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Prostatitis
Kyle Stephens, DO, MPH
Vincent Lo, MD, FAAFP
image BASICS
DESCRIPTION
  • Painful or inflammatory condition affecting the prostate gland with or without bacterial etiology, often characterized by urogenital pain, voiding symptoms, and/or sexual dysfunction
  • Significant impact on quality of life
  • <10% bacteria-proven infection
  • National Institutes of Health's classification
    • Class I: Acute bacterial prostatitis: symptomatic with fever, perineal pain, dysuria, and obstructive symptoms; polymorphonuclear leukocytes (PMNL) and bacteria in urine
    • Class II: Chronic bacterial prostatitis: symptomatic chronic or recurrent bacterial infection with pain and voiding disturbances; PMNL and bacteria in expressed prostatic secretions (EPS), or urine after prostate massage, or in semen
    • Class III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
      • Inflammatory (Subtype IIIA): chronic symptoms with PMNL in EPS/urine after prostate massage or in semen
      • Noninflammatory (Subtype IIIB): chronic symptoms without presence of PMNL in EPS/urine after prostate massage or in semen
    • Class IV: Asymptomatic inflammatory prostatitis: incidental finding during prostate biopsy for infertility, cancer workup; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen
  • System(s) affected: genitourinary, renal, reproductive
EPIDEMIOLOGY
Incidence
  • Two million cases annually in the United States
  • Predominant age: 30 to 50 years old, sexually active; chronic is more common in those >50 years.
  • Bacterial prostatitis occurs more frequently in patients with HIV.
Prevalence
  • Affects approximately 8.2% of males (1)
  • Lifetime probability of diagnosis >25% (1)
  • Accounts for 8% of visits to urologists and 1% of visits to primary care physicians (2)
  • Percentage of cases by class: Class I: <1%, Class II: 5-10%, Class III: 80-90%, Class IV: 10% (3)
ETIOLOGY AND PATHOPHYSIOLOGY
  • Acute bacterial prostatitis (Class I)
    • Likely, etiology from ascending urethral infection with intraprostatic reflux of infected urine into prostatic ducts, often associated with cystitis
    • Can occur after instrumentation of prostate
    • Usually gram-negative bacteria (Escherichia coli (most common); Proteus, Klebsiella, Serratia, and Enterobacter species; Pseudomonas aeruginosa)
    • Rarely, gram-positive bacteria (Staphylococcus aureus, Streptococcus, and Enterococcus species).
    • Confirmed Staphylococcal prostatitis should warrant evaluation for hematogenous spread, including endovascular source.
    • Atypical bacteria include Chlamydia trachomatis, Trichomonas vaginalis, and Ureaplasma urealyticum.
    • Consider Neisseria gonorrhoeae or Chlamydia trachomatis in sexually active men <35 years.
  • Chronic bacterial prostatitis (class II)
    • Similar pathogens as discussed earlier
    • Often occurs as recurrent episodes of infection by same organism
    • Progression from acute to chronic prostatitis is poorly understood but could result from inadequate treatment of acute prostatitis.
  • CP/CPPS (class III)
    • Unclear etiology, possibly due to difficult-to-culture infection
    • Inciting agent may cause inflammation or neurological damage in or around the prostate and lead to pelvic floor neuromuscular and/or neuropathic pain.
RISK FACTORS
  • Urinary tract infections
  • HIV infection
  • Prostatic calculi
  • Urethral stricture
  • Urinary catheterization: indwelling, intermittent
  • Genitourinary instrumentation including prostate biopsy (especially in patients with prior quinolone intake), transurethral resection of prostate, cystoscopy
  • Urinary retention
  • Benign prostatic hypertrophy
  • Unprotected sexual intercourse
  • Trauma (e.g. bicycle, horseback riding)
GENERAL PREVENTION
Antibiotic prophylaxis for genitourinary instrumentation and prostatic biopsy
COMMONLY ASSOCIATED CONDITIONS
  • Benign prostatic hypertrophy
  • Cystitis
  • Urethritis
  • Sexual dysfunction
image DIAGNOSIS
PHYSICAL EXAM
  • Vital signs (unstable vitals suggest sepsis)
  • Back exam (CVA tenderness)
  • Abdominal exam (bladder distension)
  • Prostate exam
    • Class I: Prostate is very tender, warm, firm, edematous.
