Prostatitis Types, Diagnosis, and Treatment

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 pain in the region of the prostate gland. Prostate pain syndrome (PPS) is sometimes used to describe men with chronic prostatic pain who have no identifiable infective cause. If the prostate gland cannot be identified as the source of pain, the term chronic pelvic pain syndrome is sometimes used. The European Association of Urology currently recommends that the term primary prostate pain syndrome (PPPS) should be used instead of chronic pelvic pain syndrome^{[1, 2]}. However, this term is not used in the UK so the terms PPS and CPPS have been retained in this article^[2].

Epidemiology^[3]

• 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 prostatitis 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 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 review reported a mean age of 59 years^[5].
• There are also suggestions that chronic prostatitis may be associated with benign prostatic hyperplasia and prostate cancer, although this association remains unclear^[6].

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^[7].

Types of prostatitis^{[2, 3, 7]}

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

• 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).
• Chronic prostatitis can be further classified as:
  • Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (sometimes also referred to as abacterial prostatitis or prostate pain syndrome) - this accounts for over 90% of men with chronic prostatitis (there is no proven bacterial infection).
  • Chronic bacterial prostatitis (CBP) - 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
• 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^[8].
• Urethral discharge.

Examination of prostatitis

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^[9]

• 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^[10].

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^{[11, 2]}. 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^[12].

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:
  • 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.
• 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 prostatitis^[2]

• 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 abacterial prostatitis

A significant number of randomised control trials (RCTs) have been published in recent years, leading to a number of evidence-based recommendations^{[13, 14]}.

• 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^[15].
• 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 include the use of neuromodulatory drugs such as pregabalin. Pudendal nerve entrapment syndrome is an important differential diagnosis which can be elicited by performing a pudendal nerve block^[16].

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.