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Prostatitis
refers to a disparate group of disorders that presents with a combination
of irritative or obstructive urinary symptoms and perineal pain.
Some result from bacterial infection of the prostate gland and others
from a poorly understood combination of noninfectious inflammatory
factors and/or spasm of the muscles of the urogenital diaphragm.
Diagnosis is clinical, along with microscopic examination and culture
of urine samples obtained before and after prostate massage. Treatment
is with a fluoroquinolone if the cause is bacterial. Nonbacterial
causes are treated with warm sitz baths, muscle relaxants, and anti-inflammatory drugs
or anxiolytics.
Etiology
Prostatitis can be bacterial or, more commonly, nonbacterial. However, differentiating bacterial and nonbacterial causes can be difficult, particularly in chronic prostatitis.
Bacterial prostatitis can be acute or chronic and is usually caused by typical urinary pathogens (eg, Klebsiella
, Proteus
, Escherichia coli) and possibly Chlamydia. How they enter and infect the prostate is unknown. Chronic infections may be caused by sequestered bacteria that antibiotics have not eradicated.
Nonbacterial prostatitis can be inflammatory or noninflammatory. The mechanism is unknown but may involve incomplete relaxation of the urinary sphincter and dyssynergic voiding. The resultant elevated urinary pressure may cause urine reflux into the prostate (triggering an inflammatory response) or increased pelvic autonomic activity leading to chronic pain (see Pain: Chronic Pain) without inflammation.
Classification
Prostatitis is classified into 4 categories (see Table 2: Prostate Disease: NIH Consensus Classification System for Prostatitis ). These categories are differentiated by clinical findings and by the presence or absence of signs of infection and inflammation in 2 urine samples. The 1st sample is a midstream collection. The patient then undergoes digital prostate massage and voids immediately; the first 10 mL of urine constitutes the 2nd sample. Infection is defined by bacterial growth on urine culture; inflammation, by presence of WBCs on urinalysis.
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Table 2
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NIH Consensus Classification
System for Prostatitis
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Category
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Characteristics
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Urine Finding
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Premassage
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Postmassage
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I Acute bacterial prostatitis
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Acute symptoms of urinary infection
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WBC
Bacteria
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+/−
+/−
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+
+
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II Chronic bacterial prostatitis
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Recurrent urinary infection with same organism
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WBC
Bacteria
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+/−
+/−
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+
+
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III Chronic prostatitis/Chronic pelvic pain syndrome
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Primarily complaints of pain, voiding, and sexual dysfunction
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IIIa Inflammatory
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WBC
Bacteria
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−
−
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+
−
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IIIb Noninflammatory
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Previously termed prostatodynia
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WBC
Bacteria
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−
−
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−
−
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IV Asymptomatic inflammatory prostatitis
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Discovered incidentally during urologic evaluation (eg, prostate biopsy, seminal fluid analysis) for other conditions
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WBC
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−
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+
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Symptoms and Signs
Symptoms vary by category but typically involve some degree of urinary irritation or obstruction and pain. Irritation is manifested by frequency and urgency; obstruction, by a sensation of incomplete bladder emptying, a need to void again shortly after urinating, or nocturia. Pain is typically in the perineum but may be perceived at the tip of the penis, lower back, or testicles. Some patients report painful ejaculation.
Acute
bacterial prostatitis often produces such systemic symptoms as fever, chills, malaise, and myalgias. The prostate is exquisitely tender and focally or diffusely swollen, boggy, and/or indurated. A generalized sepsis syndrome may result, with tachycardia, tachypnea, and sometimes hypotension.
Chronic
bacterial prostatitis presents with recurrent episodes of infection with or without complete resolution between bouts. Symptoms and signs tend to be milder than in acute prostatitis.
Chronic
prostatitis/chronic pelvic pain syndrome typically has pain as the predominant complaint, often including pain with ejaculation. The discomfort can be significant and often markedly interferes with quality of life. Symptoms of urinary irritation or obstruction also may be present. On examination, the prostate may be tender but usually is not boggy or swollen.
Asymptomatic
inflammatory prostatitis causes no symptoms and is discovered incidentally during evaluation for other prostate diseases when WBCs are present in the urine.
Diagnosis
Diagnosis is suspected clinically. Similar findings can result from urethritis, perirectal abscess, or urinary tract infection.
Febrile patients with typical symptoms and signs of acute bacterial prostatitis usually have a positive midstream urinalysis. Prostate massage to obtain a postmassage urine sample is thought to be unnecessary and possibly dangerous in these patients (although this remains unproved). Blood cultures should be obtained on toxic-appearing patients, whose symptoms include weakness, fever, confusion, and disorientation. For afebrile patients, urine samples before and after massage are adequate for diagnosis.
Other tests to consider are transrectal ultrasonography (to rule out prostatic abscess or destruction and inflammation of the seminal vesicles) and cystoscopy (to rule out other pathology).
Treatment
Treatment varies significantly with etiology.
Acute bacterial
prostatitis:
Nontoxic patients can be treated at home with bed rest, analgesics, stool softeners, and hydration. Therapy with a fluoroquinolone (eg, ofloxacin 300 mg po bid) is usually effective and can be given until culture and sensitivity results are known. If the clinical response is satisfactory, treatment is continued for about 30 days to prevent chronic bacterial prostatitis. Some clinicians have recommended frequent ejaculation but it is probably of no benefit.
If sepsis is suspected, the patient is hospitalized and given broad-spectrum antibiotics IV (eg, ampicillin plus gentamicin ) until the bacterial sensitivity is known. If the clinical response is adequate, IV therapy is continued until the patient is afebrile for 24 to 48 h, followed by oral therapy for 4 to 6 wk.
Rarely, prostate abscess develops, requiring surgery.
Chronic
bacterial prostatitis:
Chronic bacterial prostatitis is treated with oral antibiotics such as fluoroquinolones for at least 6 wk. Therapy is guided by culture results; empiric antibiotic treatment of those with equivocal or negative cultures has a low success rate. Other treatments include anti-inflammatory drugs; muscle relaxants ( cyclobenzaprine ); α-adrenergic blockers; and other symptomatic measures, such as sitz baths.
Chronic prostatitis/chronic
pelvic pain syndrome:
Treatment is difficult and often unrewarding. In addition to the above treatments, anxiolytics (eg, SSRIs, benzodiazepines), sacral nerve stimulation, and microwave therapy may be considered.
Asymptomatic
inflammatory prostatitis:
Asymptomatic prostatitis requires no treatment.
Prostate
Abscess
Prostate
abscesses are focal purulent collections that develop as complications
of acute prostatitis.
The usual infecting organisms are aerobic gram-negative bacilli or, less frequently, Staphylococcus aureus. Urinary frequency, dysuria, and urinary retention are common. Perineal pain, evidence of acute epididymitis, hematuria, and a purulent urethral discharge are less common. Fever is sometimes present. Rectal examination may show prostate tenderness and fluctuance, but prostate enlargement is often the only abnormality, and sometimes the gland feels normal.
Abscess is suspected in patients with continued or recurrent UTIs despite antimicrobial therapy and persistent perineal pain. Such patients should undergo prostate ultrasound and possibly cystoscopy. Many abscesses, however, are discovered unexpectedly during prostate surgery or endoscopy; bulging of a lateral lobe into the prostatic urethra or rupture during instrumentation reveals the abscess. Leukocytosis is common. Although pyuria and bacteriuria are frequent, urine may be normal. Blood cultures are positive in some patients. Treatment involves appropriate antibiotics plus drainage by transurethral evacuation or transperineal aspiration and drainage.
Last full review/revision November 2005
Content last modified November 2005
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