Chapter 21, ‘Urinary tract infection’, pp. 267–276).Acute bacterial prostatitis (ABP)
Chronic bacterial prostatitis (CBP)
Chronic prostatitis/chronic pelvic pain syndrome (CPPS)
Asymptomatic inflammatory prostatitis
Other rare causes of prostatitis
Prostatitis affects up to 50% of men at some time in their lives, with a prevalence of 8.2% of prostatic symptoms, similar to prevalence of chronic pelvic pain in women and chronic asthma. The National Institutes of Health produced a classification following two consensus conferences in 1995 and 1998, which is now widely used:
• Category I: acute bacterial prostatitis.
• Category II: chronic bacterial prostatitis.
• Category III: chronic (non-bacterial) prostatitis/chronic pelvic pain syndrome (CP/CPPS). Subgroups of this class are (A) inflammatory and (B) non-inflammatory (previously prostatodynia).
The majority of cases are chronic and probably 90–95% of these are abacterial. Diagnosis is largely based on symptoms, as signs and objective clinical data may be inconclusive or lacking. Symptoms that may be attributed to prostatitis/chronic pelvic pain syndrome in men are outlined in Table 12.1.
Table 12.1 Symptoms that may indicate prostatitis or chronic pelvic pain syndrome in men
| Urogenital pain | Lower urinary tract symptoms (LUTS) |
| Sexual dysfunction | Psychological |
Uncommon, but clearly identifiable, and easiest to diagnose and treat effectively. Should be considered as a complication of acute lower urinary tract infection (LUTI), caused by urinary pathogens especially Escherichia coli. There may be an underlying structural abnormality of the urinary tract, which should be investigated after resolution of the acute episode.
• Prostatitis: perineal prostatic pain.
• Those of a LUTI: dysuria, frequency, urgency, incomplete bladder emptying ( Chapter 21, ‘Urinary tract infection’, pp. 267–276).
• Bacteraemia: pyrexia, rigors, myalgia, arthralgia.
• Abscess (rare complication): intense pain and acute urinary retention. In the pre-antibiotic era, gonorrhoea was a frequent cause of a prostatic abscess.
• Gentle digital rectal examination: prostate enlarged, tender, warm, and/or boggy. Prostatic massage contraindicated in ABP as it may precipitate bacteraemia.
• Midstream sample of urine (MSSU).
• Exclude sepsis (BP, pulse, temperature, respiratory rate, FBC, CRP, blood glucose, renal function). If concerned, admit for further assessment in Emergency Department (blood cultures, arterial blood gases, lactate).
• Urology may undertake additional investigations. Transrectal ultrasound (also useful to exclude prostatic abscess). Residual bladder ultrasound to check for urinary retention.
• ABP is a serious infection: start antibiotics immediately. Oral fluoroquinolone (e.g. ciprofloxacin 500 mg bd or ofloxacin 200 mg bd). Trimethoprim 200 mg bd (if fluoroquinolone intolerant or allergic). All for 28 days. Review in 24–48 hours to check response; review with results.
• Provide analgesia: paracetamol and ibuprofen regularly combined. Stronger codeine-based analgesia if not helped.
• Admit to hospital if severely ill, unable to take oral antibiotics, urinary retention (seen in ~10%). Management as in-patient may include initial parenteral broad-spectrum cephalosporin (e.g. cefuroxime) plus gentamicin then switch to oral regimen once clinically stable. IV fluids and urinary drainage (if retention) may also be required. If abscess present that fails to respond to antibiotics—transurethral resection with drainage.
• Trauma (most common cause in young ♂): generally mild, often isolated episodes; usually self-limiting.
• Inflammation: prostatitis, seminal vesiculitis, urethritis, epididymitis.
• Obstruction/dilatation of urogenital ducts: prostatic cysts, urethral strictures, ejaculatory duct cysts, and strictures.
• Vascular abnormalities: arteriovenous malformations, venous malformations, haemangiomata.
• haematological disorders—coagulation disorders, leukaemia
Unusual, accounting for ~2–5% of prostatitis cases. Recurrent or persistent prostate infection usually due to E. coli (~80%). Patients experience recurrent UTIs with the prostate gland as the infection source, warranting urological referral. In addition, there may be obstructive urinary symptoms, perineal prostatic pain, and possibly sexual dysfunction, but unlike ABP, no systemic symptoms.
• Digital rectal examination: normal, hypertrophied, and/or tender prostate.
• Evidence of prostatic infection: bacterial colony count in expressed prostatic secretions or post-prostate massage urine specimen (Box 12.1) at least ×10 greater than FVU or MSSU.
