Prostatitis

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.

• 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.

Acute prostatitis ^[3][4][5]

• Bacterial
  • E. coli is the pathogen most commonly involved (highest prevalence in men > 35 years).
  • C. trachomatis and N. gonorrhoeae should be considered in men < 35 years of age. ^[6]
  • Mycobacterial infections are rare.
• Nonbacterial: Viral infections are rare.

Chronic prostatitis ^[7]

• Bacterial
  • E. coli
  • Other Enterobacteriaceae
• Nonbacterial
  • Immune response to a prior UTI
  • Nerve damage in the pelvic region
  • Chemical irritation (chemical prostatitis)
  • Pelvic floor muscle dysfunction
  • Parasitic or viral infections

Other causes for acute or chronic bacterial prostatitis

• Other genitourinary tract infections (e.g., urethritis, cystitis, epididymitis)
• Genitourinary tract interventions (e.g., indwelling catheter, transurethral surgery, prostate biopsy)
• Voiding dysfunction and bladder outlet obstruction

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

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

• Urinalysis
  • Mid-stream urine: ↑ WBC
  • Urine culture: E. coli is most common pathogen (80% of cases)
  • Urine Gram stain
• Blood tests
  • ↑ Inflammatory markers
  • ↑ PSA
• Blood cultures: in case sepsis is suspected

Chronic bacterial prostatitis

• Fractional urine examination
  • Collection of urine from a specified quantity or during a few specified hours instead of the entire amount voided during a full day
  • Can be used to diagnose conditions affecting the kidneys or prostate
• The following two tests are methods for diagnosing chronic bacterial prostatitis that are based on fractional urine examination.

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
  • 1^st glass (initial urine): urethral sample
  • 2^nd glass (mid‑stream urine): bladder sample
  • 3^rd glass (fluid expressed during prostatic massage): prostatic sample
  • 4^th glass (urine after prostatic massage): prostatic sample

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
  • 1^st glass: premassage urine
  • 2^nd 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.

• Urethral swab and culture: to exclude urethritis caused by sexually transmitted pathogens (e.g., chlamydia)
• Ultrasonography
  • Bladder: to assess for residual urine
  • Prostate (transrectal): to exclude prostatic abscess
• Uroflowmetry or cystoscopy: to exclude urethral stricture or bladder outlet obstruction

Bacterial prostatitis ^{[2][14][16][17]}

• First-line treatment: antibiotic therapy PO for 6 weeks
  • Fluoroquinolones (e.g., ciprofloxacin)
  • Trimethoprim-sulfamethoxazole
• In cases of acute urinary retention and persistent fever: suprapubic catheterization

Chronic pelvic pain syndrome ^[14]

• Medical therapy
  • Alpha blockers (e.g., tamsulosin, doxazosin)
  • 5-alpha-reductase inhibitors (e.g., finasteride)
  • Antibiotics
  • NSAIDs
  • Anti-inflammatory phytotherapeutic agents (e.g., cernilton)
  • Anticholinergics (e.g., oxybutynin): may lessen symptoms of voiding difficulty, especially in patients with concomitant benign prostatic hyperplasia ^[18]
• Supportive therapy
  • Psychological support and treatment
  • Physiotherapy

• Prostatic abscess
  • Clinical features: genitourinary symptoms similar to acute bacterial prostatitis (see “Clinical features” above)
  • Rectal exam: fluctuating prostate
  • Treatment: antibiotics and transrectal ultrasound-guided drainage
• Acute urinary retention
• Pyelonephritis and sepsis
• Epididymitis

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