Prostatitis

Definition
Prostatitis encompasses various inflammatory conditions affecting the prostate, including: o Acute and chronic infections with specific bacteria o Prostatic inflammation without detected organisms Classification o Acute bacterial prostatitis o Chronic bacterial prostatitis o Chronic pelvic pain syndrome (CPPS, formerly nonbacterial prostatitis) Inflammatory Noninflammatory

Epidemiology
Incidence/prevalence o Lifetime prevalence: 59% o Accounts for 8 million outpatient visits per year worldwide > 1 million visits annually in the U.S. o Accounts for 25% of all office visits involving the genitourinary system by young and middle-aged men Age o Acute bacterial prostatitis Spontaneous disease that generally affects young men (under age 35) Associated with an indwelling urethral catheter in older men o Chronic/recurrent bacterial prostatitis Often affects middle-aged men o CPPS Most cases of inflammatory CPPS occur in young, sexually active men. Most common diagnosis among men presenting with prostatitis symptoms

Risk Factors
Recent medical instrumentation or urinary catheterization Recent cystitis or urethritis Rectal intercourse Bladder outlet obstruction o Anatomically abnormal urinary tract (e.g., urethral stricture) o Benign prostatic hypertrophy Immunocompromise Possible contributing factors for acute prostatitis

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Trauma Dehydration Sexual abstinence HIV infection

Etiology
Possible mechanisms of disease
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Urinary reflux into prostate Ascending urethral infection o Direct invasion or spread via lymphatics from rectum o Hematogenous seeding Acute bacterial prostatitis o In cases not associated with catheterization, infection generally is due to common gram-negative urinary tract pathogens (Escherichia coli orKlebsiella). o In catheter-associated cases, the spectrum of etiologic agents is broader, including hospital-acquired gram-negative rods and enterococci. o Sexually transmitted infections (e.g., Neisseria gonorrhoeae or Chlamydia trachomatis) may also contribute. Chronic bacterial prostatitis o E. coli o Klebsiella o Proteus o Other uropathogenic bacteria CPPS o The likely etiology would be an infectious agent, given the association with inflammation; however, no agent has yet been identified. o Evidence for a causative role of both Ureaplasma urealyticum and C. trachomatis has been presented but is not conclusive. o The causative agent may be sexually transmitted.

Symptoms & Signs

General symptoms of prostatitis o Intermittent perineal and low-back pain o Obstructive voiding symptoms Acute bacterial prostatitis o Fever o Chills o Dysuria o Tense or boggy, extremely tender prostate o Cloudy urine

May have obstructive symptoms (dribbling, hesitancy, anuria) o Prostatic massage should be avoided. Usually produces purulent secretions with many bacteria, but may induce bacteremia Chronic bacterial prostatitis o Symptoms often are absent between episodes. o Prostate usually feels normal on palpation. o Obstructive symptoms or perineal pain develops in some patients. o Infection may spread to the bladder, producing symptoms of cystitis. Frequency Urgency Dysuria CPPS o Many cases follow an episode of nonspecific urethritis. o Symptoms of prostatitis Intermittent perineal and low-back pain Obstructive voiding symptoms o Few signs on examination o No history of recurrent episodes of bacterial prostatitis
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Differential Diagnosis

Urethritis Cystitis Pyelonephritis Benign prostatic hyperplasia Malignancy Hernia

Diagnostic Approach
Patients with acute bacterial prostatitis usually can be readily identified on the basis of typical symptoms and signs, pyuria, and bacteriuria. o Avoid prostatic massage. To classify a patient with suspected chronic prostatitis correctly, 4 samples should be cultured quantitatively and evaluated for leukocyte counts.
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First-void urine sample (510 mL) Midstream urine specimen Prostatic expressate Postmassage urine specimen For optimal results, the patient: Should have a full bladder

