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대한요로생식기감염학회지 : 제 1 호제 1 권 2006 년 10 월 Korean J UTII Vol.1, No.1, October 2006 종설 2006 유럽비뇨기과학회만성전립선염치료지침 7) 대구가톨릭대학교의과대학비뇨기과학교실 김덕윤 [Abstract] 2006 EAU Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Treatment Guidelines Duk Yoon Kim From the Department of Urology, College of Medicine, Daegu Catholic University, Daegu, Korea Advaces in research are changing the concept of the clinical management of chronic prostatitis, interstitial cystitis. As the new millennium begins, urologists and patients diagnosed with prostatits and interstitial cystitis can hope that exciting evolution will improve the dismal record for this disease. However, pain management is a subject afflicted by failure to identify its pathophysiological origins. The problem is most commonly experienced as 'interstitial cystitis (IC)' or 'chronic prostatitis (CP)'. The cause of chronic prostatitis (syndrome category IIIB) is not known, so causal treatment is a problem and many therapeutic options are justified on the basis of anecdote alone. IC is a disease of the urinary bladder, which was first described by Skene in 1887. The ulcer, which is a typical cystoscopic finding in 10-50% of IC patients, was first described by Guy L. Hunner at the beginning of the last century. In 1949, when John Hand presented a large series of IC patients with varying endoscope and histopathological presentations, he realized that his material on IC did not comprise just one single entity. Cure is not currently a realistic goal so that symptom management is the only route to an improvement in quality of life.. Various medical and intravesical treatments have been proposed and investigated for IC. When all efforts fail to relieve disabling IC symptoms, surgical removal of the diseased bladder represents an option. Three major techniques of bladder resection are common: supratrigonal (i.e. trigone-sparing) cystectomy, subtrigonal cystectomy, or radical cystectomy including excision of the urethra. All techniques require substitution of the excised bladder tissue, which is mostly performed with bowel segments. (Korean J UTII 2006;1:45-51) 서론최근 CPPS에대한관심이고조되고있으나병인이명확히밝혀져있지않고치료가다양하여지침의마련은진료에매우중요한일이지만어려운일이다. 국외의치료지침은 2003년에마련된 EAU guideline 이가장최근자료로 2006년에도같은내용으로지침이적용되고있으므로만성전립선염과간질성방광염을중심으로소개를하고자한다. 본론 교신저자 : 김덕윤대구가톨릭대학교의과대학비뇨기과학교실대구시남구대명 4 동 3056-6 Tel:053-650-4663, Fax:053-623-4660 E-mail: dykim@cu.ac.kr 1. 배경 통증은병태생리를확실히규명하기어려우며따라서치 45