Antibiotics for 4–8 weeks according to antimicrobial sensitivity, preferably a fluoroquinolone (high relative concentration in prostate tissue, 2–3× serum levels), e.g. ciprofloxacin, ofloxacin. Levofloxacin plus azithromycin is an alternative. Trimethoprim, which also has good prostate penetration, can be considered as second-line treatment. If symptoms persist following infection clearance undertake management of CP/CPPS.
Box 12.1 Prostatic assessment for inflammation and infection
• taken antibiotics within previous 4 weeks
• ejaculated within previous 48 hours
• evidence of urethritis or UTI (exclude prior to prostatic massage).
• Obtain FVU (urethral) and MSSU (bladder) prior to massage.
• Place patient in left lateral position and ensure that he is breathing easily through his mouth (to avoid valsalva manoeuvre).
• With lubricated forefinger in rectum gently press on right and left lateral aspects of prostate gland in turn and move finger to the midline. Repeat 3–4 times.
• Press on superior aspect of prostate gland in midline and move finger to its lower pole. Repeat 2–3 times.
• Prostatic fluid should appear at the urethral meatus, although sometimes gentle milking of the urethra is required.
• If this fails, the process can be repeated. However, a dry massage is fairly common.
• pH8 suggestive, but not diagnostic of prostatitis.
• Bacterial colony count in the EPS and post-prostate massage urine sample must be at least ×10 greater than FVU and pre-massage MSSU to diagnose chronic bacterial prostatitis.
• ≥10 PMNL/HPF is considered diagnostic of inflammation. If dry massage, look for PMNLs 10/HPF greater in post-massage urine than FVU and MSSU. EPS PMNLs may be absent in cases of inflammation with infection and also 10/HPF found in up to 6% of healthy controls; therefore, unreliable in subclassifying CPPS into inflammatory and non-inflammatory categories.
The most common form of prostatitis (>90% of all cases). Understanding of the causes of this syndrome is limited and other organs (including pelvic floor, bladder, and seminal vesicles) may be involved.
Genital tract post-inflammatory cytokines, possibly suggesting auto-immunity, post-infective triggers, or neurogenic inflammation. Genital or pelvic pain is required in its diagnosis, and exclusion criteria include urethritis, urogenital cancer, urinary tract disease, functionally relevant urethral stricture, or bladder neurological disease.
Subclassified as inflammatory if PMNLs found in EPS (Box 12.1), semen, or post-prostate massage urine. Patients with the non-inflammatory subtype have no evidence of inflammation. In practical terms, this differentiation is of little value as the clinical presentation and response to treatment are almost identical.
CPPS may present as chronic unilateral testicular pain, which may be provoked by coitus. This is usually idiopathic but may follow acute epididymitis, vasectomy, previous trauma, or be associated with a varicocele, hydrocele, or sexual dysfunction.
Quantitative assessment of severity of prostatitis useful in temporal review or in gauging therapeutic response using the Chronic Prostatitis Symptom Index (Box 12.2).
• By exclusion of other causes, including bladder or prostate infection, urinary obstruction, testicular cancer, genitourinary tract calculi, hernias, radiculopathies, other chronic pain syndromes.
• Digital rectal examination: prostate gland usually feels normal with variable degrees of tenderness (local, diffuse) or none.
• STI screening: Chlamydia, Gonorrhoea, Trichomonas, Ureaplasma and Mycoplasma where available.
• Consider TB, tropical infection in those at risk
• Microscopy of any discharge/threads
• Prostatic specific antigen (PSA): request if abnormal prostate, patient concerns, symptoms of bladder outflow obstruction. Beware falsely high readings following digital rectal examination and other causes.
• Urology opinion: cystoscopy, urodynamic studies, prostatic biopsy.
• Colorectal opinion: if any concerns of bowel pathology, including rectal malignancy.
• Magnetic resonance imaging (MRI) pelvis/lumbar spine: history of lower back ache, injury, possible prostatic abscess. Discuss with multi-disciplinary team (MDT).
• Psychological screening: various tools available including Chronic Prostatitis Symptom Index (Box 12.2).