Should have received no antibiotics in the preceding 4 weeks Should not have ejaculated in the preceding 2 days Chronic bacterial prostatitis o The diagnosis is established by culture of E. coli, Klebsiella, Proteus, or other uropathogenic bacteria from the expressed prostatic secretion or postmassage urine in higher quantities than are found in first-void or midstream urine. CPPS o No bacterial growth in cultures o Inflammatory The expressed prostatic secretion and the postmassage urine contain at least 10-fold more leukocytes than the midstream urine. The expressed prostatic secretion contains > 1000 leukocytes per L. o Noninflammatory Normal leukocyte counts Negative urine cultures

Laboratory Tests
All patients should undergo urinalysis. Acute bacterial prostatitis o Blood cultures o Grams staining and culture of urine o Infection is generally due to common gramnegative urinary tract pathogens (E. coli or Klebsiella). o Bloodwork may show leukocytosis. Chronic prostatitis o Urinalysis and culture of: First-void and midstream urine Expressed prostatic secretion and postmassage urine Prostatitis may cause elevation in serum levels of prostate-specific antigen (PSA).

Imaging Diagnostic Procedures Treatment Approach

General principles

Not indicated Not indicated

A long course of treatment is required because antibiotic penetration into prostatic tissue is generally poor.
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Acute bacterial prostatitis: 46 weeks Chronic bacterial prostatitis: 612 weeks

Acute bacterial prostatitis Initial therapy is given until the pathogen has been isolated and its susceptibilities determined. o An IV fluoroquinolone is the preferred initial antibiotic. o Alternative therapies Third-generation cephalosporin Aminoglycoside Imipenem in catheter-associated cases The response to antibiotics usually is prompt. Some experts recommend that patients < 35 years old who have acute bacterial prostatitis receive treatment targeting N. gonorrhoeae and C. trachomatis.

Chronic bacterial prostatitis Antibiotics promptly relieve symptoms but have been less effective in eradicating the focus of chronic infection. Best penetration into prostate

Fluoroquinolones: associated with best outcomes Trimethoprim-sulfamethoxazole (TMP-SMX) Patients with frequent episodes of acute cystitis in whom attempts at curative therapy fail can be managed with prolonged courses of low-dose antimicrobial agents. o Sulfonamide or o TMP or o Nitrofurantoin Total prostatectomy is curative but is associated with considerable morbidity. Transurethral prostatectomy is safer but cures only onethird of patients.
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CPPS The effectiveness of antimicrobial agents is uncertain. Some patients with inflammatory subgroup disease benefit from a 4- to 6-week course of treatment with: o Erythromycin or o Doxycycline or o TMP-SMX or

o Fluoroquinolone Patients with noninflammatory CPPS most likely do not have a prostatic infection and should not be given antimicrobial agents. Other therapies include: o Reassurance o Sitz baths o NSAIDs o Alpha-blockers for irritative symptoms o Acupuncture[1][2]

Specific Treatments
Treatment duration

Acute bacterial prostatitis: 46 weeks Chronic bacterial prostatitis: 612 weeks

Oral antibiotics

Empirical treatment
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TMP-SMX: 160/800 mg q12h Fluoroquinolone Ciprofloxacin: 500 mg q12h Levofloxacin: 500 mg/d The choice of drug for treatment completion should be based on culture and susceptibility results. Parenteral antibiotics

Empirical treatment
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Fluoroquinolone Ciprofloxacin: 400 mg q12h Levofloxacin: 500 mg/d o Aminoglycoside Gentamicin: 5 mg/kg qd o Third-generation cephalosporin Ceftriaxone: 12 g/d o Imipenem-cilastatin: 250500 mg q68h o For severely ill patients with acute prostatitis, consider coverage for gram-positive organisms (e.g., enterococci, staphylococci) as well. The choice of drug for treatment completion should be based on culture and susceptibility results. May complete course with oral antibiotics after patient has been afebrile for 2448 h

Monitoring

Patients with chronic bacterial prostatitis should be followed for the duration of treatment with repeat urinalysis and culture to verify cure at the end of the antibiotic course. Monitor for adverse reactions to antibiotics during treatment.

