prostatitis
PROSTATITIS

Prostatitis is the inflammation of the prostate that may be caused by infection, chronic pelvic pain syndrome or asymptomatic prostate inflammation.

Prominent features are genitourinary, pelvic or rectal pain and lower urinary tract symptoms, eg urinary frequency, urgency, hesitancy, weak stream and straining on urination, dysuria, pain that increased with urination.

Classification

    • The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) classifies prostatitis into the following:

    Acute Bacterial Prostatitis (ABP)

    • May be a serious infection needing prompt diagnosis & treatment w/ antibiotics
    • Results from the reflux of urine into the prostate gland causing proliferation of bacteria
    Chronic Bacterial Prostatitis (CBP)
    • The most frequent cause of recurrent urinary tract infection (UTI) in men, symptoms persist for at least 3 months
    • Develops from an ascending urethral infection, hematogenous spread of bacteria, lymphatic spread of rectal pathogens, recurrent urinary tract infection (UTI) w/ reflux into the prostate, or inadequately treated acute bacterial prostatitis (ABP)
    Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
    • Symptoms of pelvic pain or discomfort present for at least 3 months w/o cultured uropathogenic bacteria & other urogenital pathology
    • Etiology is poorly understood & it had been proposed to have both infectious & inflammatory mechanisms
      • Inflammatory (chronic non-bacterial prostatitis): Significant number of white blood cells (WBCs) in semen, expressed prostatic secretion (EPS) & voided bladder urine after prostatic massage (VB3)
      • Non-inflammatory (prostatodynia): Insignificant number of white blood cells (WBCs) in semen, expressed prostatic secretion (EPS), & voided bladder urine after prostatic massage (VB3)
    Asymptomatic Inflammatory Prostatitis (AIP)
    • Or histological prostatitis is an incidental finding of unknown significance
    • White blood cells (WBCs) &/or bacteria are present in the semen, expressed prostatic secretion (EPS), voided bladder urine after prostatic massage (VB3) or prostatic tissue during evaluation for other urologic disorders in asymptomatic patients

History

  • Let patient characterize pain, its location, duration, frequency, severity; lower urinary tract symptoms, eg obstructive, retention, voiding & irritative; other associated symptoms, eg fever; & effect on quality of life
  • Inquire also on patient’s sexual history, presence of neurologic disorders or previous pelvic surgery
Acute Bacterial Prostatitis (ABP)
  • Presents abruptly w/ symptoms that include fever, chills, dysuria, urinary frequency or urgency, pain in the low back, lower abdomen, rectum or perineum, hematospermia, hesitancy, incomplete emptying, poor stream, urinary straining, mildly to acutely ill presentation
  • Risk factors for developing acute bacterial prostatitis (ABP) include diabetes mellitus (DM), immunodeficiency, chronic indwelling catheters, or intermittent self-catheterization, benign prostatic hyperplasia (BPH), genitourinary infections, history of sexually transmitted diseases, prostate manipulation
Chronic Bacterial Prostatitis (CBP)
  • Patients report genitourinary pain or discomfort, dysuria & frequency w/o other signs of acute bacterial prostatitis (ABP), recurrent urinary tract infection (UTI) w/o prior bladder instrumentation, new-onset sexual dysfunction w/ no other cause, hematospermia
  • May use the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) & the International Prostate Symptom Score (IPSS) as validated tools for assessing disease severity, or quantification of symptoms
    • Both measure urinary symptoms & impact on quality of life; National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) additionally assesses pain
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
  • Symptoms vary widely & may include pain in the lower abdomen, perineum, penis or testicles, dysuria, urinary frequency or urgency, sexual (erectile) dysfunction, hematospermia, or psychological issues
  • Makes use also of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) & International Prostate Symptom Score (IPSS) questionnaires in evaluation of symptoms
  • Condition is diagnosed if w/ occurrence of pelvic pain or urinary symptoms for >3 of the prior 6 months w/o demonstrable infection & other urogenital pathology during that time

Physical Examination

Acute Bacterial Prostatitis (ABP)
  • Digital rectal exam (DRE) elicits a warm, tender & swollen prostate in acute prostatitis
    • Prostatic massage should not be done as it may cause bacteremia & sepsis
  • A distended bladder may be palpated on abdominal exam indicating urinary retention
Chronic Bacterial Prostatitis (CBP)
  • Though prostate exam is often normal, it should be performed to rule out prostatic calculi which may be a nidus of infection
  • Prostate can also be tender or boggy on digital rectal exam (DRE)
  • An abdominal exam also helps exclude other causes of abdominal pain
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
  • Examination of the abdomen, external genitalia, perineum, & prostate as well as a musculoskeletal assessment are performed to rule out underlying pathology
  • Findings are variable; however, urogenital exam is generally unremarkable

Laboratory Tests

Acute Bacterial Prostatitis (ABP)
  • A urinalysis, urine Gram stain & midstream urine culture are important in evaluating acute prostatitis; may also consider doing a postvoid residual testing if urinary obstruction is suspected
  • Imaging w/ a computed tomography (CT) scan or transrectal ultrasound of the prostate is indicated to confirm prostatic abscess in a patient unresponsive to antimicrobial therapy, ie fever persisting >36 hr post antibiotic coverage, while a pelvic ultrasound is indicated in patients w/ possible urinary retention
Chronic Bacterial Prostatitis (CBP) 
  • The Meares-Stamey 4-glass test is the gold standard for chronic bacterial prostatitis (CBP) diagnosis
    • Segmented urine & expressed prostatic secretion (EPS) are examined microscopically; a voided bladder urine after prostatic massage (VB3) or expressed prostatic secretion (EPS) colony count of >1 log(s) greater than the voided bladder 1 (VB1) specimen (the first 10 mL of voided urine) confirms chronic bacterial prostatitis (CBP)
    • Not routinely used because of difficulty obtaining samples
  • The simpler 2-glass pre- & post-prostatic massage urine sample testing gives good concordance w/ the Meares-Stamey 4-glass test & is a reasonable alternative
  • A urinalysis & a midstream urinary culture are also evaluated in chronic bacterial prostatitis (CBP)
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
  • Lab tests or imaging studies are performed to exclude other possible causes of symptoms or urologic conditions, eg bladder cancer, voiding dysfunction
  • Basic evaluation includes a urinalysis & a midstream urinary culture
Other Tests
  • Depending on the severity of presentation, a complete blood count (CBC), blood culture, or electrolyte levels may be requested
    • May be performed in patients who may have renal function impairment & in whom antimicrobial treatment is being considered
    • A blood culture may be taken if there are clinical signs of sepsis, possible hematogenous source of infection, or if patient is immunocompromised
  • The following may only be performed when clinically indicated: Serum prostate-specific antigen (PSA) level, semen culture, transrectal prostatic ultrasound, prostate biopsy, cystoscopy, urodynamic evaluation for obstructive voiding symptoms
  • Screen for sexually transmitted infections, eg Chlamydia & gonorrhea, in patients at risk: Patients who are young & sexually active, men w/ high-risk sexual behaviors & those w/ primarily urethral discharge or symptoms
    • Consider a nucleic acid amplification test (NAAT) for Chlamydia & gonorrhea & a prostatic fluid culture for ureaplasmas
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