46 대한요로생식기감염학회지 : 제 1 호제 1 권 2006 년 10 월 료도어려운주제이다. 가장흔히경험하는것은간질성방광염과만성전립선염이다. 현재의검정방법은세밀하지못하므로용어의재정립과관련자료의재평가가필요하다. 2. 정의 1) 만성골반통남성여성의골반구조물에서인지되는비악성의통증을말한다. 적어도 6개월이상재발성혹은지속성으로유지되는것으로용어는 ICS 1 와 IASP 2 분류에따라정의하였다. (1) pelvic pain syndrome은하부요로증상, 성기능, 위장관, 부인과기능이상과연관된지속적이고재발성을가진골반통을말한다. 현성감염이나다른알려진병리가없어야한다. ( 이하동일 ) (2) bladder pain syndrome은방광충만시치골상부통증이동반되는경우로감염과다른병리없이주야간빈뇨를동반한다. (3) urethral pain syndrome은배뇨시재발성의요도통증이주야간빈뇨와함께있는경우이다. (4) penile pain syndrome은요도가아닌음경내에통증이잇는경우이다. (5) prostate pain syndrome은요로나성기능장애와연관하여전립선에통증이지속적혹은재발성으로있는경우이다. NIH 분류 3 로 type A inflammatory와 type B non-inflammatory로세분한다. (6) scrotal pain은요로나성기능장애와연관하여음낭에통증이지속적혹은재발성으로있는경우이다. (7) testicular pain은요로나성기능장애와연관하여고환에통증이지속적혹은재발성으로있는경우이다. (8) epididymal pain은요로나성기능장애와연관하여부고환에통증이지속적혹은재발성으로있는경우이다. (9) endometriosis와연관된통증은 endometriosis와함께지속적, 혹은재발성골반통증이있는경우로모든증상을충분히설명할수없다. (10) vaginal pain syndrome은요로나성기능장애와연관하여질에통증이지속적혹은재발성으로있는경우이다. (11) vulvar pain syndrome은배뇨주기와연관되거나요로나성기능장애와연관하여음문부에통증이지속적혹은재발성으로있는경우이다. 지속적으로국소적인압박감을 point-pressure mapping으로한곳이상있으면 localized vulvar pain syndrome이고없으면 generalized vulvar pain syndrome이다. (12) clitoral pain syndrome은 clitoris에 point-pressure mapping으로국소적인통증이있는경우이다. (13) proctalgia fugax은불규칙한간격으로직장에심하면서짧은통증이생기는것을말한다. (14) anorectal pain syndrome은위장관장애와연관되어 rectal trigger point에지속적, 국소적, 반복적통증이있는것을말한다. (15) anismus는배변시외항문괄약근이이완하지못하여생기는항문통증을말한다. (16) pudenda lapin syndrome은직장, 요로, 성기능장애와관련하여 pudendal nerve의분포에따라생기는신경성통증을말한다. (17) perineal pain은배뇨주기와관련되거나요로나성기능장애와연관하여회음부에통증이지속적혹은재발성으로있는경우이다. (18) pelvic floor muscle pain syndrome은 trigger point와관련하여배뇨주기, 요로나성기능장애와연관하여회음부에통증이지속적혹은재발성으로있는경우이다. 3. 분류 (Table 1) 4. 만성전립선염 1) 도입전립선염은연구가어려운장기로애매하고잘규명되어있지않다. 임상적으로전립선염의 5-10% 만이세균적원인을규명할수있다. 따라서나머지 90% 는만성비세균성전립선염, 전립선통으로분류하고있는실정이다. 4-6 2) 정의만성골반통증후군과연관된만성전립선염은전립선액이나전립선맛사지후소변에서백혈구나균배양이되지않는골반의통증이나불편감을말한다. 7 NIDDK분류는다음과같다. 8

김덕윤 : 2006 EAU Chronic Prostatitis/Chronic Pelvic Pain Syndrome 치료지침 47 Table 1. Classification of chronic pelvic pain syndromes Chronic pelvic pain (new definition) Pelvic pain syndrome (1) Well- defined conditions that produce pain, examples include: Urological Bladder pain syndrome (1) Interstitial cystitis Urethral pain syndrome (1) Penile pain syndrome (new definition) Prostate pain syndrome (Adapted from NIH) (3) Scrotal pain syndrome (1) Testicular pain syndrome (new definition) Post-vasectomy pain syndrome (new definition) Epididymal pain syndrome (new definition) Gynecological Endometriosis-associated pain syndrome (new definition) Vagial pain syndrome (1) Vulvar pain syndrome (1) Generalized vulvar pain syndrome (ISSVD 1999) Localized Vestibular pain syndrome vulvar pain (ISSVD 1999) syndrome Clitorial pain (ISSVD 1999) syndrome (ISSVD 1999) Anorectal Proctalgia fugax (2) Anorectal pain syndrome (new definition) Anismus Neurological Pudendal pain syndrome (new definition) Muscular Perineal pain syndrome (1) Pelvic floor muscle pain syndrome (new definition) Urological Infective cystitis Infective prostatitis Infective urethtritis Infective epididymo-orchitis Gynecological Endometriosis Anorectal Proctitis Hemorrhoids Anal fissure Neurological Pudendal neuropathy Sacral spinal cord pathology Other Vascular Cutaneous Psychiatric 3) 병인 아직확실치않다. 