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acute inflammation of prostate

Image: Micrograph of prostate gland with an acute inflammatory infiltrate (neutrophils). H&E stain. By: Nephron. License: CC BY-SA 3.0


Definition

The different forms of prostatitis can be classified according to the duration of their symptoms. The table below outlines the forms of prostatitis and their symptoms.

Form Definition and Symptoms
Acute bacterial prostatitis An acute bacterial infection of the prostate characterized by severe symptoms complicated by an acute bacterial urinary tract infection.

Symptoms

  • Frequent urge to urinate both day and night
  • Difficulty in starting urination, with straining
  • Residual volume of urine in the bladder
Chronic bacterial prostatitis A more chronic form of bacterial infection. Patients may have prostate-related symptoms, but they are usually milder. Recurrent urinary tract infections are common.
Symptoms

  • Pain at the base of the penis or rectum when passing stool and urine
  • Problems with ejaculation
  • Difficulty achieving erection
  • Pain may refer to testicles and penis, up to the glans penis
  • Residual volume of urine in the bladder
Chronic pelvic pain Patients experience chronic pelvic pain, urinary symptoms, and, sometimes, voiding symptoms, but do not have bacterial urinary tract infections
Asymptomatic inflammatory prostatitis Inflammation of the prostate with no urinary symptoms

Epidemiology

The current estimated incidence of prostatitis is 9%, making it a common condition among men. Only 3% of men have significant prostatitis-related symptoms for which they seek medical attention.

Acute and chronic bacterial prostatitis are the only forms of prostatitis that are well defined by clinical and microbiological features. Bacterial prostatitis is responsible for only 10% of all prostatitis cases. Most patients with prostatitis have either chronic pelvic pain syndrome or asymptomatic inflammatory prostatitis.

Etiology

Ascending bacterial infections cause acute bacterial prostatitis. Gram-negative organisms such as Escherichia coli, Enterobacter, and Serratia are responsible for 80% of cases.

Patients with voiding dysfunction due to, for example, prostate hypertrophy, may also develop a chronic bacterial infection. E. coli is the most common implicated organism. Primary voiding dysfunction because of pseudodyssynergia, impaired detrusor contractility, or acontractile detrusor muscle may also lead to chronic pelvic pain syndrome without bacterial infection. Additionally, patients can develop non-specific prostatic inflammation.

Pathophysiology

Urinary tract infections and sexually transmitted diseases with chlamydia or gonorrhea predispose the patient to ascending urinary tract infections that can affect the prostate. If a biopsy is taken from the prostate while inflamed, acute inflammatory cells infiltrate and chronic inflammatory cells can be identified. Additionally, white blood cells may be present in the urine.

The presence and degree of inflammatory cells infiltrate on biopsy or in the urine do not correlate well with the severity of prostatitis.

Other organisms, such as cytomegalovirus, have been implicated in prostatitis in HIV-positive patients.

Clinical Presentation

Prostatitis can be classified into acute bacterial, chronic bacterial, chronic pelvic pain, and asymptomatic inflammatory prostatitis.

Acute Bacterial Prostatitis

Acute bacterial prostatitis is the third most common diagnosis in men over the age of 50. Patients usually have severe symptoms with sudden onset of lower abdominal paindysuriafrequency, irritative voiding, and/or fever. Abdominal examination; examination of the external genitalia to exclude possible penile discharge, as in gonorrhea; and prostate examination to elucidate prostatic tenderness should be performed. Prostate massage is not recommended as the pain can be severe. Approximately 5% of cases of acute bacterial prostatitis progress to chronic bacterial prostatitis.

Chronic Bacterial Prostatitis

Chronic bacterial prostatitis is caused by E. coli or gram-negative bacteria. Patients may present with intermittent mild dysuria and intermittent voiding problems due to obstructive urinary tract disease and a history of recurrent urinary tract infections.

Chronic Prostatitis/Chronic Pelvic Pain

The diagnosis and clinical picture of chronic prostatitis takes more time to come into focus. Its onset is much more gradual and mild than that of acute prostatitis. Although the literature does not explicitly state a cut-off time between acute and chronic forms, research guidelines recommend considering chronic prostatitis if patients experience pelvic, perineal, suprapubic, or rectal pain for at least 3 months out of the last 6 months.

Patients can also experience dysuria and incomplete voiding. Erectile dysfunction is common in these patients. Patients should not have an episode of urinary tract infection for the last 6 months.