Complications

Prognosis

Acute bacterial prostatitis o Abscess formation o Epididymoorchitis o Seminal vesiculitis o Septicemia o Residual chronic bacterial prostatitis

Acute bacterial prostatitis o Fever and dysuria usually diminish within 26 days of the start of treatment. o The long-term prognosis is good, although in some instances patients may develop complications. Chronic bacterial prostatitis o The response to antibiotics is variable. o This disease tends to recur. o Recurrences usually are re-treated with longcourse antibiotics. CPPS o Tends to be chronic with periods of exacerbation HIV infection is associated with more frequent prostatic infections that are more refractory to cure.

Prevention
Avoid unnecessary urinary tract instrumentation. Treat benign prostatic hypertrophy. Correct urinary tract anatomic abnormalities. Treat acute bacterial prostatitis with a long course (usually 46 weeks) of appropriate antibiotics to decrease the risk of chronic bacterial prostatitis.

ICD-9-CM See Also

601.9 Prostatitis, unspecified Genital Infections due to Chlamydia trachomatis Genital Mycoplasma Infections Gonococcal Infections

Internet Sites
Professionals o Homepage American Urological Association Patients

Prostatitis: Disorders of the Prostate National Kidney and Urologic Diseases Information Clearinghouse
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References
1. Lee SW et al: Acupuncture versus sham acupuncture for chronic prostatitis/chronic pelvic pain. Am J Med 121:79.e1, 2008 [PMID:18187077] 2. Schaeffer AJ: Clinical practice. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med 355:1690, 2006 [PMID:17050893]

General Bibliography
Alexander RB et al: Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial.Ann Intern Med 141:581, 2004 [PMID:15492337] Benway BM, Moon TD: Bacterial prostatitis. Urol Clin North Am 35:23, 2008 [PMID:18061021] Krieger JN, Nyberg L, Nickel JC: NIH consensus definition and classification of prostatitis. JAMA 282:236, 1999 [PMID:10422990] Nickel JC, Nyberg LM, Hennenfent M: Research guidelines for chronic prostatitis: consensus report from the first National Institutes of Health International Prostatitis Collaborative Network. Urology 54:229, 1999 [PMID:10443716] Nickel JC, Moon T: Chronic bacterial prostatitis: an evolving clinical enigma.Urology 66:2, 2005 [PMID:15992891] Pontari MA: Chronic prostatitis/chronic pelvic pain syndrome. Urol Clin North Am 35:81, 2008 [PMID:18061026] Pontari MA, Ruggieri MR: Mechanisms in prostatitis/chronic pelvic pain syndrome. J Urol 172:839, 2004 [PMID:15310980] Saint S, Savel RH, Matthay MA: Enhancing the safety of critically ill patients by reducing urinary and central venous catheter-related infections. Am J Respir Crit Care Med 165:1475, 2002 [PMID:12045119] This topic is based on Harrisons Principles of Internal Medicine, 17th edition, chapter 282, Urinary Tract Infections, Pyelonephritis, and Prostatitis by WE Stamm.

PEARLS

Isolated acute cystitis occurs uncommonly in men. o Consider acute bacterial prostatitis among men with signs and symptoms suggesting cystitis (dysuria, fever, cloudy urine).

Educate such patients about the importance of completing a long course of antibiotics to prevent the development of chronic bacterial prostatitis. To minimize the risk of inducing bacteremia, avoid vigorous prostatic massage in patients with suspected acute bacterial prostatitis. Serum PSA levels may remain elevated for 36 months after prostatic infection. o The PSA test should not be used to screen for prostate cancer during this period. Patients whose urine cultures grow Staphylococcus aureus should undergo evaluation with blood cultures to rule out hematogenous seeding as the source of infection. Patients with AIDS may develop prostatic infections with cryptococcosis.
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