Prostatitis overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]

Overview

Prostatitis is an inflammation of the prostate gland. Because women do not have a prostate gland, this condition occurs in males only. Prostatitis has been classified by International Prostatitis Collaboration Network, into 5 subtypes. This classification is done on the basis of timing of the symptoms and the presence of bacterial pathogens and other markets of infection and inflammation. The categories include acute bacterial prostatitis, chronic bacterial prostatitis, inflammatory chronic prostatitis/chronic pelvic pain syndrome, non-inflammatory chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis. By the help of microscopic histopathological studies, neutrophils or lymphocytes can be seen inside the glands, between the cells of epithelium or inside the stromal component. The most common bacteria causing prostatitis are aerobic gram-negative bacilli, Escherichia coli is responsible for 50-80% incidents of bacterial prostatitis. Though a single definitive cause has not been established, different theories exist about chronic prostatitis/chronic pelvic pain syndrome pathogenesis including chemical damage owing to reflux or autoimmune process. Prostatitis must be differentiated from various causes of dysuria including pyelonephritis, cystitis, urethritis, benign prostatic hyperplasia, prostatic abscess, bladder cancer, urinary tract stones, and a foreign body within the urinary tract. Recurrent urinary tract infections, benign prostatic hyperplasia, urethral strictures, bladder neck hypertrophy, prostatic carcinoma, and catheterization are risk factors for prostatitis. Acute prostatitis usually results in complete recovery without sequelae. If left untreated, patients with acute bacterial prostatitis may progress to develop chronic prostatitis, epididymitis, prostatic abscess, septicemia, urosepsis, urinary retention and metastasis of infection to spinal cord or sacroiliac joint. Patients with untreated chronic prostatitis may develop chronic pelvic pain, sexual dysfunction, infertility and recurrent urinary tract infections. Frequency, urgency, burning during urination, nocturia, urinary retention and pain in the genital area, groin, lower abdomen, or lower back may be the presenting features. Other features include fever, nausea, and [[vomiting] in acute infection]. Laboratory findings show an increase in the number of leukocytes on CBC, bacteria on urine culture, elevated C-reactive protein, and transiently elevated PSA (prostate specific antigen) levels in case of bacterial prostatitis. While in chronic bacterial prostatitis negative pre-massage urine culture results, more than 10 to 20 leukocytes per high-power field in both the pre- and the postmassage urine specimen, bacteriuria in the postmassage urine specimen, and lower leukocyte and bacterial counts in voided bladder urine specimens as compared to bacterial count in post-prostatic massage voided urine or expressed prostatic secretions are seen. The absence of bacterial growth on cultures is diagnostic of chronic nonbacterial prostatitis. Antimicrobial therapy is indicated for acute and chronic prostatitis.

Historical Perspective

In 350 BC, the anatomical positioning and existence of the prostate gland was explained by Herophilus. prostatic incitement was recognised as a cause of prostatitis in 1800. In 1978 Drach et al. gave the basis of the current classification of prostatitis.

Classification

Prostatitis has been classified by International Prostatitis Collaboration Network, into 5 subtypes. This classification is done on the basis of timing of the symptoms and the presence of bacterial pathogens and other markets of infection and inflammation. The categories include:

• Acute bacterial prostatitis
• Chronic bacterial prostatitis
• Inflammatory chronic prostatitis/chronic pelvic pain syndrome
• Non-inflammatory chronic prostatitis/chronic pelvic pain syndrome
• Asymptomatic inflammatory prostatitis.

Pathophysiology

The exact pathogenesis of bacterial prostatitis is not yet fully understood. Ascending urethral infection and the reflux of urine via the ejaculatory and prostatic ducts are two possible mechanism explained in this regard. The pathogenesis of chronic prostatitis/chronic pelvic pain syndrome includes hypothalamic-pituitary-adrenal axis dysfunction and adrenocortical hormone abnormalities primarily due to the response to stress, neurogenic inflammation, and myofascial pain syndrome.On microscopic histopathologic analysis, prostatitis may be characterized by either neutrophils or lymphocytes within the glands, between the epithelial cells or within the stroma.

Causes

The most common bacteria causing prostatitis are aerobic gram-negative bacilli, Escherichia coli is responsible for 50-80% incidents of bacterial prostatitis. > Though a single definitive cause has not been established, different theories exist about chronic prostatitis/chronic pelvic pain syndrome pathogenesis including chemical damage owing to reflux or autoimmune process.

