Page 1 of 5 Prostatitis Prostatitis is inflammation of the prostate gland and can result in various clinical syndromes. Causes can be broadly divided into non-bacterial or bacterial, with the former being more common. However, the majority of acutely presenting cases are usually bacterial in nature. Epidemiology Prostatitis is common with a prevalence of 2.2-9.7%. [1] 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. [2] In addition ~6% of autopsies on men reveal histological prostatitis. Chronic prostatitis is much more common than acute prostatitis. Bacterial prostatitis is the most common form in those 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] There are also suggestions that chronic prostatitis may be associated with benign prostatic hyperplasia and carcinoma of prostate. [4] Aetiology Bacterial: Usually Gram-negative organisms, especially Escherichia coli, Enterobacter, Serratia, Pseudomonas, and Proteus species. Sexually transmitted infections may also be a cause, e.g Neisseria gonorrhoeae and Chlamydia trachomatis. Rarer causes include Mycobacterium tuberculosis. Non-bacterial: Elevated prostatic pressures. Pelvic floor myalgia. Emotional disorders. Risk factors Sexually transmitted infections. Urinary tract infections (UTIs). Indwelling catheters. Acute bacterial prostatitis can occur after sclerotherapy for rectal prolapse. Following manipulation of the gland, eg post-biopsy. Increases with increasing age. [1] Classification [1] [5] A classification system has been proposed and it divides the various syndromes into four broad categories: Acute bacterial prostatitis. Chronic bacterial prostatitis. Chronic prostatitis/chronic pelvic pain syndrome (CPPS) - further subdivided into a and b according to presence or absence of inflammation. Asymptomatic inflammation. Page 2 of 5 History 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 pain. Pain on ejaculation is commonly reported, especially in CPPS, but it has been very poorly investigated. [6] Urethral discharge. Examination 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. There may also be features of UTI and systemic infection, eg tachycardia, dehydration. In chronic bacterial and non-bacterial prostatitis: The gland feels normal or may be hard from calcification. Differential diagnosis [7] Cystitis. Benign prostatic hyperplasia. Urinary tract stones. Foreign body in the urinary tract. Bladder neoplasia. Prostatic abscess. Enterovesical fistula. Investigations If the patient is toxic and septicaemia is possible then FBC, U&E and creatinine are 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. Do not use prostatic massage in acute prostatitis, as it is painful and may spread infection. For this reason the '2-glass' test where by urine sample is examined for sediment before and after prostatic massage, has fallen out of favour. If there is suspicion of carcinoma of prostate check the PSA, but remember it can be elevated in any form of prostatitis. [8] Chronic non-bacterial prostatitis Chronic non-bacterial prostatitis or 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. [9] It contains 13 items that are scored in three discrete domains: Pain. Urinary symptoms. Page 3 of 5 Quality-of-life impact. The NIH Chronic Prostatitis Symptom Index (NIH-CPSI) has now been validated in several languages and it shows that chronic non-bacterial prostatitis is a significant problem across the world. Hopefully, this will help improve the quality of research to obtain guidelines for management. Diagnostic criteria for this condition include: Symptoms suggestive of prostatitis (eg pelvic discomfort or pain) lasting for more than three months. Negative cultures of urine and prostatic fluid. In the inflammatory type, leukocytes are present in prostatic fluid. In the non-inflammatory type, no leukocytes 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. Management Acute prostatitis [10] A patient with acute prostatitis may be acutely ill and require admission to hospital. They may also be in septic shock and require resuscitation. Adequate analgesia may also be required. 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 of contact tracing. Flouroquinolones are first-line, eg ciprofloxacin or ofloxacin, and should be prescribed for four weeks. Severely ill patients may require parenteral aminoglycosides in addition to flouroquinolones. Second-line agents include trimethoprim-sulfamethoxazole and macrolides. 