Ryan S. Levey, MD
Justin D. Ellett, MD, PhD
BASICS
DESCRIPTION
• Prostatitis is a general term that refers to inflammation of the prostate.
• Traditionally classified as acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia today the definitions used are much more precise and based on the NIH system (1).
• Revised 1995 NIH classification of prostatitis is standard nomenclature:
– NIH Class I: Acute bacterial prostatitis; infection of prostate, sudden onset, often associated with UTI
>10 WBC/HPF in 1st 10 mL voided urine and midstream catch
Positive culture in 1st 10 mL voided urine and midstream catch
– NIH Class II: Chronic bacterial prostatitis; insidious onset, relapsing, recurrent UTI
>10 WBC/HPF
Positive culture in expressed prostatic secretions (EPS) and 1st 10 mL of voided urine after EPS
– NIH Class III: Chronic prostatitis (CP)/Chronic pelvic pain syndrome (CPPS):
– NIH Class IIIA: Inflammatory: Inflammatory cells in prostatic secretion, seminal fluid, postprostatic massage urine
>10 WBC/HPF in EPS, 1st 10 mL of voided urine after EPS, or semen
– NIH Class IIIB: Noninflammatory: Insignificant inflammatory cells
<10 WBC/HPF in EPS, 1st 10 mL voided urine after EPS, or semen
– NIH Class IV: Asymptomatic inflammatory prostatitis, incidental biopsy finding
>10 WBC/HPF and/or bacteria in EPS, 1st 10 mL voided urine after EPS, semen, or histologic specimens in asymptomatic patients
EPIDEMIOLOGY
Incidence
• 2 million cases annually
• 9–16% men have had diagnosis of prostatitis
• 3–12% male outpatient urology visits
• Most common urologic diagnosis in men <50 yr, 3rd most common >50 yr (2)
– Overall incidence of acute prostatitis or prostatitis NOS 2.8/1,000 person-years (PY) over 70,166 PY of follow-up (3)
3.2/1,000 PY in patients aged 20–29 yr
3.6/1,000 PY in patients aged 30–39 yr
5.4/1,000 PY in patients aged 70–79 yr
Prevalence
N/A
RISK FACTORS
• Acute epididymitis
• Chronic catheterization (indwelling or condom)
• Dysfunctional voiding
• Immunocompromised states
• Intraprostatic ductal reflux
• Phimosis
• Urethral stricture, distal
• BPH
• Prostatic calculi
• Transurethral surgery/instrumentation
• Transrectal prostate biopsy
• Unprotected anal sex
• UTI
Genetics
N/A
PATHOPHYSIOLOGY
• Extension of UTI
• Manipulation of urinary tract or prostate
• Bacterial:
– Ascending infection through urethra
– Refluxing urine into prostate ducts
– Direct extension or lymphatic spread from rectum
– Hematogenous spread
– Calculi serve as a nidus for infection
– Aerobic gram-negative bacteria (Enterobacteriaceae [most common cause], Escherichia coli [most common organism], Pseudomonas, Klebsiella, Proteus, Serratia), Neisseria gonorrhoeae, Burkholderia pseudomallei
– Miscellaneous: Chlamydia trachomatis
– Gram-positive bacteria (Enterococcus, Streptococcus faecalis, Staphylococcus aureus)
• Organisms suspected, but unproven: Staphylococcus epidermidis, micrococci, nongroup D Streptococcus, diphtheroids, Ureaplasma urealyticum, Trichomonas vaginalis
• Nonbacterial:
– Leading theory: Nonrelaxation of internal urinary sphincter and pelvic floor muscles leading to increased prostatic urethral pressure and intraprostatic urinary reflux
• Uncommon: Mycobacterium tuberculosis, parasitic, mycoses (blastomycosis, coccidioidomycosis, Cryptococcus, histoplasmosis, candidiasis paracoccidiomycosis)
ASSOCIATED CONDITIONS
• Cystitis (secondary to bacterial prostatitis)
• Epididymitis
• Prostatic hypertrophy
• STD
• Urethritis/urethral stricture
• UTI
GENERAL PREVENTION
• Proper treatment of acute bacterial prostatitis may reduce chronic bacterial prostatitis (NIH II)
• Safe sex practices
DIAGNOSIS
HISTORY
• Acute bacterial prostatitis (NIH I)
– Fever, chills, malaise
– Perineal, suprapubic pain
– Irritative voiding symptoms: Urgency, frequency, dysuria
– Obstructive voiding symptoms: Hesitancy, intermittent stream, acute urinary retention
– Rare sepsis
– 5% will develop CP
• Chronic bacterial prostatitis (NIH II)
– Recurrent UTIs
– Asymptomatic or CPPS (see below)
• CP/CPPS (NIH IIIA/B)
– Pain in perineum, suprapubic region, penis, testicles, groin, low back
– Pain especially after or during ejaculation
– Irritative/obstructive voiding symptoms lasting >3 mo
– ED, sexual disturbances, severe effect on quality of life
• NIH Class IV: None; usually only elevated PSA or nodule that prompts biopsy
PHYSICAL EXAM
• Acute bacterial prostatitis (NIH I):
– Suprapubic tenderness
– Assess for acute urinary retention
– DRE: Hot, boggy, exquisite tenderness
– Sepsis: Febrile, tachycardia
• Chronic bacterial prostatitis/CPPS (NIH II/IIIA/IIIB)
– Suprapubic tenderness
– DRE: May be normal or soft/boggy, variable amounts of pain, prostatic calculi
ALERT
Do not perform massage or aggressive rectal exam in the face of acute prostatitis or prostatic abscess.
