• Clinical science

Prostatitis

Summary

Prostatitis is an inflammation of the prostate gland that may be of infectious (acute and chronic bacterial prostatitis) or noninfectious origin (chronic pelvic pain syndrome, or CPPS). Acute and chronic bacterial prostatitis are most often caused by Escherichia coli, while in CPPS no causative organism can be identified. Patients with acute bacterial prostatitis typically present with spiking fevers, chills, perineal pain, and symptoms of bladder irritation. The presentation of chronic bacterial prostatitis and CPPS is more subtle, including symptoms of chronic or recurrent urinary tract infections and genitourinary pain. Findings on examination include a tender, boggy prostate in acute bacterial prostatitis, and mildly tender or normal prostate in chronic bacterial prostatitis and CPPS. Diagnostics aim to identify a potential causative organism via urine culture or fractional urine examination. Empirical antibiotic treatment is the primary therapeutic approach for acute and chronic bacterial prostatitis, whereas treatment for CPPS is multimodal, including pharmacological treatment, psychological support, and physiotherapy. Acute bacterial prostatitis can lead to complications (e.g., acute urinary retention, prostatic abscess formation, sepsis) that may require additional treatment, such as suprapubic catheterization or ultrasound-guided abscess drainage.

Epidemiology

  • Common urologic diagnosis in men < 50 years of age [1][2]
  • In men, there is an ∼ 8% lifetime risk of developing prostatitis.
  • Bacterial prostatitis (2–5% of cases): most commonly men between 20 and 50 years of age
  • Chronic pelvic pain syndrome (90–95% of cases): primarily men between 40 and 60 years of age

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Acute prostatitis [3][4][5]

  • Bacterial
  • Nonbacterial: Viral infections are rare.

Chronic prostatitis [7]

Other causes for acute or chronic bacterial prostatitis

Chronic pelvic pain syndrome (CPPS) [8][9]

  • Exact etiology unknown
  • CPPS has been associated with:
    • Pathogens that are difficult to detect (e.g., Mycoplasma, Ureaplasma)
    • Increased prostatic tissue pressure
    • Autoimmune processes
    • Psychosomatic dysfunction

Clinical features

Overview of clinical features of bacterial prostatitis and chronic pelvic pain syndrome [2][10][11][12]
Acute bacterial prostatitis Chronic bacterial prostatitis Chronic pelvic pain syndrome (CPPS)

Constitutional symptoms

  • Spiking fevers, chills
  • Malaise
  • Commonly absent
  • Low-grade fever in some patients
  • Commonly absent

Genitourinary tract symptoms

  • Acute bladder irritation
    • Acute dysuria
    • Frequency
    • Urgency
  • Cloudy urine

Genitourinary pain

  • Severe
    • Lower back
    • Perineal
    • Pelvic
    • With defecation
  • Mild
  • Moderate, diffuse

Prostate

  • Tender, boggy
  • Warm, swollen
  • Often normal
  • May be enlarged and tender
  • Usually normal
  • May be slightly tender

Diagnostics

Clinically suspected bacterial prostatitis is confirmed by detection of bacteria in urinalysis and culture. Chronic pelvic pain syndrome is a diagnosis of exclusion. [13][14][15]

Laboratory tests

Acute bacterial prostatitis

Chronic bacterial prostatitis

Four-glass test

  • Overview
    • Used to determine the location of the infection by culturing various urine samples
    • Difficult technique, therefore not performed often
  • Procedure: 4 samples are taken and cultured

Two-glass test

  • Overview
    • Suggested as an acceptable alternative to four-glass test
    • Easier to perform and only slightly lower sensitivity
  • Procedure: 2 samples are taken and cultured
    • 1st glass: premassage urine
    • 2nd glass: postmassage urine

Further diagnostics

These tests should not be performed routinely and are only indicated if a complication is suspected or to exclude differential diagnoses in CPPS.

Treatment

Bacterial prostatitis [16][2][14][17]

Chronic pelvic pain syndrome [14]

Complications

We list the most important complications. The selection is not exhaustive.

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last updated 10/27/2020
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