oxford: Isis Medical Media; 1999;115-21 3. Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999;282:236-7 4. Roberts RO, Lieber MM, Rhodes T, Girman CJ, Bostwick DG, Jacobsen SJ. Prevalenceof a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology 1998;51:578-84 5. Wagenlehner FM, Weidner W, Sörgel F, Naber KG. The role of antibiotics in chronic bacterial prostatitis. Int J Antimicrob Agents 2005;26:1-7 6. McRae SN, Shortliffe LMD. Bacterial infections of the genitourinary tract. In: Tanagho EA, McAninch JW, editors. Smith's general urology. 15th ed. New York: McGraw-Hill; 2000;254-60 7. Neal DE Jr. Treatment of acute prostatitis. In: Nickel JC, editor. Textbook of prostatitis. 1st ed. Oxford: Isis Medical Media; 1999;279-84 8. Nickel JC. Prostatitis: evolving management strategies. Urol Clin North Am 1999;26:737-51 9. Clemens JQ, Meenan RT, O'Keeffe Rosetti MC, Kimes T, CalhounEA. Prevalence of and risk factors for prostatitis: population based assessment using physician assigned diagnoses. J Urol 2007;178: 1333-7 10. Nickel JC, Downey J, Hunter D, Clark J. Prevalence

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