Asymptomatic Inflammatory Prostatitis

Patients with asymptomatic inflammatory prostatitis do not have any symptoms or signs of prostatitis.

Diagnostic Work-up

Acute Bacterial Prostatitis

Urinary analysis and culture are mandatory in these patients. Urinary analysis shows white blood cells. Culture studies usually show a single gram-negative organism.

Transrectal prostatic ultrasonography or computerized tomography scan of the prostate is recommended only when initial antimicrobial therapy fails. The goal of imaging is to exclude prostate abscess. Serum prostate-specific antigen should not be checked in these patients.

Chronic Bacterial Prostatitis

Digital Rectal Exam (Male)

Image: Digital rectal exam. Released by the National Cancer Institute, ID 7136. License: Public domain.

Prostatic fluid analysis for bacterial culture confirms the diagnosis of chronic bacterial prostatitis in spite of a negative culture report because of insufficient urine collection, if the patient starts antibiotics a few days prior to collecting a urine sample. The 4-glass or 2-glass test should be performed in these patients. The 4-glass test comprises taking 10 ml of urine, followed by 10 ml of midstream urine, followed by a glass of prostate secretions after a digital rectal massage of the prostate (see image), and completed by a post-massage urinary sample. As this procedure is considered too complex for many urologists, the 2-glass test is usually preferred. This test comprises a simple pre- and post-massage urinary culture.

Transrectal prostate ultrasonography and semen cultures are not beneficial in diagnosing chronic bacterial prostatitis.

Chronic Prostatitis/Chronic Pelvic Pain

The diagnosis of chronic bacterial prostatitis needs to be excluded. Accordingly, a 4-glass or 2-glass test should be performed. These patients may have obstructive urinary symptoms and can benefit from urodynamic testing to assess flow rates, post-void residual, and pressure-flow studies. These tests also assess detrusor muscle function.

Asymptomatic Inflammatory Prostatitis

Patients with asymptomatic inflammatory prostatitis are usually not diagnosed because of a lack of symptoms and because currently there are no recommended investigations that can be performed.

Treatment

Acute Bacterial Prostatitis

Patients with acute bacterial prostatitis should receive broad-spectrum antibiotics. Combination therapy may include aminoglycosides plus ampicillin, or a third-generation cephalosporin plus a fluoroquinolone for the ill patient. Patients who do not have sepsis can receive oral trimethoprim-sulfamethoxazole or a fluoroquinolone.

Patients with severe urinary obstructive symptoms may need a single catheterization. A prostatic abscess is a possible complication of acute bacterial prostatitis. A prostatic abscess needs surgical drainage.

Chronic Bacterial Prostatitis

These patients should receive a fluoroquinolone for approximately 6 weeks. Patients with chronic bacterial prostatitis and severe urinary obstructive symptoms may benefit from combining a fluoroquinolone with an alpha-blocker such as doxazosin. Patients with severe obstructive symptoms and recurrent bacterial prostatitis who do not respond to antimicrobials may benefit from surgery to remove the prostate.

Chronic Prostatitis/Chronic Pelvic Pain

Management of chronic prostatitis or chronic pelvic pain without evidence for bacterial infection is challenging. Multimodal therapy is currently recommended for these patients instead of a monotherapy.

Patients with depression, anxiety, or other psychiatric conditions may benefit from cognitive behavioral therapy, anti-depressants, and anti-anxiolytics.

Patients with confirmed prostatitis by biopsy or who have lower urinary tract obstruction can benefit from alpha-blockers, quercetin, or a prostatectomy.

Antibiotics should not be used unless there is evidence of a previous or recent urinary tract infection.

Patients with chronic pelvic pain may have primary voiding dysfunction due to neuropathy or detrusor muscle dysfunction. Gabapentin, amitriptyline, and neuromodulation therapy can help these patients.

Non-steroidal anti-inflammatory drugs can help alleviate symptoms in some patients.

Asymptomatic Inflammatory Prostatitis

Currently, patients with asymptomatic inflammatory prostatitis do not receive any specific therapy.

Complications

  • Bladder outlet obstruction/urine retention
  • Pyelonephritis
  • Abscess formation in immunocompromised patients
  • Recurrent cystitis
  • Pyelonephritis
  • Infertility due to scarring

Prognosis

Prognosis in patients who have had a first episode of acute bacterial prostatitis is good. Mortality is associated with urosepsis in patients with diabetes mellitus, those who are undergoing dialysis for chronic renal failure, in immunocompromised patients, and in post-surgical cases.

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