    • Class II: Often normal but enlarged, tender, edematous, nodular prostate also encountered
    • Class III: Often normal prostate
DIFFERENTIAL DIAGNOSIS
  • Lower urinary tract infection
  • Pyelonephritis
  • Cystitis (bacterial, interstitial)
  • Urethritis
  • Prostatic abscess
  • Acute/chronic urinary retention
  • Benign prostatic hypertrophy Malignancy (prostate, bladder)
  • Obstructive calculi
  • Foreign body
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Suspected acute prostatitis (Class I)
    • Urinalysis; urine Gram stain/culture and sensitivity
    • CBC with differential; blood culture if fever, chills, or signs of sepsis are present
  • Suspected chronic bacterial prostatitis (class II)
    • Urinalysis; urine/EPS/semen: Gram stain/culture and sensitivity
    • Review previous urine culture results.
    • National Institute of Health—Chronic Prostatitis Symptom Index (NIH-CPSI): 9-question symptom survey (http://www.prostatitis.org/symptomindex.html)
    • Diagnostic gold standard: Meares-Stamey 4-glass test (not performed often)
    • 2-glass test (pre- and postmassage urine testing) more common and easier with equivalent sensitivity and specificity (4)
      • Cultures of mid-stream preprostate massage urine and EPS/postmassage urine
    • Consider urinary flow rate and postvoid residual volume if urinary retention is present.
  • Suspected CP/CPPS (class III)
    • Diagnosis of exclusion
    • Urinalysis; urine/EPS/semen: Gram stain/culture and sensitivity
    • Hematuria if present: urine cytology, cystoscopy, CT urography with or without contrast
    • PSA is not indicated unless malignancy is suspected.
    • Concomitant abdominal pain: CT abdomen
    • Testicular pain: scrotal US
    • Sensation of incomplete bladder emptying: postvoid residual volume with bladder US or catheterization
    • Lumbar radiculopathy: MRI spine
Follow-Up Tests & Special Considerations
  • Failure to respond to initial antibiotic therapy: US, CT, or MRI to image prostate and urology referral
  • US or CT or MRI if prostatic calculi, malignancy, or abscess are suspected
  • Acute bacterial: urinalysis and culture 30 days after initiating treatment
  • Chronic bacterial: urinalysis and culture every 30 days (may take several months of treatment to clear)
P.859

Diagnostic Procedures/Other
  • Needle biopsy or aspiration for culture
  • Urodynamic testing (prostatodynia) if indicated
  • Cystoscopy (in persistent nonbacterial prostatitis to rule out bladder cancer, interstitial cystitis)
image TREATMENT
GENERAL MEASURES
  • Analgesics/antipyretics/stool softeners
  • Hydration
  • Sitz baths to relieve pain and spasm
  • Suprapubic catheter for urinary retention
  • Anxiolytics, antidepressants if anxiety and/or depression are present
MEDICATION
First Line
  • Acute bacterial (outpatient) (3)[A]
    • Fluoroquinolone (ciprofloxacin 500 mg PO q12h or levofloxacin 500 mg PO once daily) for 2 to 4 weeks or
    • Trimethoprim-sulfamethoxazole 1 double-strength tab PO q12h for 2 to 4 weeks or
    • If gram-positive cocci are seen in initial urine Gram stain, start with amoxicillin 500 mg PO q8h. Adjust antibiotics once culture and sensitivities report is available.
    • Local sensitivity pattern should guide therapy.
    • Ceftriaxone 250 mg IM 1 dose plus doxycycline 100 mg PO q12h daily for 1 week or (azithromycin 1 g PO single dose if at risk for sexually transmitted infection (STI) pathogens
  • Acute bacterial (inpatient) (3)[A]
    • Ampicillin 2g IV q6h or fluoroquinolone (ciprofloxacin 400 mg IV q12h or levofloxacin 500 mg q24h); begin oral therapy after afebrile for 24 to 48 hours
  • Chronic bacterial (class II) (3,5,6)[A],(7)[C]
    • Fluoroquinolone (e.g., levofloxacin 500 mg PO) once daily for 4 weeks or ciprofloxacin 500 mg PO q12h for 4 to 12 weeks
    • Combination therapy with azithromycin may help to eradicate atypical pathogens.
    • Anti-inflammatory agents for pain symptoms and &agr;-blockers for urinary symptoms
  • CP/CPPS (class III) (8,9)[A],(7)[C]
    • No universally effective treatment
    • Treatment choice is patient-centered focusing on symptoms relief of four domains: pain, lower urinary tract symptoms (LUTS), psychological stress, and sexual dysfunction.