Box 12.2 Chronic Prostatitis Symptom Index
1. Have you experienced any pain or discomfort in the following areas?
• Perineum (i.e. from rectum to testicles)
• Penile tip (unrelated to urination)
• Below waist (pubic/bladder area)
2. Have you experienced?
• Pain/burning during micturition
• Pain/discomfort during/after ejaculation
3. How often have you had pain or discomfort in any of these areas?
4. Which number describes your average pain/discomfort on the days you had it on a 0–10 point scale?
• ‘No pain’ (0) to ‘Pain as bad as you can imagine’ (10)
5. How often have you sensed incomplete bladder emptying?
6. How often have you had to repeat urination within <2 hours?
7. How much have the symptoms restricted you from doing things?
8. How much have you thought about your symptoms?
9. How would you feel if they persisted for the rest of your life?
• Calculate and report 3 separate scores: pain (1–4), urinary symptoms (5 and 6), and impact of symptoms/quality of life (7–9).
• Calculate and report a pain and urinary score (range 0–31) referred to as the ‘symptom scale score’:
Calculate and report total score (range 0–43), referred to as the ‘total score’. Assess at baseline and follow over time (and treatment) using each patient as his own control. Can also be used to compare with established and published ‘norms’.
Reproduced from Litwin M, McNaughton-Collins M., Floyd K. et. al. (1999) The National Institutes of Health Chronic Prostatitis Symptom Index: Development and Validation of a New Outcome Measure. J Urol 162(2): 369–375, © American Urological Association, Inc. with permission from Elsevier.
Investigations and management should be undertaken as part of a coordinated MDT to avoid delay, repetition, and improve the patient journey. Specialties involved may include: GUM, Urology, Colorectal, Pain team, Clinical psychology, Physiotherapy, and Psychosexual therapy, with advice from Microbiology and Radiology. A Biopsychosocial model of care should be provided.
In view of the lack of understanding and imprecision in diagnosis, it is difficult to evaluate treatments properly. No therapy has been demonstrated to be absolutely effective.
• Antibiotics: provide first line CBP regimen; only give a second line course if improvement of symptoms or proven infection. There is no benefit in giving further courses of antibiotics unless infection is isolated. Depending on presence/severity of symptoms can add in another agent to initial antibiotics. If not resolved after antibiotics, refer from sexual health based on local arrangements for further management.
• Alpha-blocking drugs (e.g. tamulosin): relax the bladder neck and prostate gland. Give for 4–6 weeks and if no benefit stop. Particularly useful if lower urinary tract symptoms are present.
• Pain management: same principles as that of chronic pain ( Chapter 31, ‘Management’, pp. 368–371). Options include:
• non-steroidal anti-inflammatory drugs (NSAIDs)—stop at 6 weeks if no benefit
• topical lidocaine–can be applied to penile tip, perineum.
• neuropathic pain medication—tricyclic antidepressants (e.g. amitriptyline) or anticonvulsants (gabapentin).
• pain team—advice on prescribing, consideration of blocks, carbamazepine, opioids, specific pain psychology, and education of patient on pain theory.
• Psychological treatment: assessment required if depressed or distressed. Mindfulness and cognitive behavioural therapy can help with chronic pain management.
• Physiotherapy: assess and manage pelvic hypertonia, desensitization techniques, transcutaneous electrical nerve stimulation (TENS).
• 5-alpha reductase inhibitors (e.g. finasteride): if LUTS and benign prostatic enlargement present. No benefit seen in using alone.
• Surgery without evidence of pathology present is not recommended. (e.g. orchidectomy).
Usually an incidental finding arising during the investigation of the genitourinary tract for other reasons (e.g. prostate biopsy for possible prostate cancer because of an elevated serum prostate specific antigen test or infertility investigations). The patient has no symptoms, but excess leucocytes in the seminal fluid are common findings. STI screening should be undertaken and treated accordingly. Consider tuberculosis (TB).
• Mycobacterium tuberculosis and other atypical mycobacteria: granulomatous prostatitis
• Parasites: e.g. Trichomonas vaginalis, Schistosoma haematobium.
• Viruses: e.g. HSV and cytomegalovirus (CMV) in immunocompromised patients. May also present acutely.
• Mycoses: e.g. coccidioidomycosis, blastomycosis, cryptococcosis, histoplasmosis, candidiasis. More common in immunosuppressed people causing a granulomatous reaction.
Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, and Mycoplasma hominis have been implicated in chronic prostatitis. Their nucleotide sequences have been reported in up to 10% of cases from prostatic secretions or semen without associated demonstrable urethral infection. However, there is no clear consistent evidence to support a causative role. If found, they should be treated.
risk of prostatic abscess in those immunosuppressed with acute prostatitis.
Further information
http://uroweb.org/wp-content/uploads/EAU-Extended-Guidelines-2015-Edn.pdf
https://www.bashhguidelines.org/media/1065/bju-prostatitis-2015.pdf