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 III Chronic 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
- 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 )
- 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 )
- 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
- Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406. PMID: 20704171
- Prostatitis Infectious Disease Antimicrobial agents Dierdre L Church MD PhD FRCPC Prostatitis – Infectious Disease and Antimicrobial Agents (antimicrobe.org)
- Prostatitis Diagnosis and treatment RACGP Volume 42 , No 4 , April 2013 RACGP – Prostatitis – diagnosis and treatment
- 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 - CKS NHS Chronic Prostatitis https://cks.nice.org.uk/topics/prostatitis-chronic/
- Virtual Mentor. 2006;8(11):748-751. doi: 10.1001/virtualmentor.2006.8.11.cprl1-0611.
- Leeds NHS Trust Acute and Chronic Prostatitis – Primary Care Acute and Chronic Prostatitis (leedsth.nhs.uk)
-
Prostatitis (acute): antimicrobial prescribing NICE guideline [NG110]
Published date: - 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