여러가지가설이있다. 배뇨증상과관련이있으므로방광경부문제나배뇨근괄약근기능부전, 요도협착, 배뇨시높은압력등하부요로폐색과관련이있다는설이있다. 8-13 다른연구자는높은 Table 2. Classification of prostatitis according to NIDDK/NIH Ⅰ. Acute bacterial prostatitis (ABP) Ⅱ. Chronic bacterial prostatitis (CBP) Ⅲ. Chronic pelvic pain syndrome (CPPS) A. Inflammatory CPPS: WBC in semen/eps/voided bladder urine-3 (VB3) B. Noninflammatory CPPS: no WBC in semen/eps/vb3 Ⅳ. Asymptomatic inflammatory prostatitis (histological prostatitis) 압력으로전립선사출관내의역류나해부학이상에의한와류형성에기인한다는이론이있다. 14-17 미생물관련원인은아직검출하지못하는감염균에의한원인을설명한다. 면역학적병인은비세균성전립선염에인지되지않는항원이나자가면역질환에의해역류등이비감염성염증반응을자극한다는이론을제기한다. 신경근육병인은회음부나골반저에반사성교감신경실조에의해증상이생긴다는가설로상당한호응을받고있다. 18-20 4) 진단하부요로의다른병리없이 3개월이상지속되는요로생식기통증이있어야한다. 진행과치료에대한반응은

48 대한요로생식기감염학회지 : 제 1 호제 1 권 2006 년 10 월 증상점수에의거하여평가한다. 21,22 삶의질에미치는영향은심근경색증, 불안정협심증, 크론씨병과비슷하다. 요역동학검사소견에는요속저하, 방광경부나전립선요도의불완전한이완, 휴지기시높은요도폐쇄압등이있고, 배뇨시외요도괄약근의이완은정상이다. 23 검사실소견은 4-배분법이 gold standard이다. 24 검사가어려우므로비용효과가큰 2-배분법을할수있다. 전립선액내에백혈구나지방을포함한대식세포를관찰할수있다. 에효과가있다. 항콜린제는요저장증상과성기능회복에도움이된다. Phytotherapy와 pentosanpolysulphate의긍정적인결과가있으나추가적인연구가필요하며 heat therapy는일부환자에서효과가있다. 방광경부절개술, 경요도절제술, 근치적전립선전적출술같은수술은제한적인효과가있고추가적인연구가필요하다. 27 5. 간질성방광 1) 도입 1887년 Skene에의해처음서술되고 Hunner, Bumpus 등이추가로연구하여점막하궤양등을설명하였다. 1949 년 John Hand는내시경, 병리조직학소견을종합하여단순한한개의범주에속하지않는다는설명을하였다. 28 2) 정의 1987년 NIDDK정의가만들어져대부분이인정하고있으나임상에사용하기에는너무엄격하다는의견도있다. Fig. 1. Diagnostic assessment of chronic prostatitis 5) 치료원인규명이어려우므로치료도쉽지가않다. 완치는현실적이지못하므로삶의질을향상시키는증상완화가목적이다. 25 근이완제는골반근, 회음부근육울이완시키는데도움이된다. 그러나전향적인연구결과가아직없다. 알파차단제는 48-80% 의증상호전을보고하고있다. 바이오피드백, 운동, 생활습관개선, 침술, 마사지치료, 카이로프락틱, 명상요법등이증상을호전시킨다. 25 항균제요법은 4-6주간혹은더길게지속할수있다. 중단후지속적인저용량요법을할수있다. 장기간 trimethoprim-sulphamethoxazole은결과가좋지못하며, quinolone계통의치료결과는희망적이다. 26 진통제는대부분환자에서사용되나장기간결과는제한적이다. NSAID는일부에서효과적이며 cytokine inhibitor가유용하다. Finasteride같은 5-환원효소차단제는배뇨와통증 Table 3. Research definition of interstitial cystitis established by NIDDK Workshop on IC, 28-29 August 1987 (70) Automatic inclusions Hunner s ulcer Positive factors Pain on bladder filling relieved by emptying Pain (suprapubic, pelvic, urethral, vaginal or perineal) Glomerulations on endoscopy Decreased compliance on cystometrogram Automatic exclusions < 18 years old Benign or malignant bladder tumor Radiation cystitis Tuberculous cystitis Bacterial cystitis Vaginitis Cyclophosphamide cystitis Symptomatic urethral diverticulum Uterine, cervical, vaginal or urethral cancer Active herpes Bladder or lower ureteral calculi Walking frequency< five times in 12 hours Nocturia< 2 times Symptoms relieved antibiotics, urinary antiseptics, urinary analgesics Duration < 12 months Involuntary bladder contractions(urodynamics) Capacity > 400cc, absence of sensory urgency

