Prostatitis

Prostatitis is inflammation or an irritative condition of the prostate that presents as different syndromes: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain, and asymptomatic. Bacterial prostatitis is easier to identify clinically and the management (antibiotics) is better established. Whether the condition is in an acute or chronic state determines the length of antibiotic treatment. The main diagnostic tools are history, physical examination, and work-up investigating the sources of infection (urinalysis and culture). Digital rectal examination is only recommended in patients with chronic prostatitis and not in acute bacterial prostatitis due to the risk of sepsis. Chronic pelvic pain syndrome is a diagnosis of exclusion and requires multimodal pain management with established patient expectations. The asymptomatic type is an incidental finding that is recognized when a patient has other urologic issues.

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Overview

Definition

Prostatitis is inflammation of the prostate gland that presents as different syndromes:

  • Acute bacterial prostatitis: acute bacterial infection of the prostate with lower urinary tract symptoms
  • Chronic bacterial prostatitis: chronic bacterial infection of the prostate with lower urinary tract symptoms
  • Chronic prostatitis/chronic pelvic pain syndrome (CPPS):
    • Chronic lower pelvic pain and inflammation of the prostate gland ≥ 3 months
    • May or may not be associated with infection
  • Asymptomatic inflammatory prostatitis: non-infectious, nonspecific prostate gland inflammation

Epidemiology and etiology

  • Prostatitis accounts for 2 million urology visits in the United States annually.
    • CPPS is the most common diagnosis.
    • Incidence of acute and chronic bacterial prostatitis is about 4%–5%.
  • Risk factors for acute and chronic bacterial prostatitis: 
    • Inflammatory disorders: cystitis or urethritis
    • Other genitourinary (GU) infections: 
      • Gram-negative urinary tract infections (Escherichia coli, Enterobacter, and Serratia) are responsible for 80% of cases in men > 35 years old.
      • STIs: Neisseria gonorrhoeae and Chlamydia trachomatis in men < 35 years old
    • Prostate gland or bladder stones posing as nidus for infection
    • Iatrogenic:
      • Recent GU instrumentation
      • Chronic indwelling Foley catheters
      • GU trauma 
    • Anatomic considerations: Urethral strictures can increase the risk of prostatitis.
  • Chronic pelvic pain/CPPS: unclear pathogenesis
  • Asymptomatic inflammatory prostatitis: most often incidental finding and no underlying etiology usually found

Microscopic appearance of chronic prostatitis:
Numerous small, dark-blue lymphocytes are seen in the stroma between the glands.

Image: “The relationship between histological prostatitis and lower urinary tract symptoms and sexual function” by Kumsar S, Kose O, Aydemir H, Halis F, Gokce A, Adsan O, Akkaya ZK. License: CC BY 4.0

Clinical Presentation

Acute bacterial prostatitis

  • Acutely ill appearing on clinical exam
  • Generalized symptoms: 
    • High fevers
    • Subjective chills
    • Malaise
  • Lower urinary tract symptoms: 
    • Dysuria
    • Urinary frequency/urgency
    • Urge incontinence
  • Localized pain symptoms: 
    • Pelvic or perineal pain
    • Pain at the tip of the penis
    • Inguinal or scrotal pain

Chronic bacterial prostatitis

  • Subtle clinical picture:
    • Usually not ill appearing
    • May be asymptomatic
  • Generalized symptoms: low-grade fever or subjective chills
  • Lower urinary tract symptoms:
    • Dysuria
    • Urinary frequency/urgency
    • Urge incontinence
  • Localized pain symptoms: 
    • Perineal discomfort
    • Bladder irritation
    • Pelvic pain

Chronic pelvic pain syndrome and asymptomatic inflammatory prostatitis

  • CPPS: 
    • Lower urinary tract symptoms:
      • Urinary frequency/urgency
      • Painful bladder-filling sensation
      • Dysuria
    • Localized pain symptoms:
      • Perineal tenderness (most common)
      • Mildly tender prostate
      • Myofascial tenderness
      • Suprapubic tenderness
    • Sexual dysfunction
  • Asymptomatic inflammatory prostatitis: 
    • Usually asymptomatic
    • Evidence of prostate gland inflammation found incidentally

Diagnosis

Physical exam

  • Acute bacterial prostatitis:
    • Gentle digital rectal exam (DRE): edematous and exquisitely tender prostate
    • Vigorous prostate massage can induce acute bacteremia
    • General GU exam (assess other associated abnormalities)
  • Chronic bacterial prostatitis: 
    • DRE may reveal edematous prostate gland or normal exam.
    • Inguinal exam to assess for tenderness or masses
    • Pelvic exam to assess for tenderness or neuropathy
    • General GU exam

