Prostatitis: a concise review
Cause
Bacterial and non-bacterial
etiologies
Epidem
Prostatitis
affects up to 50% of men at some point in their lives. Affects men of all ages
About 8% of all urology visits
in United States related to prostatitis
Only about 6-8% of men with prostatitis will have bacterial prostatitis
Pathophys: NIH
classification and definitions of prostatitis:
I. Acute bacterial prostatitis.
II. Chronic bacterial prostatitis: recurrent infection.
III. Chronic abacterial prostatitis/chronic pelvic pain syndrome:
no demonstrable infection
IIIA. Inflammatory chronic pelvic pain syndrome: wbc present in semen/expressed prostatic secretions or voided
bladder urine (VB3).
IIIB. Noninflammatory chronic pelvic pain syndrome: no wbc noted in semen/expressed prostatic secretions or VB3.
IV. Asymptomatic inflammatory prostatitis:
detected by prostate bx or presence of wbcs in prostatic
secretions during evaluation for other disorders.
Organisms isolated in acute and chronic bacterial prostatitis are
same as those causing UTI
E. coli accounts for 80% of prostatic
infections;
Other gram-negative organisms (Pseudomonas aeruginosa,
Serratia, Klebsiella proteus) account for 10-15% of infections.
Enterococci identified in 5-10% cases of prostatitis
Role
of Chlamydia trachomatis in prostatitis is
controversial.
Etiology of acute bacterial prostatitis is often due to reflux of
infected urine into prostatic ducts that drain into posterior urethra
Inflammation and edema may lead
to occlusion of these ducts, trapping bacteria within, leading to chronic
bacterial prostatitis
Intraprostatic urinary reflux,
causing a “chemical” prostatitis, may play a role in etiology of nonbacterial
prostatitis
Symptoms
Urinary
frequency and urgency, dysuria, malaise, pain in perineum, groin, testes, back,
suprapubic area
Signs
Fever/chills if
acute bacterial, decreased urine flow rate, nocturia; tender, boggy, or firm
prostate on DRE
Differential diagnosis
Distal
ureteral calculus, Müllerian remnant, urethral stricture,
BPH, seminal vesicle cyst, prostatic cyst, IC, bladder cancer, urachal remnant, hernia, ejaculatory duct
cyst, depression/stress, spinal stenosis, mesenteric cyst, fibromyalgia
Lab
Meares-Stamey test (4 glass test) is gold standard
for diagnosis of bacterial prostatitis. After cleansing and
retraction of foreskin, pt voids first 10 mL into sterile
container (VB1), then collects midstream 5-10 mL (VB2),
then prostatic massage performed, collect expressed prostatic secretions and
review under microscope and collect first 10 mL of urine
after massage (VB3).
Modification of Nickels allows for simple testing with 91%
sens and specif compared to
Meares-Stamey technique.
Modified Nickels technique: Collect midstream urine and
perform prostatic massage, then collect postmassage urine and perform UA, C&S on both.
Future studies include
immunologic techniques to allow for ab screening of the
expressed prostatic secretions or VB3 specimen for common prostatic pathogens
and molecular biologic techniques using PCR to id bacterial gene products
Radiology
Bladder scanner PVR to ensure complete bladder emptying. Uroflow helpful in
pts with voiding complaints.
Cystoscopy not indicated in most pts.
Videourodynamics in pts with nonbacterial chronic prostatitis may demonstrate spastic dysfunction of bladder neck and prostatic urethra
Cystoscopy not indicated in most pts.
Videourodynamics in pts with nonbacterial chronic prostatitis may demonstrate spastic dysfunction of bladder neck and prostatic urethra
Treatment
Acute bacterial prostatitis with abx; typically fluoroquinolones for 6-12 wk. TMP/SMX may be used.
Chronic bacterial prostatitis rx with abx for extended periods; in pts with frequent recurrent infections long-term prophylactic
abx may be employed.
Chronic nonbacterial prostatitis may be treated as follows:
Category IIIA: Trial of broad-spectrum
abx, alpha-blocker therapy, anti-inflammatory agents,
finasteride or other 5-alpha reductase inhibitor if enlarged prostate, prostatic
massage (2-3 ×/wk), supportive therapy (counseling),
transurethral microwave therapy or phytotherapy.
Category IIIB: Alpha-blocker therapy,
muscle relaxant, analgesics, biofeedback, relaxation exercises, supportive
therapy (counseling).
Other Therapies: Sitz baths; avoidance of
spices, caffeine, and alcohol. Biofeedback has encouraging results in pts with noninflammatory chronic pelvic pain syndrome