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• PSA may be elevated with prostatitis PSA should not be checked in cases of acute bacterial prostatitis.
• Suspected acute bacterial prostatitis:
– Urinalysis, urine culture, CBC, blood culture
• Suspected CPB/CP/CPPS (NIH II/III)
– Urinalysis, urine culture
– Meares–Stamey 4-glass test (gold standard)
– 2-glass test more convenient: Pre/postprostatic massage:
Urine microscopy and culture of midstream urine specimen prior to prostate massage (Pre-M)
Urine microscopy and culture of 10-mL urine postprostate massage (Post-M)
With NIH II (chronic bacterial):
– Pre-M: ± Urine WBC, ± culture
– Post-M: + Urine WBC, + culture
NIH IIIA inflammatory CP/CPPS:
– Pre-M: − Urine WBC, − culture
– Post-M: + Urine WBC, − culture
NIH IIIB noninflammatory CP/CPPS
– Pre-M: − Urine WBC, − culture
– Post-M: − urine WBC, − culture
Imaging
• CT: If suspicion of abscess/malignancy or failure appropriate antimicrobial treatment
• Transrectal US: If suspicion of abscess or fail antibiotic therapy (rule out abscess, calculi)
Diagnostic Procedures/Surgery
• PVR if sensation of incomplete emptying
• Urodynamics: CPPS patients; debatable utility
• Cystoscopy: CPPS patients with hematuria; rules out bladder neck pathology, lower tract malignancy
Pathologic Findings
• Sheets, clusters, nodules of lymphocytes, plasma cells in fibromuscular stroma
• No relationship to the ducts and acini
• Infiltrates of inflammatory cells restricted to the glandular epithelium and lumen found in prostate and BPH
• Inflammatory changes noted in up to 44% of asymptomatic males at autopsy
DIFFERENTIAL DIAGNOSIS
• Acute urinary retention
• Cystitis (bacteria, interstitial)/urethritis
• Obstructive bladder calculus
• Prostate cancer
• Prostatic abscess
• Pyelonephritis
TREATMENT
GENERAL MEASURES
• NIH I acute prostatitis:
– IV antibiotics, then switch to oral agents
– Acute retention may be treated with in-and-out catheter or small-caliber Foley for <12 hr or suprapubic drainage with acute prostatitis
– Acute bacterial prostatitis that does not resolve with conventional measures; must rule out prostate abscess
• NIH II: Long-term antibiotic therapy
• NIH IIIA/B: Similar management; empiric antibiotics often used with variable success, focus on symptomatic and supportive therapy; α-adrenergic blockers and NSAIDs may be useful adjuncts in this population
• NIH IV is only a histologic diagnosis and no specific therapy necessary
MEDICATION
First Line
• Antibiotics: For acute bacterial prostatitis (inpatient)
– Ampicillin with gentamicin (ampicillin 1–2 g IV every 4–6 hr, 500 mg PO every 6 hr; gentamicin 1–2 mg/kg IV every 8–12 hr or daily dosing 4–7 mg/kg every 24 hr IV)
– Fluoroquinolones
Levofloxacin, 250–750 mg daily IV or by mouth (PO)
Ciprofloxacin, 250–750 mg PO twice daily (BID), 400 mg IV BID
– Ceftriaxone 1–2 g IV or IM daily
– Afebrile 24–48 hr may change to oral antibiotics
• Acute bacterial prostatitis (outpatient)
– Trimethoprim–sulfamethoxazole DS PO BID for 2–4 wk
– Ciprofloxacin 500 mg PO BID for 2–4 wk
• Chronic bacterial prostatitis:
– Ciprofloxacin 500 mg PO BID for 4–6 wk; levofloxacin has daily dosing and may have better prostatic penetration
– Fluoroquinolones more cost effective and may be superior to TMP/SMX
• CP/CPPS:
– NIH IIIA: Antibiotics may reduce symptoms but should work within 4–6 wk
– Previously treated men do not benefit from further antibiotics
• α-Adrenergic blockers:
– Chronic bacterial prostatitis (NIH II): In combination with antibiotics, will reduce symptoms
– CP/CPPS (NIH III): Benefit men with recent onset of symptoms, not heavily treated, and on medication for >6 mo
• Anti-inflammatory agents:
– NSAIDs/analgesics/antipyretics
• Stool softeners
Second Line
• Antibiotics: Erythromycin, azithromycin, clarithromycin if Chlamydia trachomatis implicated
• Finasteride or dutasteride: Only if associated BPH in patients with CP/CPPS
SURGERY/OTHER PROCEDURES
• Transurethral resection: If concern for prostatic abscess or in the setting of intractable chronic bacterial disease
• Transurethral microwave therapy: Refractory CP
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Numerous unproven therapies have been suggested with little to no evidence for treatment of CP or CPPS, including: Allopurinol, balloon dilation, TUNA, acupuncture, neuromodulation
• Frequent ejaculation (in patients with enlarged, symptomatically congested glands), prostatic massage (not in acute prostatitis)
• Dietary modification
• Sitz baths for symptomatic relief
Complementary & Alternative Therapies
• Phytotherapy provides modest benefit in CP/CPPS
• Neuromodulation (CP/CPPS): Amitriptyline, gabapentin, acupuncture, biofeedback, massage, neurostimulation
ONGOING CARE
PROGNOSIS
• Prolonged course, often difficult to cure
• 50–97% cure rate, depending on category
• 20% with recurrent or persistent infection
COMPLICATIONS
• Acute urinary retention
• Chronic bacterial prostatitis with incomplete treatment of acute bacterial prostatitis
• Epididymitis, orchitis, seminal vesiculitis (rare)
• Gram-negative sepsis, bacteremia
• Prostatic abscess
FOLLOW-UP
Patient Monitoring
• Most improve with antibiotics in 3–4 wk
• Long-term management of CP/CPPS requires multimodal therapy and supportive care
Patient Resources
Urology Care Foundation. http://www.urologyhealth.org/urology/index.cfm?article=15
REFERENCES
1. Sharp VJ, Takacs EB, Powerll CR. Prostatitis: Diagnosis and treatment. Am Fam Physician. 2010;82(4):397–406.
2. Roberts RO, Lieber MM, Rhodes T, et al. Prevalence of a physician-assigned diagnosis of prostatitis: The Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology. 1998;51(4):578–584.
ADDITIONAL READING
Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236–237.
See Also (Topic, Algorithm, Media)
• Prostate, Abscess
• Prostatitis, Acute, Bacterial (NIH I)
• Prostatitis, Asymptomatic Inflammatory (NIH IV)
• Prostatitis, Chronic, Bacterial (NIH II)
• Prostatitis, Chronic Nonbacterial, Inflammatory and Noninflammatory (NIH CP/CPPS III A and B)
• Prostatitis, Granulomatous
• Stamey Test (3-Glass Test, 4-Glass Tests, Meares–Stamey Test)
CODES
ICD9
• 601.0 Acute prostatitis
• 601.1 Chronic prostatitis
• 601.9 Prostatitis, unspecified
ICD10
• N41.0 Acute prostatitis
• N41.1 Chronic prostatitis
• N41.9 Inflammatory disease of prostate, unspecified
CLINICAL/SURGICAL PEARLS
• Prostatitis is considered the most common urologic diagnosis in men <50.
• If suspected CBP/CP/CPPS, perform 2-glass test to help establish the diagnosis.
• Most chronic bacterial prostatitis cases improve after 3–4 wk of antibiotics.