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Prostatitis

Prostatitis describes a combination of infectious diseases ( acute or bacterial prostatitis ) chronic pelvic pain syndrome and asymptomatic inflammation ( Krieger et al 2008 )

 

Prevalence is high , comparable to rates of IHD and diabetes Third most important condition of the prostate AAFP reports prevalence of 8.2 % ( range from 2.2 to 9.7 % ) Rosebud et al quote a prevalence of 5 % to 9 % among unselected men in the community The lifetime probability of a man being diagnosed as prostatitis exceeds 25 % and prostatitis accounts for about ~ 25 % of men seeking medical attention for genitourinary complaints.

 

Type 1 or Acute bacterial prostatitis acute infection of the prostate / urinary tract infection can be medical emergency with severe symptoms , systemic upset true incidence is not known but it is estimated that this may constitute about
10 % of all cases of prostatitis.

 

Type II Chronic bacterial prostatitis persistent bacterial infection of the prostate gland causing recurrent UTI’s caused by the same strain of bacteria duration > 3 months.

 

Type IIIChronic prostatitis/chronic pelvic pain syndrome most common subtype no identifiable infection further subdivided into
○ Type A : inflammatory CPS previously known as chronic non bacterial prostatitis
○ Type B non inflammatory CPS previously called prostatodynia

 

Type IV asymptomatic inflammatory prostatitis no symptoms but documented inflammation in prostatic tissue abnormal semen analysis , elevated PSA or incidental finding of prostatitis on examination of a biopsy specimen

 

What causes prostatitis is a matter of ongoing debate Multiple etiologies both infectious & non infectious Some cases clearly infectious Majority of cases have no evidence of genitourinary infection and the cause is usually not known Risk factors include
○ genetic , behavioural and environmental factors
○ inflammatory mediators
○ urinary tract instrumentation
○ men with chronic indwelling catheters
○ diabetes
○ cirrhosis
○ a h/o sexually transmitted infections
○ having a urethral stricture

 

Acute bacterial prostatitis –Acute prostatitis is used interchangeably with acute acute bacterial prostatitis ( ABP ) in literature NICE in its draft for consultation ( May 2018 ) mentions that
○ acute prostatitis is a bacterial infection of the prostate needing treatment with antibiotics
○ usually caused by bacteria which enter the prostate from the urinary tract
○ ABP can happen spontaneously or after medical procedures as prostate biopsy 
○ it can last for several weeks
○ complications include urinary retention & prostatic abscess ABP can be a life threatening event – requires prompt recognition and treatment.

 

Presentation -Systemic symptoms as -fever / chills / malaise / tachycardia dysuria , frequency , urinary retention
( edema of prostate can cause lower
urinary tract obstruction ) pelvic / lower back / rectal / perineal pain tender , enlarged or boggy prostate painful ejaculation , haematospermia and 
painful defecation may also be reported.

 

Cause -most are community acquired Escherichia coli is a common cause ( Gram negative uropathogen ) other pathogens may include Pseudomonas aeruginosa and Enterococcus species some episodes may be seen after transurethral manipulation procedures such as urethral catheterization and cystoscopy or after 
TRUS ( transrectal prostate biopsy )

 

Tests -Urine dipstick NICE recommends that a MSU should be sent before starting antibiotic Examine 
○ abdominal ( e.g distended bladder )
○ genital
○ DRE ( consider a gentle examination as vigorous prostatic examination can induce bacteremia ) Consider STI screen You may consider additional lab tests based on risk factors & severity of illness.

 

Differentials -sexually transmitted infections prostatic abscess chronic prostatitis Lower or upper urinary tract infection Benign prostatic hypertrophy ( hyperplasia ) Chronic pelvic pain syndrome Cystitis Diverticulitis Epididymitis Orchitis Proctitis Prostate cancer.

 

Admit -Urinary retention systemically unwell Unable to tolerate oral medications Immunocompromised Complexities for e.g pre-existing urological condition Symptoms do no improve after 48 hrs of starting antibiotic Risk factors for antibiotic resistance.

 

Antibiotic treatment -Most cases are managed in primary care Diagnosis is made based on history and physical examination ( helped by urinalysis ) Treatment is with antibiotic & supportive measures Adjust the antibiotic choice based on culture & sensitivity results when available Consider the severity , risk of complications , treatment failure , previous antibiotic use & local antibiotic resistance data.

 

First choice -Ciprofloxacin 500 mg bd X 14 days Ofloxacin 200 mg bd x 14 days

 

Alternative 1st choice -Trimethoprim 200 mg bd x 14 days

Second choice -Following discussion with specialist
 Levofloxacin 500 mg od x 14 days Co-trimoxazole 960 mg bd x 14 days.

 

Fluoroquinolones – consider restrictions and precautions as per MHRA advice
○ rare reports of disabling & potentially long-lasting irreversible SEs of musculoskeletal and nervous systems
○ advice to stop at 1st sign of serious adverse reaction such as tendonitis
○ prescribe with special caution in over 60s
○ avoid co-administration with a corticosteroid
 Co-trimoxazole – only use if there is bacteriological evidence of sensitivity & good reasons to prefer this combination.

