AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Prostatitis is an infection or inflammation of the prostate gland that presents as several syndromes with varying clinical features. The term prostatitis is defined as microscopic inflammation of the tissue of the prostate gland, which spans a broad range of clinical conditions.

The National Institutes of Health (NIH) has recognized and defined a classification system for prostatitis in 1999. The 4 syndromes of prostatitis are as follows: 

• I - Acute bacterial prostatitis
• II - Chronic bacterial prostatitis
• III - Chronic prostatitis and chronic pelvic pain syndrome (CPPS)
• • Inflammatory
  • Noninflammatory
• IV - Asymptomatic inflammatory prostatitis.

Acute and chronic bacterial prostatitis are defined by documented bacterial infections of the prostate.

Chronic pelvic pain syndrome is characterized primarily by urological pain complaints in the absence of urinary tract infection. This syndrome includes several exclusion criteria, such as presence of active urethritis, urogenital cancer, urinary tract disease, functionally significant urethral stricture, or neurological disease affecting the bladder. It is subdivided into inflammatory and noninflammatory subtypes.

Asymptomatic inflammatory prostatitis is characterized by the incidental discovery of prostatic inflammation without any genitourinary complaints. These patients are usually diagnosed while undergoing workup for infertility or elevated prostate-specific antigen (PSA) level.

Pathophysiology

In bacterial prostatitis, sexual transmission of bacteria is common, but hematogenous, lymphatic, and contiguous spread of infection from surrounding anatomy must also be considered. Although various routes have been postulated, none have been firmly substantiated.

The presence of acute inflammatory cells in the glandular epithelium and lumens of the prostate, with chronic inflammatory cells in the periglandular tissue, characterizes prostatitis. However, the presence and quantity of inflammatory cells in the urine or prostatic secretions does not correlate with the severity of physical symptoms.

Chronic pelvic pain syndrome is diagnosed based on pain in the setting of negative culture results of the urine and prostatic secretions. Neuromuscular dysfunction or congenital reflux of urine into the ejaculatory and prostatic ducts may be a precipitating factor.

Viral and granulomatous prostatitis may be associated with HIV infection and is another cause of culture-negative disease. A common viral pathogen of prostatitis in HIV-infected patients is cytomegalovirus (CMV). Mycobacteria, such as Mycobacterium tuberculosis, and fungi, such as Candida albicans, have also been associated with culture-negative disease in this population.

Frequency

United States

Prostatitis is one of the most common diseases seen in urology practices in the United States, accounting for nearly 2 million outpatient visits per year, with chronic bacterial prostatitis and chronic pelvic pain syndrome being most frequently diagnosed. The diagnosis of prostatitis is made in approximately 25% of male patients presenting with genitourinary symptoms. Autopsy studies have revealed a histologic prevalence of prostatitis of 64-86%.

Of the 4 categories of prostatitis, the most common is chronic prostatitis/chronic pelvic pain syndrome, accounting for 90-95% of cases of prostatitis. Acute bacterial prostatitis and chronic bacterial prostatitis each make up another 2-5% of cases.

International

The incidence of mycobacterial prostatitis, concomitant with disseminated disease, is increased in underdeveloped countries. Areas with widespread sexually transmitted disease (STD) rates and prostitution have a higher incidence of acute bacterial prostatitis.

Mortality/Morbidity

• Particularly susceptible patients include those with diabetes mellitus, patients on dialysis for chronic renal failure, patients who are immunocompromised, and postsurgical patients who have had urethral instrumentation. In these patients, prostatitis can lead to urosepsis with significant associated mortality. Do not overlook the prostate gland when searching for a source of sepsis in these patients.
• In the United States, the long-term prognosis of the first occurrence of acute bacterial prostatitis is good with antibiotic therapy in compliant patients.

Sex

• Prostatitis is a disease of men only.

