Prostatitis

Prostatitis is inflammation of the prostate gland. It may present as an acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, or prostatodynia. In the last there are complaints consistent with prostatitis but no evidence of prostatic inflammation.

Most cases of prostatitis are nonbacterial but bacterial infection accounts for the majority of acutely presenting cases.

Most cases of bacterial prostatitis in young men are sexually transmitted but it can also be spread through the blood, lymphatics or contiguous spread from surrounding areas.

• Prostatitis is common. Approximately 2-10% of adult men suffer from symptoms compatible with chronic prostatitis at any time and 15% of men suffer from symptoms of prostatitis at some point in their lives.¹
• There are also suggestions that chronic prostatitis may be associated with benign prostatic hyperplasia and carcinoma of prostate.² Chronic and nonbacterial forms are most frequent.
• The diagnosis of prostatitis is made in around 25% of male patients with genitourinary symptoms but only 5 to 10% have positive cultures.
• Bacterial prostatitis is the commonest form under 35 years old.
• Younger patients may also have HIV infection. This predisposes to infection with atypical organisms and they may be predisposed to carcinoma of prostate.³
• Chronic prostatitis is much more common than acute prostatitis.
• About 6% of autopsies on men reveal histological prostatitis.

• It is commonly sexually transmitted in young men
• Indwelling catheters increase the risk
• Prostatic biopsy
• Acute bacterial prostatitis can occur after sclerotherapy for rectal prolapse.

Common complaints include:

• Fever, malaise, arthralgia and myalgia
• Urinary frequency, urgency, dysuria, nocturia, hesitancy, and incomplete voiding
• Low back pain, low abdominal pain, perineal pain and pain in the urethra. In chronic prostatitis the most consistent finding is that of chronic pelvic pain⁴
• Pain on ejaculation is commonly reported, especially in chronic pelvic pain syndrome, but it has been very poorly investigated.⁵
• Urethral discharge

There may be fever.

In acute bacterial prostatitis findings include:

• The gland may feel nodular, boggy or possibly normal
• The gland may be tender on palpation and feel hot to touch
• Inguinal lymphadenopathy and urethral discharge.

In chronic bacterial and nonbacterial prostatitis:

• The gland feels normal or may be hard from calcification.

• Consider Neisseria gonorrhoea and Chlamydia trachomatis in anyone under 35 with urinary tract symptoms.
• Ascending infection can occur from the urethra with reflux into the prostate ducts. About 80% are due to Gram negative organisms, especially E coli, Enterobacter, Serratia, Pseudomonas, Enterococcus, and Proteus species. Nonbacterial pathogens include C trachomatis and Ureaplasma. Rarely Mycobacterium tuberculosis may be involved.
• Prostatodynia is not a true inflammation but may be due to some abnormality of voiding and there may be a psychological component.⁶

• If the patient is toxic and septicaemia is possible then FBC is required along with blood cultures.
• In acute bacterial prostatitis, diagnosis is made on urine culture. There is also microscopy for white blood cell count and bacterial count along with presence of oval fat bodies and lipid-laden macrophages.
• Fractionated specimens have fallen from favour.
• Do not use prostatic massage as it is painful and may spread infection.
• If there is suspicion of carcinoma of prostate get PSA. Sometimes PSA is elevated in chronic prostatitis but it reduces with treatment.⁷

Chronic nonbacterial prostatitis or chronic pelvic pain syndrome (CPPS) impairs quality of life and a diagnostic index is required to aid diagnosis and research into outcome. The National Institutes of Health (NIH)-funded Chronic Prostatitis Collaborative Research Network (CPCRN) has developed a psychometrically valid index of symptoms and quality-of-life impact in men with chronic prostatitis.⁸ It contains 13 items that are scored in 3 discrete domains:

• Pain
• Urinary symptoms
• Quality-of-life impact.

The NIH Chronic Prostatitis Symptom Index (NIH-CPSI) has now been validated in several languages and it shows that chronic nonbacterial prostatitis is a significant problem across the world. Hopefully, this will help improve the quality of research to obtain guidelines for management as the Clinical Knowledge Summaries guidelines are rather unflattering about much of methodology in published papers.