 

Review if symptoms worsen and consider
○ alternative diagnoses
○ complications as acute urinary retention , prostatic abscess or sepsis
○ antibiotic resistance
 Following 2 week antibiotic use
○ stop or continue for additional 14 days if needed based on history , symptoms , clinical examination , urine and blood tests.

 

Chronic bacterial prostatitis -Symptoms persist > 3 months CBP – most common presentation is recurrent urinary tract infection from the same organism Rees et al report that the pain is a predominant symptom of both CBP and CP/ CPPS with the four main symptoms domains of CBP & Cp/ CPPS being
○ urogenital pain (perineal , inguinal , suprapubic , scrotum , testis , penile tip , lower back , rectum )
○ lower urinary tract symptoms ( LUTS )
○ psychological issues
○ sexual dysfunction
 CBP can be a complication of ABP in about 5 % of men About 10 % of CP have a bacterial cause.

 

Cause -ascending urethral infection lymphogenous spread of rectal bacteria hematogenous spread of bacteria from a remote source undertreated acute bacterial prostatitis recurrent UTI with prostatic reflux.

 

Pathogens -similar to ABP E Coli responsible for majority of cases other identified pathogens include Chlamydia trachomatis , Ureaplasma species , Trichomonas vaginalis and Mycobacterium tuberculosis.

 

Diagnosis -Can be challenging as history and examination can be highly variable.

 

Meares-Stamey ( 1968 ) four glass test- finds mention in most papers as being gold standard but nor rarely used Urinalysis Expressed prostatic secretions culture Semen culture Further testing based on clinical suspicion for e.g PSA , STI screen , cystometric studies.

 

Treatment -can be difficult includes trial of antibiotics , alpha adrenergic agents for refractory cases options tried include
○ alternative agents as fosfomycin
○ direct antimicrobial injections into the prostate
○ surgical removal of infected prostate tissue
○ chronic oral antibiotic suppression
○ novel therapies as utilizing bacteriophages to target antibiotic resistant bacteria.

 

Complex condition of largely unknown cause – usually diagnosis of exclusion.

PATIENT INFORMATION LINKS

Urology Care Foundation has a section for patients with diagrams which can be useful when explaining the condition https://www.urologyhealth.org/urology-a-z/p/prostatitis-(infection-of-the-prostate)

Excellent collection of resource both for the patient and the professional from Prostate Cancer UK https://prostatecanceruk.org/search-results?q=prostatitis#results

Brigham and Women’s Hospital has a FAQ like a section for patients who wish to know more https://www.brighamandwomens.org/surgery/urology/prostatitis-inflamed-prostate

Prostate Scotland has a section for the patient with explainer videos https://www.prostatescotland.org.uk/disease-tests-and-treatments/prostatitis

 

References

  1. Krieger JN, Lee SW, Jeon J, Cheah PY, Liong ML, Riley DE. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008 Feb;31 Suppl 1(Suppl 1):S85-90. doi: 10.1016/j.ijantimicag.2007.08.028. Epub 2007 Dec 31. PMID: 18164907; PMCID: PMC2292121. ( Abstract )
  2. Roberts, R.O., Jacobsen, S.J. Epidemiology of Prostatitis. Curr Urol Rep 1, 135–141 (2000). https://doi.org/10.1007/s11934-000-0048-7 ( Abstract )
  3. Benjamin A. Lipsky, Ivor Byren, Christopher T. Hoey, Treatment of Bacterial Prostatitis, Clinical Infectious Diseases, Volume 50, Issue 12, 15 June 2010, Pages 1641–1652, https://doi.org/10.1086/652861
  4. Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406. PMID: 20704171
  5. Prostatitis Infectious Disease Antimicrobial agents Dierdre L Church MD PhD FRCPC Prostatitis – Infectious Disease and Antimicrobial Agents (antimicrobe.org)
  6. Prostatitis Diagnosis and treatment RACGP Volume 42 , No 4 , April 2013 RACGP – Prostatitis – diagnosis and treatment
  7. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic
    pain syndrome: a consensus guideline Jon Rees, Mark Abrahams*, Andrew Doble† and Alison Cooper‡ for the Prostatitis Expert Reference Group (PERG)
    Backwell and Nailsea Medical Group, Bristol, *Department of Pain Medicine, †
    Department of Urology, Addenbrooke’s Hospital, Cambridge, and ‡
    Evidence Team, Prostate Cancer UK, London, UK https://www.bashhguidelines.org/media/1065/bju-prostatitis-2015.pdf
  8. CKS NHS Chronic Prostatitis https://cks.nice.org.uk/topics/prostatitis-chronic/
  9. Virtual Mentor. 2006;8(11):748-751. doi: 10.1001/virtualmentor.2006.8.11.cprl1-0611.
  10. Leeds NHS Trust Acute and Chronic Prostatitis – Primary Care Acute and Chronic Prostatitis (leedsth.nhs.uk)
  11. Prostatitis (acute): antimicrobial prescribing NICE guideline [NG110]Published date: 

  12. Su, Z.T., Zenilman, J.M., Sfanos, K.S. et al. Management of Chronic Bacterial Prostatitis. Curr Urol Rep 21, 29 (2020). https://doi.org/10.1007/s11934-020-00978-z

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