Age

• In patients younger than 35 years, the most common variant of the syndrome is acute bacterial prostatitis.
• HIV-related disease is also predominantly seen in younger patients.
• Rare causes should be noted. According to case reports of Wegener granulomatosis in the fourth and fifth decades of life, prostatitis can be a presenting feature of Wegener granulomatosis and a clinical manifestation of relapse. Fungal infection with C albicans and Coccidioides immitis and mycobacterial infection with M tuberculosis have also been reported.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Acute bacterial prostatitis
• • Fever
  • Chills
  • Malaise
  • Arthralgias
  • Myalgias
  • Perineal prostatic pain
  • Dysuria
  • Obstructive urinary tract symptoms, including frequency, urgency, dysuria, nocturia, hesitancy, weak stream, and incomplete voiding
  • Low back pain
  • Low abdominal pain
  • Spontaneous urethral discharge
• Chronic bacterial prostatitis
• • Intermittent dysuria
  • Intermittent obstructive urinary tract symptoms
  • Systemic symptoms typically absent 
• Chronic prostatitis and chronic pelvic pain syndrome
• • Pelvic pain or discomfort including perineal, suprapubic, coccygeal, rectal, urethral, and testicular/scrotal pain
  • Obstructive urinary tract symptoms, including frequency, dysuria, and incomplete voiding
  • Ejaculatory pain
  • Erectile dysfunction
• Asymptomatic inflammatory prostatitis - This diagnosis is defined by its lack of symptoms.

Physical

• Acute bacterial prostatitis
• • Tender, nodular, hot, boggy, or normal-feeling gland on digital rectal examination
  • Suprapubic abdominal tenderness
  • Enlarged tender bladder due to urinary retention
• Chronic bacterial prostatitis
• • Normal examination findings between acute episodes
  • Tender, nodular, or normal gland on digital rectal examination
  • Suprapubic tenderness during acute episodes
• Chronic prostatitis and chronic pelvic pain syndrome
• • Mildly tender or normal prostate on digital rectal examination
  • Tight anal sphincter on digital rectal examination
• Asymptomatic inflammatory prostatitis - Normal or calcified prostate on digital rectal examination

Causes

• Consider Neisseria gonorrhoeae and Chlamydia trachomatis infection in any male younger than 35 years presenting with urinary tract symptoms.
• Acute bacterial prostatitis may be caused by the following:
• • Ascending infection through the urethra
  • Refluxing urine into prostate ducts
  • Direct extension or lymphatic spread from the rectum
  • Approximately 80% are gram-negative organisms (eg, Escherichia coli, Enterobacter, Serratia, Pseudomonas, Enterococcus, and Proteus species). Mixed bacterial infections are uncommon. One case report of prostatitis caused by methicillin-resistant Staphylococcus aureus was documented in a diabetic patient.
• Chronic bacterial prostatitis may be due to the following:
• • A primary voiding dysfunction, either structurally or functionally
  • E coli is responsible for 75-80% of chronic bacterial prostatitis cases. Enterococci and gram-negative aerobes such as Pseudomonas are usually isolated the remainder of the time.
  • C trachomatis, Ureaplasma species, Trichomonas vaginalis
  • Uncommon organisms, such as M tuberculosis and Coccidioides, Histoplasma, and Candida species, must also be considered. Tuberculous prostatitis may be found in patients with renal tuberculosis.
  • Human immunodeficiency virus
  • Cytomegalovirus
  • Inflammatory conditions such as sarcoidosis
• Chronic prostatitis and chronic pelvic pain syndrome
• • About 5-8% of men with this syndrome eventually have a bacterial pathogen isolated from their urine or prostatic fluid.
  • Functional or structural bladder pathology, such as primary vesical neck obstruction, pseudodyssynergia (failure of the external sphincter to relax during voiding), impaired detrusor contractility, or acontractile detrusor muscle
  • Ejaculatory duct obstruction
  • Increased pelvic side wall tension
  • Nonspecific prostatic inflammation
• Asymptomatic inflammatory prostatitis - Causes are similar to chronic inflammatory prostatitis without symptoms.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Complete blood count: A complete blood count (CBC) with differential and blood cultures are indicated in cases of acutely toxic patients or suspected septicemia.
• Urinalysis: Obtain quantitative values for the white blood count and bacterial count, presence of oval fat bodies, and lipid-laden macrophages.
• Urine culture: A urine culture can be used to identify the causative organism, if any.
• Chemistry: Obtain electrolyte panel, including BUN and creatinine values, in patients presenting with urinary retention or obstruction.
• Prostate-specific antigen determination: PSA determination may help in supporting the diagnosis of acute bacterial prostatitis if the diagnosis is unclear. It is also indicated if a neoplasm is suspected as an underlying cause.