      • &agr;-Blockers, antibiotics, and combinations of these therapies achieve greatest improvement in clinical symptoms scores compared to placebo.
      • Tamsulosin 0.4 mg PO once daily at bedtime for 4 to 6 weeks. Continue if there is a positive response.
Second Line
  • Piperacillin or ticarcillin with aminoglycoside, erythromycin, tetracycline, cephalexin, fluoroquinolones, (dicloxacillin, nafcillin IV, vancomycin IV
  • Finasteride (in patients >45 years, class IIIA, and enlarged prostate glands)
  • Atypical: may benefit from erythromycin, doxycycline
ISSUES FOR REFERRAL
Urology referral if antibiotic treatment fails, symptoms persist (especially obstructive voiding symptoms), hematuria, elevated PSA, or for surgical drainage if an abscess persists after ≥1 week of therapy
ADDITIONAL THERAPIES
  • Psychotherapy if sexual dysfunction is present
  • 5-&agr;-reductase inhibitors, nonsteroidal anti-inflammatory medications, pelvic floor physical therapy, transurethral microwave thermotherapy (7)[C]
SURGERY/OTHER PROCEDURES
Surgical resection for intractable chronic disease or to drain an abscess (7)[C]
COMPLEMENTARY & ALTERNATIVE MEDICINE
Class III: Acupuncture, phytotherapies (pollen extract, quercetin), heat therapy, and myofascial release have limited data to support (7)[C],(10)[A].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Proven or suspected abscess
  • Unstable vital signs (sepsis)
  • Immunocompromised
  • Failed outpatient treatment
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Negative urine culture at 7 days predictive of cure after completion of treatment course
  • Consider prostatic abscess in patients who do not respond well to therapy.
Patient Monitoring
NIH Chronic Prostatitis Symptom Index (NIH-CPSI): 9 questions, which can be used to evaluate severity of patient symptoms and response to treatment within three domains:
  • Pain
  • Urinary symptoms
  • Quality of life
PROGNOSIS
  • Fever and dysuria usually resolve in 2 to 6 days.
  • Acute infection usually improves in 3 to 4 weeks.
  • Course of chronic prostatitis is often prolonged and difficult to cure; 55-97% cure rate depending on population and drug used
  • 20% have reinfection or persistent infection.
REFERENCES
1. Krieger JN, Lee SW, Jeon J, et al. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008;31(Suppl 1):S85-S90.
2. Collins MM, Stafford RS, O'Leary MP, et al. How common is prostatitis? A national survey of physician visits. J Urol. 1998;159(4):1224-1228.
3. Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostatitis. Clin Infect Dis. 2010;50(12):1641-1652.
4. Nickel JC, Shoskes D, Wang Y, et al. How does the pre-massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119-124.
5. Videčnik Zorman J, Matičič M, Jeverica S, et al. Diagnosis and treatment of bacterial prostatitis. Acta Dermatovenerol Alp Pannonica Adriat. 2015;24(2):25-29.
6. Perletti G, Marras E, Wagenlehner FM, et al. Antimicrobial therapy for chronic bacterial prostatitis. Cochrane Database Syst Rev. 2013;(8):CD009071.
7. Rees J, Abrahams M, Doble A, et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015;116(4):509-525. doi:10.1111/bju.13101.
8. Zhu Y, Wang C, Pang X, et al. Antibiotics are not beneficial in the management of category III prostatitis: a meta analysis. Urol J. 2014;11(2);1377-1385.
9. Anothaisintawee T, Attia J, Nickel JC, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAMA. 2011;305(1):78-86.
10. Anderson RU, Wise D, Sawyer T, et al. 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training. J Urol. 2011;185(4):1294-1299.
See Also
&NA;
  • Prostate Cancer; Prostatic Hyperplasia, Benign (BPH); Urinary Tract Infection (UTI) in Males
  • Algorithm: Hematuria
Codes
&NA;
ICD10
  • N41.9 Inflammatory disease of prostate, unspecified
  • N41.0 Acute prostatitis
  • N41.1 Chronic prostatitis
Clinical Pearls
&NA;
  • Vigorous prostatic massage is contraindicated in acute prostatitis.
  • Antibiotic therapy is not proven to be effective in CP/CPPS (Class III) (8).
  • At least 14 to 30 days of antibiotic therapy is required for acute prostatitis; longer for chronic bacterial prostatitis
  • Imaging is often not needed.