168 CHAPTER 5 Infections and inflammatory conditions
Prostatitis: presentation, evaluation, and treatment
Evaluation
•History of previous urological disease and conditions
•NIH-CPSI questionnaire (National Institute of Health Chronic Prostatitis Symptom Index). This scores three main symptom areas: pain (location, frequency, severity), voiding (obstructive and irritative symptoms), and impact on quality of life. It can be useful in guiding response to therapy.
•Segmented urine cultures and EPS. When cultures are negative, increased leukocytes per high-powered field (>10) favor a diagnosis of inflammatory chronic pelvic pain syndrome.
Acute bacterial prostatitis
Acute bacterial prostatitis (NIH I) is infection of the prostate associated with lower urinary tract infection and generalized sepsis. E. coli is the most common cause; Pseudomonas, Serratia, Klebsiella, and enterococci are less common causes.
Acute onset of fevers, chills, nausea and vomiting; perineal and suprapubic pain; irritative urinary symptoms (urinary frequency, urgency, and dysuria); and obstructive urinary symptoms (hesitancy, strangury, intermittent stream or urinary retention) are the hallmarks. Signs of systemic toxicity (fever, tachycardia, hypotension) may be present.
Suprapubic tenderness and a palpable bladder will be present if there is urinary retention. On digital rectal examination, the prostate is extremely tender and aggressive manipulation of the prostate is to be discouraged.
Treatment
If the patient is not systemically ill, use an oral quinolone such as ciprofloxacin 500 mg bid for at least 3 weeks.
For a patient who is ill, use IV gentamicin with a third-generation cephalosporin or ampicillin, pain relief, anti-inflammatory medications, and relief of retention if present. Traditional teaching was that a suprapubic (rather than urethral) catheter should be inserted to avoid the potential obstruction of prostatic urethral ducts by a urethral catheter. However, in-and- out catheterization or a short period with an indwelling catheter probably does no harm and is certainly an easier way of relieving retention than suprapubic catheterization.
A total course of 3 weeks of antibiotics is essential to minimize the chance for the development of chronic bacterial prostatitis. A negative culture should be confirmed after treatment.
Chronic bacterial prostatitis
NIH II classification of chronic bacterial prostatitis typically presents with history of documented recurrent UTI. E coli is responsible for 75–80% of cases, with enterococci and other gram-negative aerobes responsible.
Chronic episodes of genitourinary pain and voiding dysfunction may be a feature. DRE may show a tender, enlarged, and boggy prostate, or it may be entirely normal.
PROSTATITIS: PRESENTATION, EVALUATION, AND TREATMENT 169
This condition is characterized by bacterial growth in culture of the expressed prostatic fluid, semen, or post-massage urine specimen. The EPS usually contains >10 WBCs/HPF and macrophages. The recurrent organism is usually the same each time.
Treatment
An empiric trial of antibiotics is used if the evaluation suggests chronic bacterial prostatitis and is administered long term (4–6 weeks).
•Trimethoprim-sulfamethoxazole (TMP-SMZ) 80/400 mg PO bid given twice a day
•Fluoroquinolone (e.g., ciprofloxacin 500 mg or ofloxacin 400 mg) PO bid. Ofloxin may be the best choice in men <35 years because of increased activity against Chlamydia.
Chronic pelvic pain syndrome (CPPS)
Both inflammatory (IIIA) and noninflammatory (IIIB) types present with >3-month history of localized pain (perineal, suprapubic, penile, groin, or external genitalia); pain with ejaculation; LUTS (frequency, urgency, poor flow); and erectile dysfunction. Prostadynia is an older term that should no longer be used.
Etiology is not clear. Symptoms can recur over time and severely affect the patient’s quality of life.
There is no evidence of pyuria and bacteriuria, but excess WBCs in EPS may be found in IIIA but are absent in IIIB.
Treatment
•While there is not a defined role for antibiotics, an empiric trial of a quinolone or TMP-SMX is often tried with variable results.
•A-Blockers (doxazosin, terazosin, tamsulosin) have become the mainstay of therapy. These act on prostate and bladder neck A-receptors, causing smooth muscle relaxation, improved urinary flow, and reduced intraprostatic ductal reflux.1
•Anti-inflammatory drugs
•Sitz baths, more frequent ejaculation, dietary modifications (avoid caffeine, tobacco, spicy foods), biofeedback, and significant psychological support all may have potential benefits in this group of patients.
•Microwave thermotherapy is considered when severe symptoms are refractory to all treatments.
Asymptomatic inflammatory prostatitis
There is incidental histological diagnosis of prostatic inflammation from prostate tissue taken for other indications (i.e., biopsy for raised PSA). No specific therapy is usually indicated for this incidental finding.
Further reading
Habermacher GM, Chason JT, Schaeffer AJ (2006). Prostatitis/chronic pelvic pain syndrome. Annu Rev Med 57:195–206.
1 Nickel JC (2005). Alpha-blockers for treatment of the prostatitis syndromes. Rev Urol. 7(Suppl 8):S18–25.
170 CHAPTER 5 Infections and inflammatory conditions
Other prostate infections
Prostatic abscess
Failure of acute bacterial prostatitis to respond to an appropriate antibiotic treatment regimen (i.e., persistent symptoms and fever while on antibiotic therapy) suggests the development of a prostatic abscess.
A transrectal ultrasound or CT scan (if the former proves too painful) is the best way of diagnosing a prostatic abscess. This may be drained by a transurethral incision.
Granulomatous prostatitis
This is a very uncommon form of prostatitis and can result from bacterial, viral, or fungal infection, systemic granulomatous diseases, and the use of BCG to treat bladder cancer. Most often it is idiopathic.
Patients can present as with bacterial prostatitis. Rectal examination is similar to prostate cancer (hard, indurated, nodular). The diagnosis is usually made after prostate biopsy to rule out cancer.
Some patients respond to antibiotic therapy and temporary bladder drainage. With histological evidence of eosinophilic granulomatous prostatitis, steroids may be useful.
TURP may be necessary if there is no response to treatment and the patient has bladder outlet obstruction.
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