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 (eg obstruction, indwelling catheter). Immunocompromised people require specialist urological management. They may require more intensive treatment. Aspergillus spp. and Cryptococcus spp. may require aggressive antifungal treatment. Acute urinary retention requires suprapubic catheterisation, as insertion of a urethral catheter may damage the prostate. Following recovery, all men require referral for investigation of their urinary tract, to exclude structural abnormalities. Chronic infective prostatitis [11] 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 4-6 weeks and repeat courses may be necessary. Analgesia and stool softeners may be necessary. In chronic prostatitis, where calculi serve as a nidus for infection, transurethral resection of the prostate (TURP) or total prostatectomy may be required. Page 4 of 5 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. [12] Either paracetamol or a non-steroidal anti-inflammatory drug (NSAID) would be a reasonable choice 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. If they do work, they should be given for 3-6 months and the less highly selective blockers are preferable. [12] A recent analysis suggests that, of all the therapies, the alpha-blockers, antibiotics or a combination of these provide the best outcomes. [13] 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 randomised controlled trials on this, and treatment may be difficult to access in both primary and secondary care. [14] 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 and quercetin. 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. [15] Prognosis 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. Further reading & references Guidelines on Chronic Pelvic Pain, European Association of Urology (2012) 1. Schiller DS, Parikh A; Identification, pharmacologic considerations, and management of prostatitis. Am J Geriatr Pharmacother. 2011 Feb;9(1):37-48. 2. Krieger JN; Classification, epidemiology and implications of chronic prostatitis in North America, Europe and Asia. Minerva Urol Nefrol. 2004 Jun;56(2):99-107. 3. Crum NF, Spencer CR, Amling CL; Prostate carcinoma among men with human immunodeficiency virus infection. Cancer. 2004 Jul 15;101(2):294-9. 4. Roberts RO, Bergstralh EJ, Bass SE, et al; Prostatitis as a risk factor for prostate cancer. Epidemiology. 2004 Jan;15(1):939. 5. Krieger JN, Nyberg L Jr, Nickel JC; NIH consensus definition and classification of prostatitis. JAMA. 1999 Jul 21;282(3):236-7. 6. Luzzi GA, Law LA; The male sexual pain syndromes. Int J STD AIDS. 2006 Nov;17(11):720-6; quiz 726. 7. Sharp VJ, Takacs EB, Powell CR; Prostatitis: diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406. 8. Schaeffer AJ, Wu SC, Tennenberg AM, et al ; Treatment of chronic bacterial prostatitis with levofloxacin and ciprofloxacin lowers serum prostate specific antigen. J Urol. 2005 Jul;174(1):161-4. 9. Litwin MS; Areview of the development and validation of the National Institutes of Health Chronic Prostatitis Symptom Index. Urology. 2002 Dec;60(6 Suppl):14-8; discussion 18-9. 10. Prostatitis - acute; NICE CKS, February 2009 11. Prostatitis - chronic; NICE CKS, February 2009 12. Lee SW, Liong ML, Yuen KH, et al; Chronic prostatitis/chronic pelvic pain syndrome: role of alpha blocker therapy. Urol Int. 2007;78(2):97-105. 13. Anothaisintawee T, Attia J, Nickel JC, et al; Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic JAMA. 2011 Jan 5;305(1):78-86. 14. Anderson RU, Wise D, Sawyer T, et al; Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005 Jul;174(1):155-60. 15. Muller A, Mulhall JP; Sexual dysfunction in the patient with prostatitis. Curr Opin Urol. 2005 Nov;15(6):404-9. Page 5 of 5 Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions. Original Author: Dr Gurvinder Rull Current Version: Dr Gurvinder Rull Peer Reviewer: Dr John Cox Last Checked: 19/07/2012 Document ID: 2674 (v29) © EMIS View this article online at www.patient.co.uk/doctor/Prostatitis.htm. Discuss Prostatitis and find more trusted resources at www.patient.co.uk. EMIS is a trading name of Egton Medical Information Systems Limited.