Prostatitis

What is 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. Non-bacterial prostatitis is more common, although it is the acute symptoms of bacterial prostatitis that drive most patients to consult their GP or attend A&E departments in the first instance.

Various terms have been used for men who have chronic pain in the region of the prostate gland. These include:¹

• Chronic prostatitis, chronic pelvic pain syndrome, primary prostate pain syndrome, and abacterial prostatitis - overlapping descriptions of chronic prostate-related pain that is not due to a proven infection.

• Chronic bacterial prostatitis - a chronic bacterial infection of the prostate.

The European Association of Urology favours the term primary prostate pain syndrome (PPPS) to describe persistent or recurrent episodic pain, which is convincingly reproduced on palpation of the prostate, but with no proven infection or other obvious local pathology. PPPS is considered as one of the chronic pelvic pain syndromes.²

Epidemiology³

• Prostatitis is common with a prevalence of 2.2-9.7%. Approximately 2-10% of adult men experience symptoms compatible with chronic prostatitis at any time and 15% of men experience symptoms of prostatitis at some point in their lives.

• Chronic prostatitis is much more common than acute prostatitis.

• Men aged between 50-59 years old have a three-fold increased risk of having chronic prostatitis (or PPPS) than men aged between 20-39 years.²

• Bacterial prostatitis is the most common form in those under 35 years of age.⁴

• HIV infection may be a risk factor for prostatitis.⁵⁶Older studies (predating the widespread availability of effective antiretroviral treatment for HIV) reported the presence of HIV-infected cells within prostatic tissue of men with AIDS, suggesting a potential direct inflammatory effect of the virus.⁷

• There are also suggestions that chronic prostatitis may be associated with benign prostatic hyperplasia and prostate cancer, although this association remains unclear.⁸

Aetiology

Bacterial

• Usually Gram-negative organisms, especially Escherichia coli, Enterobacter, Serratia, Pseudomonas and Proteus species.

• Sexually transmitted infections may also be a cause - for example, 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 (STIs).

• Urinary tract infections (UTIs).

• Indwelling catheters.

• Acute bacterial prostatitis can occur after sclerotherapy for rectal prolapse.

• Following manipulation of the gland - for example, post-biopsy.

• Increases with increasing age⁹ .

Types of prostatitis ^{3 9}

There are various different classification systems and terminologies for prostatitis and its subtypes. The National Institutes of Health (NIH) classification remains influential. It defines four broad categories:¹⁰

• Acute bacterial prostatitis.

• Chronic prostatitis: this can be defined as at least three months of urogenital pain, which may be perineal, suprapubic, inguinal, rectal, testicular, or penile and is often associated with lower urinary tract symptoms (such as dysuria, frequency, hesitancy, and urgency), and sexual dysfunction (erectile dysfunction, painful ejaculation, or postcoital pelvic discomfort). This is further divided into:

  • Chronic bacterial prostatitis - less than 10% of men with chronic prostatitis. CBP is suspected if there is a history of urinary tract infection, or an episode of acute prostatitis within the preceding 12 months

  • Chronic prostatitis or chronic pelvic pain syndrome (primary prostate pain syndrome and abacterial prostatitis would also be included in this category). This accounts for over 90% of men with chronic prostatitis, and there is no proven bacterial infection.

• Asymptomatic inflammatory prostatitis.

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. There is also a significant association with premature ejaculation.¹¹

• Urethral discharge.

Examination of prostatitis¹

Systemic upset, such as fever, may be seen in acute bacterial prostatitis, but not in chronic prostatitis (whether bacterial or non-bacterial).

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 - for example, tachycardia, dehydration.

Chronic bacterial and non-bacterial prostatitis
The gland feels normal or may be hard from calcification. It may, or may not, be tender to palpation.

Differential diagnosis¹²

• Cystitis.

• Benign prostatic hyperplasia.

• Urinary tract stones.

• Foreign body in the urinary tract.

• Bladder cancer.

• Prostatic abscess.

• Enterovesical fistula.

Prostatitis 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 a painful condition and may spread infection. For this reason the 'two-glass' test, whereby the urine sample is examined for sediment before and after prostatic massage, has fallen out of favour.

• If there is suspicion of prostate cancer, check the PSA but remember it can be elevated in any form of prostatitis.¹³

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.¹⁴ It contains 13 items that are scored in three discrete domains:

• Pain.

• Urinary symptoms.

• 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. It is hoped that this will help improve the quality of research to obtain guidelines for management.

Diagnostic criteria for this condition include:

• Symptoms suggestive of prostatitis (for example, 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.

Recent evidence suggests that pain, particularly the extent of pain, is the most important feature to affect quality of life.¹⁵

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.

Prostatitis treatment and management

Acute prostatitis

• 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 genitourinary clinic may be valuable, both in terms of accurate diagnosis and of contact tracing.