Diagnostic criteria for this condition include:

• Symptoms suggestive of prostatitis (e.g. pelvic discomfort or pain) lasting for more than 3 months.
• Negative cultures of urine and prostatic fluid.
• In the inflammatory type, leucocytes are present in prostatic fluid.
• In the non-inflammatory type, no leucocytes are present in prostatic fluid.

The cause is unknown, but theories include:

• Infection with an organism that has not yet been identified
• An immune reaction to a persistent antigen from an organism or from a urinary constituent
• Pelvic sympathetic nervous system dysfunction
• Interstitial cystitis
• Prostatic cysts and calculi
• Mechanical problems causing retention of prostatic fluid

Acute prostatitis

• A patient with acute prostatitis may be acutely ill and require admission to hospital.
• If there is retention of urine a suprapubic catheter may be required.
• Avoid repeated rectal examination for fear of seeding infection and give parenteral antibiotic to cover Gram negative organisms.
• If the disease is sexually transmitted a GUM clinic may be valuable both in terms of accurate diagnosis and contact tracing.
• Clinical Knowledge Summaries advise that ciprofloxacin or ofloxacin should be prescribed for 4 weeks but if they are inappropriate, trimethoprim is an alternative.
• Quinolones are very effective against Gram negative organisms and penetrate the prostate well. For inpatient care a parenteral aminoglycoside may be required. Doxycycline penetrates the prostate well and is used for nonbacterial causes.
• Analgesia is required. If a paracetamol with codeine mixture is used, a stool softener may be desirable.

Referral may be required for several reasons:

• The patient may be toxic, severely ill, unable to tolerate oral antibiotics or deteriorating on oral antibiotics. Admission is required for intravenous antibiotics.
• An inadequate response to antibiotics may require investigation by transrectal ultrasound examination or CT scan of the prostate to seek a prostatic abscess which would need surgical drainage.
• Pre-existing urological conditions (e.g. obstruction, indwelling catheter)
• Immunocompromised people require specialist urological management. They may require more intensive treatment. Aspergillus and Cryptococcus may require aggressive antifungal treatment.
• Acute urinary retention requires suprapubic catheterization as insertion of a urethral catheter may damage the prostate.
• Clinical Knowledge Summaries advise that after recovery, all men require referral for investigation of their urinary tract to exclude structural abnormality.

Chronic infective prostatitis

• Referral should be made if the patient has chronic prostatitis but whilst he is waiting to be seen it is worth trying to treat the infection and the pain.
• Antibiotics should be prescribed along the same lines as for acute prostatitis. This usually requires a quinolone for 4 weeks.
• Analgesia and stool softeners may be necessary.
• In chronic prostatitis where calculi serve as a nidus for infection, TURP or total prostatectomy may be required.

Chronic abacterial prostatitis

There is very poor evidence for how to treat the condition. A systematic review of diagnosis and treatment of chronic abacterial prostatitis concluded that there is no gold standard test. There are a few trials of weak methodology and small numbers.⁹

• Either paracetamol or an NSAID would be a reasonable for analgesia
• Antibiotics may possibly help occult infection but this is unsupported by evidence.
• Prazosin or another alpha blocker may be of value but the evidence is inconclusive.⁹ If they do work, they should be given for 3 to 6 months and the less highly selective blockers are preferable.¹⁰
• Stress management has been suggested for individuals who are suspected to have a strong psychological component to their symptoms, although there are no trial data on the effectiveness of psychological interventions.
• Physiotherapy and relaxation techniques: new research in this area suggests that muscle tension may be the cause of pain in the pelvic floor. Observational data suggest that physiotherapy (applying pressure to trigger points in the pelvic floor), in conjunction with relaxation techniques, may be of benefit. The authors were unable to find any randomized controlled trials on this, and treatment may be difficult to access in both primary and secondary care.¹¹
• Other treatments that have been investigated include thermotherapy (transurethral microwave hyperthermia or transurethral microwave thermotherapy), bioflavonoids (quercetin), allopurinol, finasteride, and anti-inflammatory preparations. Newer approaches include trials of finasteride, quercetin and rofecoxib. A recent systematic review demonstrated that none of the current diagnostic and treatment methods for CPPS is supported by a robust evidence base.
• Pain on sexual activity may contribute to erectile dysfunction.¹²

In acute bacterial prostatitis the prognosis is good if treatment is swift and adequate.

In chronic disease with exacerbations it is important to identify and treat underlying conditions. The help of a urologist is required as relapses are common.