김덕윤 : 2006 EAU Chronic Prostatitis/Chronic Pelvic Pain Syndrome 치료지침 49 3) 병인원인은아직확실히알수가없다. 감염의연관성에대해서는원인균이나바이러스를입증하지못하였다. 그러나배양이까다로운균의가능성등이있어아직결론이난것은아니다. 염증반응은전체방광이나신경주위임파구, plasma 세포침윤등염증반응이나타난다. 전형적인환자에서 Mast cell수가 10배정도증가하고 histamine, leukotriene, serotonin, cytokineemd 분비물이통증, 빈뇨, 부종, 섬유화를초래하는것으로생각된다. 요로상피세포기능이상이나 GAG layer 의결손으로점막균열등이방광충만시관찰된다. 전자현미경에서 tight junction이넓어지고투과성이증가하고 GAG layer 의결손으로소변내여러독성물질에노출되어증상을유발할수있다. 29 자가면역기전은환자에서여러항핵항체등이발견되어관련성을제기하고있다. 면역관련으로 complement 의활성화, T-cell, B-cell의침윤이환자에서확인되었다. NO기전은경구로 L-arginine을복용한결과 NO-관련효소의증가를환자소변에서관찰하였다. 신경생물학적으로환자에서교감신경항진이관찰되었으며 S-100 proteins이말초신경계의 Schwann cell에보이며궤양이없는환자에서는감소하는소견이있다. 소변내저분자량의 heat labile cationic toxic agent가방광의손상을초래하여점막의방어를감소시킨다. 또점막하층의미세혈관의밀도의감소가환자에서관찰되어방광충만시방광의투과성을감소시킨다는연구결과가있다. 4) 역학서양인에더흔한것으로관찰되며미국에서는성인의 0.5%, 인구만명당 5-6명이이환된것으로추정된다. 30 10:1로여성에흔하며, 연간 1억달러이상의경제적비용이들것으로추정된다. Hunner ulcer를동반하는 classic type은 5-10% 혹은 20% 를차지하고나머지는궤양을동반하지않는형태로나타난다. 5) 관련질환염증성장질환, 전신성홍반, 과민성장증후군등이연관되어발병한다. 6) 진단증상, 신체검사, 소변검사, 방광경검사, 방광확장및조직검사로진단한다. 치골상부통증이방광충만과연관되어나타나며사타구니, 질, 직장등으로확대되어나타난다. 야간뇨를포함한심한빈뇨를동반한다. 방광경검사에서 classic type은가운데반흔을중심으로작은혈관이방사형으로위치하며점막이붉게나타난다. 방광충만시반흔은파열되면서폭포형태의출혈을보인다. 마취하에서방광용적감소와연관이많다. Non-ulcer IC는처음정상방광점막을보이나방광충만시 glomerulation이나타나면진단할수있다. 31 조직검사가도움이되며상피내암, 결핵성방광염과감별진단에중요하다. Potassium chloride 검사는최근변별력이떨어지는것으로알려져있으며증상점수를이용하기도한다. 7) 약물치료진통제는통증완화를위해대부분환자에서투여되나효과가적다. 만성적인경과를보이는질병의특성이있으므로조심스럽게사용되어야한다. 스테로이드는결과가상반되어있으며부작용이많으므로적절한용량의결정등문제가있다. 항알러지약물은 mast cell 의활성을줄이며 histamine을감소시키는효과가있다. hydroxyzine은 H1 길항제로 25mg을취침전복용하며 75mg까지증량할수있다. 부작용으로전신쇠약이있으나대부분자연소실된다. 편두통, 과민성장질환, 알러지등동반질환에같이효과가나타난다. Cimetidine 은 H-2 blocker로 3개월복용후통증, 빈뇨등에효과가있다는보고가있다. Amitriptyline은아세틸콜린수용체차단을통해 serotonine, norepinephrine의재흡수를차단하고 H1 수용체를차단한다. Sodium pentosan polysulphate (PPS) 는통증, 요절박, 빈뇨에효과가있다. Classic type에더효과적이며 150-200mg을 2회분복한다. 항균제는제한적인효과를보이며일부환자의증상을호전시키나보편적으로사용할수는없다. azathioprine같은면역억제제는빈뇨, 통증을감소시키며 cyclosporine, methotrexate도통증완화에효과를보인다. 방광내 oxybutynin주입으로방광용적을, 최초방