Diagnostic approach

  • Acute and chronic bacterial prostatitis are worked up similarly on initial presentation:
    • Urinalysis (UA) revealing:
      • Pyuria: elevated WBCs
      • May be nitrite positive
      • May be leukocyte esterase positive
    • Urine culture identifies the organism and determines sensitivity.
    • STI panel: Test for Neisseria gonorrhoeae and Chlamydia trachomatis.
    • CBC: may show elevated WBC count suggestive of infection
    • Blood culture:
      • Usually not needed
      • May help assess complications at high risk for sepsis (e.g., valvular disease)
    • PSA: 
      • Nonspecific but will show acute elevation in value
      • Can be elevated in other conditions
    • For chronic bacterial prostatitis, an additional diagnostic test performed is prostatic fluid collection (Meares-Stamey 4-glass test):
      • Requires fractional urine specimen and prostate secretion collection after prostatic massage
      • Specimens: 1st-void urine (urethra), midstream urine (bladder), prostatic secretions, and post-massage urine
      • Not usually done clinically due to cumbersome nature
    • Imaging:
      • Transrectal prostatic ultrasonography (TRUS) or CT scan of the prostate is recommended only when initial therapy fails.
      • The goal of imaging is to exclude prostate abscess.
  • CPPS is a diagnosis of exclusion: 
    • A clinical diagnosis arrived upon after treatment of initial bacterial prostatitis (patient usually presents with persistent pelvic pain and lower urinary tract symptoms)
    • Need to rule out persistent infection or abscess

Pelvic CT of prostatic abscesses:
Prostatic hypertrophy and intraprostatic abscesses: 20 × 15 × 33 mm and 64 × 21 × 26 mm in the right lobe and 38 × 10 × 30 mm in the left lobe

Image: “Prostatic abscesses and severe sepsis due to methicillin-susceptible Staphylococcus aureus producing Panton-Valentine leukocidin” by Dubos M, Barraud O, Fedou AL, Fredon F, Laurent F, Brakbi Y, Cypierre A, François B. License: CC BY 4.0

Management

Treatment

  • Acute bacterial prostatitis: 
    • Antibiotics with high level of penetration into the prostate tissue
    • Patients with major comorbidities such as uncontrolled diabetes or heart disease should consider inpatient admission.
    • Severe urinary obstructive symptoms: 
      • Avoid Foley catheter insertion due to risk of sepsis
      • If needed, proceed with suprapubic catheter insertion with urology.
  • Chronic bacterial prostatitis: 
    • Antibiosis with agents covering gram-negative organisms
    • Prolonged course of antibiotics for about 8–12 weeks
    • Management of urinary obstruction as needed
  • Chronic prostatitis/chronic pelvic pain: 
    • Multimodal therapy
    • Manage urinary obstructive symptoms with alpha-blockers (tamsulosin).
    • Anti-inflammatory medications: 
      • Ibuprofen/diclofenac as needed
      • Neuroleptic medications: pregabalin/gabapentin
    • Pelvic floor physical therapy
  • Asymptomatic inflammatory prostatitis: 
    • No treatment indicated
    • Usually incidental finding

Antibiotic regimen

  • Acute bacterial prostatitis, uncomplicated: 
    • Trimethoprim-sulfamethoxazole
    • Fluoroquinolone (ciprofloxacin or levofloxacin)
    • Men < 35 years of age with higher risk of STIs or those with high-risk behaviors: 
      • Doxycycline/azithromycin and ceftriaxone for C. trachomatis and N. gonorrhoeae, respectively
      • Antibiotics given empirically
  • Acute bacterial prostatitis, complicated (requiring hospitalization), treated with parenteral antibiotics:
    • Broad-spectrum coverage: carbapenem or piperacillin-tazobactam
    • Fluoroquinolones (ciprofloxacin or levofloxacin)
    • Aminoglycosides (gentamicin or tobramycin)
  • Chronic bacterial prostatitis: 
    • Gram-negative coverage agents for prolonged course (8–12 weeks)
    • Fluoroquinolones (ciprofloxacin or levofloxacin)
    • Trimethoprim-sulfamethoxazole

Differential Diagnosis

  • Prostate abscess: manifestation of delayed diagnosis of acute bacterial prostatitis or progression from inappropriate antibiotic therapy. Clinically, men present with decompensated state, increasing lower urinary tract symptoms, and continued prostatic pain despite treatment. Diagnosed with either TRUS or CT to search for prostatic abscess. Treatment with transurethral unroofing of abscess in the operating room.
  • UTI/cystitis: GU infection involving the lower urinary tract including the bladder. If not treated appropriately, the condition may progress to upper tract infection involving the renal system. Patients with UTI/cystitis present with similar symptoms of lower urinary tract infection: dysuria, hematuria, and urinary frequency/urgency. Diagnosis is with history/physical exam and UA with culture. Treatment is with empiric antibiotics and culture-directed adjustment as needed.

References

  1. Meyrier, A. (2019). Acute bacterial prostatitis. UpToDate. Retrieved January 30, 2021, from: https://www.uptodate.com/contents/acute-bacterial-prostatitis
  2. Meyrier, A. (2020). Chronic bacterial prostatitis. UpToDate. Retrieved January 30, 2021, from: https://www.uptodate.com/contents/chronic-bacterial-prostatitis
  3. Pontari, M. (2020). Chronic prostatitis and chronic pelvic pain syndrome. UpToDate. Retrieved January 30, 2021, from: https://www.uptodate.com/contents/chronic-prostatitis-and-chronic-pelvic-pain-syndrome

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