• Start oral antibiotic treatment, taking into account local antimicrobial resistance data. Prescribe an oral antibiotic for 14 days:¹⁶

  • Ciprofloxacin 500 mg twice daily or ofloxacin 200 mg twice daily first-line, or if they are unsuitable trimethoprim 200 mg twice daily.

  • Levofloxacin 500 mg once daily, or co-trimoxazole 960 mg twice daily (when there is bacteriological evidence of sensitivity and good reasons to prefer this combination to a single antibiotic) second-line.

• Men taking fluoroquinolones should be advised of the risks and benefits of these drugs, and stop treatment if they develop serious adverse reactions. These reactions may include tendonitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, or central nervous system effects. If any of these occur, they should be reported to a doctor.

• Note the 2024 Medicines and Healthcare products Regulatory Agency (MHRA) alert that systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate.¹⁷ At the time of writing, ciprofloxacin and levofloxacin remained the first-choice oral antibiotics recommended by the National Institute for Health and Care Excellence (NICE) for acute prostatitis.¹⁶

• If the patient is not to be treated in the community immediately, offer safety netting advice and review in 48 hours. If there is no improvement at that stage, refer to hospital.

• If the cause is a sexually transmitted infection, refer urgently to a genitourinary medicine specialist.

• After 14 days, review antibiotic treatment and either stop or prescribe an additional 14 days depending on history, symptoms, clinical examination, urine and blood tests.

• Following recovery, refer for investigation to rule out structural abnormality of the urinary tract.

Chronic infective prostatitis¹

• Referral should be made if the patient has chronic prostatitis. However, whilst he is waiting to be seen it is worth trying to treat the infection and the pain.

• A single course of antibiotics should be prescribed. Options include:

  • Trimethoprim 200 mg twice a day for 4-6 weeks; or

  • Doxycycline 100 mg twice daily for 4-6 weeks

• Analgesia such as paracetamol or NSAIDs 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.

Chronic non-bacterial prostatitis

Chronic non-bacterial prostatitis/chronic pelvic pain syndrome/primary prostate pain syndrome can be difficult to treat, although most men notice an improvement within six months.¹

Patient engagement and education as to the nature and outlook of the condition are important. Interventions should be tailored towards the manifestations of the condition in each individual person. The UPOINT system may be helpful to establish the presence and extent of issues in six different domains (urinary symptoms, psychosocial dysfunction, organ-specific-symptoms, infection-related symptoms, neurological/systemic conditions, and tenderness of skeletal muscles)¹⁸, which may guide specific treatment approaches. Sexual dysfunction is also common.

Treatment options, depending on symptoms, include:¹²

• Pain:

  • Paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDs).

  • Alpha-blockers such as doxazosin or tamsulosin (as well as improving urinary symptoms - see below - these may have a moderate effect on pain).

  • Acupuncture.

  • Pelvic physiotherapy, for pain related to pelvic floor dysfunction.¹

  • Antibiotics (see below).

  • Neuropathic agents such as tricyclic antidepressants, duloxetine, and gabapentinoids may have a role in selected patients if there is evidence of neuropathic pain. However, one RCT suggests that pregabalin may be ineffective in chronic prostatitis,¹⁹ but some experts feel it may have a role in selected patients.²

  • Opiates should be avoided.¹

• Lower urinary tract symptoms (LUTS):

  • Alpha-blockers such as tamsulosin or doxazosin.

• Psychosocial symptoms:

  • Depending on the nature and severity of the symptoms, options include targeted CBT, counselling, and antidepressant therapy.

• Constipation:

  • Stool softeners such as docusate or lactulose may be helpful if defecation is painful.¹

• Sexual dysfunction:

  • Non-pharmacological treatments to reduce anxiety about sexual function.

  • Phosphodiesterase inhibitors for erectile dysfunction.

• Other treatment options include:

  • Antibiotics, although this is controversial. Some patients improve with antibiotic therapy, even without objective evidence of infection. The EAU guidelines recommend a trial of antibiotics (tetracyclines or fluoroquinolones) for six weeks in treatment-naïve patients with symptoms for less than one year;² note however that the MHRA advises that fluoroquinolones should not be prescribed for non-bacterial chronic prostatitis.²⁰ Other sources recommend a trial of trimethoprim or doxycycline for 4-6 weeks in people with symptoms for less than six months.¹

  • High-dose oral pentosane polysulphate; in one study this was associated with a significant improvement in clinical global assessment and quality of life over placebo.²¹

  • Phytotherapy (herbal therapy). There is some limited evidence that specific pollen extracts, quercetin, and saw palmetto extract may improve pain in some patients.

  • Botulinum toxin type A injection into the pelvic floor (or prostate) - this may have a modest effect on symptoms.

• A multidisciplinary approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, GPs, cognitive behavioural therapists/psychologists, sexual health specialists) is recommended.

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.