50 대한요로생식기감염학회지 : 제 1 호제 1 권 2006 년 10 월 광충만감에호전을보이나통증에는효과가적다. 항경련제인 gabapentin은통증완화에효과를보인다. Suplatast tosilate는 helper T-cell이매개하는알러지반응을억제하며 1년치료시방광용적증가와증상의호전을나타낸다. Quercetin은 bioflavinoid로골반통에효과가있는것으로알려져있다. 8) 방광내치료부작용을줄이면서장기내직접고농도를주입할수있으나도뇨관삽입이필요하며비용, 감염의우려가있다. 국소마취제는 lidocaine이점막에작용하나흡수가거의안된다. PPS 300mg을 50mL 생리식염수에녹여주 2회, 3개월사용한결과일부환자에서증상의호전, 방광용적의증가를보였다. Heparin 은 10mL증류수에 10,000 unit를섞어주3회, 3개월치료하여반이상에서증상의호전을보였다. Hyaluronic acid는 4주치료시 56%, 7주치료시 71% 에서효과를보였으며 2/3에서장기간효과를나타내었다. Dimethyl sulphoxide(dmso) 는진경, 항염증, 근이완효과를나타내며 50% 용액을주 2회투여하여 53% 에서증상호전을보였으며요로감염이있거나, 조직검사후에는사용하면안된다. 32 BCG는 6주주입시 60% 에서반응을보였으며 DMSO와이중맹검, 교차시험에서더효과적이지는않다. Clorpactin은결핵성방광염에사용되는 hypochloric acid로상피세포를탈락시키고재생을돕는작용을한다. 마취하에주입하며 6-12개월치료시 50-70% 에서효과를보이나조직검사후나역류가있으면사용하지않는다. 부작용의빈도 가높다. Resiniferatoxin 같은 vanilloid는빈뇨, 통증감소가 50% 정도에서나타나며배뇨근과반사를억제시킨다. 33 9) 관혈적치료방광확장술은 1930년대부터시도되어온방법으로여러보고가있으나최근 Glemain이 65명을대상으로 3 시간 balloon hydrodistension으로치료하여 6개월에 38%, 1년에 22% 효과를보이며용적이 150mL이상으로늘어났다. 많이치료되는방법이지만진단적가치가높고치료효과는제한적이다. Electromotive drug administration (EMDA) 는 iontophoresis로이온화된약물을조직에침투시키는방법으로 Guipinar 는 1.5% lidocaine, 1:100,000 epinephrine을사용하여증상호전과방광확장이가능하였다고하였으며 34 Rosamilia는 dexamethasone을사용하여 2주에 85%, 2개월에 63% 에서좋은효과를보였다고하였다. 값이비싸고충분한연구가되지는않았다. 경요도절제술, 응고술, 레이저수술은점막병소를제거하여증상을호전시키지만비수술방법보다낫지는않다. Rofeim은 Nd-YAG laser로궤양을치료하여 23개월에통증, 빈뇨등이유의하게호전되었으나 24명중 11명에서 4회의추가치료가필요하다고하였다. Non-ulcer type에는적용되지않으며완치를할수없고대조연구가없다. 10) 보완요법방광훈련은 Parsons에의하면 21명중 15명에서 50% 의요절박, 빈뇨의감소와방광용적증가를보였다고하 Table 4. Level of evidence and grade of recommendation Level Type of evidence 1a Meta-analysis of randomized trials 1b At least on randomized trial 2a One-well-designed controlled study without randomization 2b One other type of well-designed quasi-experimantal study 3 Non-experimantal study (comparative, correlation study, case reports) 4 Expert committee, expert opinion Grade A B C Basis for recommendation Clinical studies of good quality and consistency including at least one randomized trial Well-conducted clinical studies without randomized trials Absence of directly applicable clinical studies of good quality

김덕윤 : 2006 EAU Chronic Prostatitis/Chronic Pelvic Pain Syndrome 치료지침 51 Table 5. Medical treatment of IC Level of evidence Grade of recommendation Comment Analgesics 4 C Indications limited to cases awaiting further treatment Corticosteroids 3 C Corticosteroids not recommended as long-term treatment Hydroxyzine 2b B Standard treatment Cimetidine 1b A Preliminary data so far Amitriptyline 1b B Standard treatment Sodium PPS 1a A Standard treatment Antibiotics 1b A Limited role in the treatment of IC Prostaglandins 3 C Insufficient data on IC, adverse effects L-arginine 1b Effect in IC uncertain Immunosuppressants 3 C Insufficient data on IC, adverse effects Oxybutynin 3 C Limited indication in IC Tolterodine 3 C Limited indication in IC Gabapentin 3 C Preliminary data so far Suplatast Tosilate 3 C Preliminary data so far Quercetin 3 C Preliminary data so far Table 6. Intravesical, interventional, alternative