Differential Diagnosis

Prostatitis must be differentiated from various entities on the basis of dysuria, that include acute cystitis, benign prostatic hyperplasia, prostatic abscess, bladder cancer, urinary tract stones, and a foreign body within the urinary tract.

Epidemiology and demographics

In men who are younger than 50 years, prostatitis is the most common urinary tract problem. It is the 3rd most common urinary diagnosis made in men over age 50. There are approximately 2 million health care visits yearly, associated with prostatitis. The most common form of prostatitis is chronic prostatitis/chronic pelvic pain syndrome.

Risk Factors

Common risk factors in the development of prostatitis include recurrent urinary tract infections, benign prostatic hyperplasia, urethral strictures, bladder neck hypertrophy, prostatic carcinoma, and previous instrumentation or catheterization.

Natural History, Complications, and Prognosis

If left untreated, patients with acute bacterial prostatitis may progress to develop chronic prostatitis, prostatic abscess, septicemia, urosepsis, urinary retention and metastasis of infection to spinal cord or sacroiliac joint. Patients with untreated chronic prostatitis may develop chronic pelvic pain, sexual dysfunction, infertility, severe urinary frequency and urgency, and recurrent urinary tract infections. Full recovery without sequelae is usual among patients with acute prostatitis. Patients with chronic prostatitis have a gradual recovery and relapse is common.

Diagnosis

History and Symptoms

A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient include previous history of sexually transmitted diseases, any new sexual partners, known urogenital disorders, and recent catheterization or other genitourinary instrumentation. Common symptoms of acute and chronic bacterial prostatitis include urinary frequency, urinary urgency, burning during urination, nocturia, urinary retention and pain in the genital area, groin, lower abdomen, or lower back. Symptoms of acute prostatitis may also include fever, nausea, and vomiting.

Physical Examination

Patients with chronic prostatitis are usually well-appearing. Patients with acute prostatitis may appear ill and have systemic symptoms such as fever, chills, and nausea. In acute prostatitis, palpation of the prostate reveals a tender and enlarged prostate. In chronic prostatitis, palpation of the prostate reveals a tender and soft (boggy) prostate gland. A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis.

Laboratory Findings

The laboratory tests used in the diagnosis of prostatitis are CBC, urinalysis, serum PSA (prostate-specific antigen) levels, urine culture, postvoid residual volume levels, 2-glass pre- and post-prostatic massage test, Stamey-Meares four-glass test, and a semen analysis. Laboratory findings consistent with the diagnosis of acute prostatitis include increased leukocytes on CBC, bacteria seen on urine culture, elevated C-reactive protein, and transiently elevated PSA (prostate specific antigen) levels. Laboratory findings consistent with the diagnosis of chronic bacterial prostatitis include negative pre-massage urine culture results, more than 10 to 20 leukocytes per high-power field in both the pre- and the postmassage urine specimen, bacteriuria in the postmassage urine specimen, and lower leukocyte and bacterial counts in voided bladder urine specimens as compared to bacterial count in post-prostatic massage voided urine or expressed prostatic secretions. The absence of bacterial growth on cultures is diagnostic of chronic nonbacterial prostatitis.

Imaging Findings

Findings of prostatitis on CT include a diffusely enlarged, edematous gland with predilection for peripheral zone involvement. When an abscess is present it is seen as a rim-enhancing, unilocular or multilocular, hypodensity in the peripheral zone. On ultrasound, prostatitis is characterized by a focal hypoechoic region in the peripheral zone of the gland. Discrete fluid collection suggests abscess formation. Colour Doppler ultrasound demonstrates increase flow in the periphery of the abscess. On MRI, the prostate will be diffusely enlarged, often with associated inflammatory changes of periprostatic fat and of the seminal vesicles.

Treatment

Medical Therapy

Antimicrobial therapy is indicated for acute and chronic prostatitis. Patients are generally treated in an outpatient setting unless severe disease (e.g. bacteremia) is suspected. Empirical therapy for both acute and chronic prostatitis includes monotherapy with either ciprofloxacin, levofloxacin, or TMP-SMX for at least 6 weeks. When culture results are obtained, antimicrobial therapy may be narrowed down to cover the causative pathogen more adequately. Addition of alpha blocker may be considered for the symptomatic management of bacterial prostatitis. Inflammatory prostatitis may be treated with NSAIDs, allopurinol, or cernilton.