Prostatitis and Prostatic Abscess Dr Khoo Say Chuan Department of Urology Hospital Selayang Introduction • Most common urological diagnosis in men < 50 yrs and 3rd most common urologic diagnosis in men >50 yrs after BPH and PCa • Incidence 10-30 % • Affect men of all ages Definition • Prostatitis is an infection or inflammation of the prostate gland that presents as several syndromes which have different causes, clinical features and therapeutic strategy in managing the syndromes NIDDK Categorization and Criteria for the Prostatitis Syndromes • Category 1 : Acute bacterial Prostatitis acute symptomatic bacterial infection LUTS associated with profound SIR • Category 2 : Chronic bacterial Prostatitis Hx recurrent UTI Meares-Stamey 4 glass test vs 2 glass test NIDDK Categorization and Criteria for the Prostatitis Syndromes • Category 3 : CPPS (Chronic abacterial prostatitis) IIIA : inflammatory type WBC in EPS/VB3 Culture negative IIIB : non inflammatory type no WBC in EPS/VB3 NIDDK Categorization and Criteria for the Prostatitis Syndromes • Category 4 : Asymptomatic inflammatory Prostatits (Histological Prostatitis) incidental detection on Bx or prostatic fluid examination treatment not warranted Acute Bacterial Prostatitis • Eetiology KEEPS: Klebsiella, E. coli (80%), Enterococci, Pseudomonas, Proteus, S. Fecalis ascending urethral infection and reflux into prostatic ducts invasion of rectal bacteria most infections occur in the peripheral zone medical procedures Acute Bacterial Prostatitis • Clinical features rectal, low back and perineal pain urinary irritative symptoms systemic symptoms: myalgia, arthralgia, fevers, chills hematuria Acute Bacterial Prostatitis • Diagnosis rectal exam enlarged, tender, warm prostate prostatic massage is not recommended due to extreme tenderness and risk of inducing sepsis, abscess or epididymo-orchitis urine C&S blood C&S Acute Bacterial Prostatitis • Treatment PO antibiotics treat for 4-6 wks to prevent complications supportive measures (antipyretics, analgesics, stool softeners) admission criteria: sepsis, urinary retention, immunodeficiency IV antibiotics; VB2 urine C&S 1 and 3 months post-antibiotic therapy to R/O chronic prostatitis Chronic Bacterial Prostatitis • Diagnosis split urines for C&S to determine site of infection; collect 4 specimens (Meares-Stamey 4 glass test) colony colony counts in expressed prostatic secretions (EPS) and VB3 should exceed those of VB1 and VB2 by 10-fold Alternative : 2 cups test Technique and interpretation of the Meares-Stamey four-glass lower urinary tract localization test for chronic prostatitis / CPPS (CAT, category; EPS, expressed prostatic secretion; VB, voided bladder; WBC, white blood cell) *If culture positive, consider repeating after a short course of antibiotic Four Glass Urine Test • Introduced in 1968 by Meares & Stamey • Is the most accurate (gold standard) test for differentiating between chronic bacterial prostatitis, inflammatory types of chronic nonbacterial prostatitis and non-inflammatory types of chronic nonbacterial prostatitis (prostatodynia) • When the patient attends for prostatic massage: No antibiotics should have been taken for 1 month No evidence of urethritis or urinary tract infection is presence The patient should not have ejaculated for 2 days The patient should have a full but not distended bladder Chronic Bacterial Prostatitis Treatment prolonged course of antibiotics (3-4 months) fluoroquinolones, TMP; addition of an α-blocker reduces symptoms Chronic Bacterial Prostatitis – Options of Treatment • Medical Therapy Antimicrobials Therapy Alpha Blockers Anti-Inflammatory Phytotherapeutic Agents Hormonal Therapy Muscle Relaxants • Minimally Invasive Therapy Balloon Dilatation Transurethral Needle Ablation (TUNA) of prostate Microwave Hyperthermia & Thermotherapy • Surgery • Physical Therapy Prostatic Massage Trigger Point Release Biofeedback Chronic Pelvic Pain Syndrome CPPS Pain lasting > 3/12 inflammatory type previously called nonbacterial prostatitis noninflammatory type previously called prostatodynia most common of the prostatic syndromes and most poorly understood • Chlamydia, Ureaplasma and Mycoplasma may be culprits • autoimmune inflammatory reaction ± intraprostatic reflux of urine ± urethral hypertonia • similar symptoms as chronic bacterial prostatitis • • • • • Treatment trial of antibiotic therapy fluoroquinolone or doxycycline if chlamydia is suspected α-adrenergic blocker (e.g. prazosin) to relieve sphincter spasms and symptoms NSAIDs may provide symptomatic relief Chronic Pelvic Pain Syndrome CPPS • Antibiotics therapy may benefits Class III (CPPS) chronic prostatitis patients by 3 different mechanisms: A strong placebo effect The eradication or suppression of non-cultured microorganisms Independent anti-inflammatory effect of some antibiotics Asymptomatic inflammatory Prostatits • This type of prostatitis is not included in the Traditional Classification of Prostatitis • By definition patient is asymptomatic • Patient usually present for investigation or management of infertility, BPH, elevated PSA or prostate cancer • Subsequent microscopy of EPS or semen, histologic examination of BPH chips, prostate biopsy or prostate cancer specimens disclose evidence of prostatic inflammation +/- infection • By definition not require treatment for the prostatitis Prostatic Abscess Introduction • Rare due to antibiotic treatment and decrease incidence of gonoccocal infections • Preantibiotic era : N Gonorrhoea (75%) • Antibiotic era : gram –ve (60-80%) • Common in DM, immune compromised, chronic catheters Introduction • Complications of acute bacterial prostatitis that were inadequately or inappropriately treated • Retrograde flow of contaminated urine • Recent biopsy or instrumentation of lower tract • Hematogeneous spread Introduction • Differential diagnosis btw acute bacterial prostatitis and prostatic abscess difficult • High mortality rate • Severe complication, urosepsis • DRE : tender, fluactuant Management • • • • Imaging : TRUS or pelvic CT antibiotic and drainage Transrectal drainage TUR if transrectal drainage inadequate Management • TRUS drainage vs TUR • TUR : TUR shorter hospital stay less recurrence more invasive, GA, surgical complications • TRUS : less invasive, LA, sedation placement of drainage tube