and surgical treatment of IC Level of evidence Grade of recommendation Comment Intravesical anaesthetics 3 C Intravesical PPS 1b A Intravesical heparine 3 C Intravesical hyaluronic acid 3 C Intravesical DMSO 1b A Intravesical BCG 1b Not recommended beyond clinical trials Data contradictory Intravesical Clorpactin 3 Not recommended Obsolete Intravesical vanilloids 1b Not recommended beyond clinical trials Insufficient data on IC Bladder distension 3 C EMDA 3 B TUR coagulation and laser n.a. A/B Hunner s ulcer only Nerve blockades/epidural pain pumps 3 C For crisis intervention, effect on pain only Sacral neuromodulation 3 B Patients without pain Bladder training 3 B Manual and physical therapy 3 B Diet 3 C Data contradictory Acupuncture 3 C Hypnosis No data Psychological therapy 3 B Ultima ratio, experienced surgeons Surgical treatment n.a. A n.a.=not applicable 였으며 Chaiken 은 42명에서 12주훈련으로 83% 에서증상의유의한호전이있었다고하였다. 음식조절은환자들이 fiber는많이, calory나커피ㅂ지방섭취는적게하는것을관찰하였고 Gillespie는산성음식, arylalkylamine 을제한하면증상의완화를가져온다고하였다. 자가조절이가능하여비용이저렴하지만단독요법으로는효과가제한적이다. 침술은 Chang 이 52명을대상으로 85% 의 환자에서증상을호전시키고방광용적이늘어났으며반복시술시효과가있다고하였으나과학적근거가부족하다. 최면요법은만성통증환자에서시도되나역시과학적근거가부족하다. 12) 수술요법다른방법으로수년간치료하여실패하였을때고려

52 대한요로생식기감염학회지 : 제 1 호제 1 권 2006 년 10 월 Fig 2. Flowchart of the diagnosis and therapy of IC 한다. 3가지방법즉삼각부상부절제술, 부분방광절제술, 전방광절제술이있다. 방광확장이나대치에소장, 맹장, 우측대장, S자결장이이용된다. 술기는술자의경험에다라선택되면방광경검사와조직검사결과에따라절제범위를정할수있다. 방광전척출술후회장도관이가장많이선호되는방법이며최근정위성방광으로확대수술을할경우수술후자가도뇨가필요하므로이에대한고려가필요하다. 35 REFERENCES 1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Society. Am J Obstet Gynecol 2002;187:116-26 2. Merskey H, Bogduk N. Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. IASP Press 2002 3. Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999; 282:236-7 4. de la Rosette JJ, Hubregtse MR, Meuleman EJ, Stolk- Engelaar MV, Debruyne FM. Diagnosis and treatment of 409 patients with prostatitis syndromes. Urology 1993;41:301-7 5. Meares EM Jr. Prostatitis. Med Clin North Am 1991; 75:405-24 6. Brunner H, Weidner W, Schiefer HG. Studies on the role of Ureaplasma urealyticum and Mycoplasma hominis in prostatitis. J Infect Dis 1983;147:807-13 7. Nickel JC, Weidner W. Chronic prostatitis: Current Concepts and antimicrobial therapy. Infect Urol 2000; 13:22. 8. Barbalias GA, Meares EM Jr, Sant GR. Prostatodynia: clinical and urodynamic characteristics. J Urol 1983; 130:514-7 9. Blacklock NJ. Urodynamic and psychometric observations and their implication in the management of prostatodynia. In: Weidner W, Brunner H, Krause W, Rothague CF, eds. Therapy of Prostatitis. Munich: Zuckschwerdt Verlag, 1986;201

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