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 Accident and Emergency departments in the first instance. Prostate pain syndrome (PPS) is sometimes used to describe men with chronic prostatic pain who have no identifiable infective cause. If the prostate cannot be identified as the source of pain, the term chronic pelvic pain syndrome (CPPS) is sometimes used.^[1]

Epidemiology^[2]

• 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.
• Bacterial prostatitis is the most common form in those under 35 years old.^[3]
• HIV infection predisposes to prostate cancer. Younger patients were once in the majority but in the post-highly active antiretroviral therapy (HAART) era the age profile is similar to prostate cancer patients who do not have HIV. One study reported a mean age of 59 years.^[4]
• There are also suggestions that chronic prostatitis may be associated with benign prostatic hyperplasia and prostate cancer.^[5]

Aetiology

Bacterial

• Usually Gram-negative organisms, especially Escherichia coli, Enterobacter, Serratia, Pseudomonas and Proteus species.
• Sexually transmitted infections may also be a cause - eg, 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 - eg, post-biopsy.
• Increases with increasing age.^[6]

Classification^{[2, 6]}

A classification system has been proposed and it divides the various syndromes into four broad categories:

• Acute bacterial prostatitis.
• Chronic bacterial prostatitis.
• Chronic prostatitis/CPPS - further subdivided into a and b according to presence or absence of inflammation.
• Asymptomatic inflammation.

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.^[7]
• Urethral discharge.

Examination

There may be fever.

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.

Chronic bacterial and non-bacterial prostatitis

• The gland feels normal or may be hard from calcification.

Differential diagnosis^[8]

• Cystitis.
• Benign prostatic hyperplasia.
• Urinary tract stones.
• Foreign body in the urinary tract.
• Bladder cancer.
• 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, 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.^[9]

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.^[10] 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 (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.

Recent evidence suggests that pain, particularly the extent of pain, is the most important feature to affect quality of life.^[11]

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^[12]

• 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.
• 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^[13]

• 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.
• 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.

Chronic abacterial prostatitis

A significant number of randomised control trials (RCTs) have been published in recent years, leading to a number of evidence-based recommendations.^{[14, 15]}

• Either paracetamol or a non-steroidal anti-inflammatory drug (NSAID) would be a reasonable choice for analgesia.
• Antibiotics may possibly help occult infection but repeated courses should be avoided.
• 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.
• Analysis suggests that, of all the therapies, the alpha-blockers, antibiotics or a combination of these provide the best outcomes.^[16]
• 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.
• A multidisciplinary approach (urologists, pain specialists, nurse specialists, specialist physiotherapists, GPs, cognitive behavioural therapists/psychologists, sexual health specialists) is recommended.
• Emerging therapies that have been investigated include thermotherapy (transurethral microwave hyperthermia or transurethral microwave thermotherapy), bioflavonoids (quercetin), bee pollen, saw palmetto, mepartricin, finasteride and anti-inflammatory preparations. Few of these therapies are supported by gold standard evidence from RCTs.^{[17, 18]}

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.