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JNP
Prostatitis
Annually about 2 million physician visits result in a diagnosis of prostatitis. The lifetime prevalence of
prostatitis varies from 5% to 9%.1 A nationwide study reported that approximately 15% of men who
presented with genitourinary symptoms received a diagnosis of prostatitis.2
MEN’S HEALTH
Demetrius J. Porche
Prostatitis Classification
Prostatitis is an inflammation of the prostatic
gland. The prostatic gland is responsible for the
production of seminal fluids that assist in the
nourishment and transport of sperm. The prosta-
tic gland is a male-specific organ and an exclu-
sively male health condition. Prostatitis is a com-
mon male condition associated with chronic pain
syndromes that involve the pelvic area. Prostati-
tis has classically been categorized into the fol-
lowing four types based on symptom chronicity:
acute prostatitis (type I), chronic bacterial prosta-
titis (type II), chronic nonbacterial prostatitis
(type III), and prostadynia.1
A new classification system of prostatitis was pro-
posed by the National Institutes of Health (NIH) with
current use varying among clinicians. The proposed
system does not change the categorization of acute
and chronic bacterial prostatitis. These categories are
referred to as I, acute prostatitis, and II, chronic bacte-
rial prostatitis. The NIH system changes the category
for chronic nonbacterial prostatitis and prostadynia.
Chronic nonbacterial prostatitis is categorized as IIIa,
662 The Journal for Nurse Practitioners - JNP
chronic nonbacterial prostatitis/chronic pelvic pain syn-
drome inflammatory, and IIIb, chronic nonbacterial
prostatitis/chronic pelvic pain syndrome noninflamma-
tory. The differentiation between category IIIa and IIIb
depends on the presence or absence of white blood
cells in the prostatic secretions. The presence of
white blood cells supports a diagnosis of IIIa. The
fourth NIH category, IV, is asymptomatic prostatitis.1,3
Cause and Clinical
Presentation
The common causative agent for bacterial pro-
statitis consists of organisms originating from
the urinary or intestinal tract. Pathogens associ-
ated with bacterial prostatitis include Escherichia
coli (most common), Staphylococcus aureus, and
Streptococcus faecalis. Other pathogen species
can include Klebsiella, Proteus, Enterococci,
Pseudomonas, and Chlamydia. In addition, pro-
statitis can be associated with the presence of
urinary catheters or other invasive devices. The
cause of nonbacterial prostatitis or chronic pelvic
pain syndrome is not well understood. Associ-
ated conditions of nonbacterial prostatitis or
chronic pelvic pain syndrome are heavy lifting,
occupations that require long periods of sitting,
physical activity that may irritate the prostatic
gland such as jogging or biking, or pelvic muscle
spasms.
Men typically present with complaints of flulike
symptoms, fever, chills, and pain. The pain is located
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or concentrated typically in the lower back or in the
genital or pelvic area. Dysuria and nocturia may be
present. Men may complain of urinary problems such
as difficulty urinating, feeling of urgency and fre-
quency, and blood-tinged urine. A common complaint
is difficulty starting and continuing a steady urine
stream when urinating. Some men report a history of
painful ejaculations.1
Diagnosis
The differential diagnosis of prostatitis should
include urinary tract infection, prostate cancer, anal
trauma or infection, sexually transmitted infections,
epididymitis, orchitis, and benign prostatic hyper-
trophy. The diagnosis of prostatitis depends on an
integrated history, physical examination, and labora-
tory results.
Diagnostic tests consist of urinalysis with and
without prostatic massage, prostate-specific antigen
(PSA) level, and digital rectal examination. Urine
specimens can be obtained as initial voided urine,
midstream urine, or after prostatic massage. The ini-
tial voided urine tests for urethral infection or inflam-
mation, the midstream urine tests for urinary bladder
infection, and the expressed prostatic secretions and
voided urine test for prostatic infection. The premas-
sage and postmassage prostate test consists of col-
lecting two urine specimens; one specimen is col-
lected as a midstream urine specimen before a pro-
static massage, and the second specimen is col-
lected after a prostatic massage.
The digital rectal examination (DRE) consists
of examining the consistency, size, and presence
of nodules. The DRE provides supporting but
nondefinitive evidence for a prostatitis diagnosis.
The PSA is also nonspecific for prostatitis but
provides supportive evidence for a prostatitis
diagnosis. The PSA level frequently increases
with the presence of prostatitis. The level or rate
of PSA increase is not definitely associated with
the severity of prostatitis. Men who present with
an elevated PSA level should be examined for
prostate cancer.1,4
Treatment
The treatment of prostatitis depends on the pres-
ence or absence of bacteria. Bacterial prostatitis is
www.npjournal.org
treated with antibiotics as a first-line therapy. Com-
mon antibiotic regimens for bacterial prostatitis
include trimethoprim-sulfamethoxazole, doxycy-
cline, ciprofloxacin, norfloxacin, or ofloxacin. In
addition, complementary treatment options consist
of ␣-blockers, analgesics, muscle relaxants, lower
pelvic floor exercises, sitz baths, or prostatic mas-
sage. Surgical intervention is typically limited to
relieve prostatic obstructions.1,5
Summary
Prostatitis is an acute or chronic, bacterial or non-
bacterial infection of the prostatic gland. Men pres-
ent with typical symptoms that support a diagnosis
of prostatitis, which depends on a history, physical
examination, and laboratory testing. Treatment for
prostatitis includes pharmacologic and nonpharma-
cologic interventions.
References
1. Stevermer JJ, Easley SK. Treatment of prostatitis. Am Fam
Physician. 2000;61(10):3015-3022, 3025-306.
2. Collins MM, Stafford RS, O’Leary MP, Barry MJ. How common is
prostatitis? A national survey of physician visits. J Urol.
1998;159(4):1224-1228.
3. Nickel JC, Moon T. Chronic bacterial prostatitis: an evolving clinical
enigma. Urology. 2005;66(1):2-8.
4. Kawakami J, Siemens DR, Nickel JC. Prostatitis and prostate cancer:
implications for prostate cancer screening. Urology. 2004;64(6):1075-
1080.
5. Dimitrakov JD, Kaplan SA, Kroenke K, Jackson JL, Freeman MR.
Management of chronic prostatitis/chronic pelvic pain syndrome: an
evidence-based approach. Urology. 2006;67(5):881-888.
Demetrius J. Porche, DNS, RN, APRN, is a professor, director
of the doctor of nursing science program, and associate dean
of the School of Nursing at Louisiana State University in New
Orleans. He can be reached at dporch@lsuhsc.edu.
1555-4155/06/$ see front matter
© 2006 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2006.10.008
The Journal for Nurse Practitioners - JNP 663