Imaging Studies

• Transrectal ultrasonography
• • Characteristic features are capsular thickening and prostatic calculi.
  • Hypoechoic halo in the periurethral region, heterogeneous echo pattern, and enlargement and thickening of the septa of the seminal vesicles may be seen.
  • Interpretation is highly subjective and therefore not very reliable; diagnosis requires clinical correlation and digital rectal examination.
• In acute prostatitis, a marked increase in color in the prostatic urethral site, around the ejaculatory ducts, and close to the seminal vesicles is visualized on color Doppler ultrasonography.
• Computed tomography (CT) studies of the pelvis may be useful in evaluation of prostatic abscess or suspected neoplasm.
• Cystoscopy is useful in follow-up of refractory cases to rule out neoplasm of the bladder or interstitial cystitis.
• Intravenous urography or voiding cystourethrography is appropriate for evaluation of the outlet system in patients with full renal function.

Other Tests

• Fractional urine examination
• • The use of fractional urine specimens may be useful in the diagnosis of prostatitis. Although not practical in most emergency departments, this technique is used by urologists if the diagnosis of prostatitis remains unclear.
  • The initial 10 mL of voided urine represents urine from the urethra and is termed voided urine 1 (V1). Elevated bacterial counts in V1 suggest urethritis. The next 200 mL of voided urine is discarded, and a midstream urine sample (V2) is collected, which represents bladder urine. Bacterial counts elevated in the midstream sample suggest cystitis without prostatitis. Next, the physician performs a prostatic massage and the expressed prostatic secretions (EPS) are collected from the urethral meatus. Finally, the 10 mL of voided urine following prostatic massage (V3) are collected. The bacterial findings of the EPS and V3 samples represent the microbiologic characteristics of the prostate gland.
  • Chronic bacterial prostatitis can be diagnosed if the culture of the EPS and V3 samples produce the same bacteria as the first-voided specimen and the colony count of the 2 cultures is at least 10 times as great as the first-void specimen.

Procedures

• Suprapubic catheterization: This may be warranted in severe obstruction and should be placed in consultation with a urologist.
• Needle biopsy or aspiration: In cases of prostatic abscess, the fluctuant site may be drained under local anesthesia through the perineal route, followed by insertion of a pigtail catheter.
• Urodynamic testing may be indicated.
• Cystoscopy may be performed to rule out bladder cancer and interstitial cystitis.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

No specific prehospital treatments of prostatitis exist; treatment should be tailored to symptoms and be supportive.

Emergency Department Care

• Individuals with acute bacterial prostatitis who appear acutely ill, have evidence of sepsis, or both require admission for parenteral antibiotics and supportive care.
• • Antibiotic therapy should initially include parental bactericidal agents such as broad-spectrum penicillin derivatives, third-generation cephalosporins with or without aminoglycosides, or fluoroquinolones.
  • Patients without a toxic appearance can be treated as outpatients with a 14- to 28-day course of oral antibiotics. Urologic follow-up is necessary to ensure eradication and to provide continuity of care to prevent relapse.
  • Urinary retention may complicate acute infection and warrant hospitalization. Suprapubic catheters are considered safer than urethral catheterization in severe obstruction and may be placed in consultation with a urologist.
  • Provide supportive measures such as antipyretics, analgesics, hydration, and stool softeners as needed.
  • Avoid serial examinations of the prostate to avoid seeding of the blood and subsequent bacteremia in acute bacterial prostatitis.
• Chronic bacterial prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis are probably best treated by or in consultation with a urologist.
• • A 4-week trial of antibiotic therapy is indicated in chronic bacterial prostatitis and chronic pelvic pain syndrome with inflammation, but no consensus exists regarding its use in chronic pelvic pain syndrome without inflammation and asymptomatic prostatitis.
  • Supportive measures such as analgesics (particularly nonsteroidal anti-inflammatory drugs [NSAIDs]), alpha-blocking agents, hydration, stool softeners, and sitz baths are often used.
• In cases where infected prostatic calculi serve as a nidus, transurethral resection or total prostatectomy may result in a cure.

Consultations

• Consult a urologist.  
• Notify the health department, if reportable STD is cultured.
• Consult a psychiatrist, if psychosomatic disorder is suspected.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The different NIH prostatitic categories are treated with various medical therapies, depending on the underlying pathology.

Antibiotic therapy is essential in the treatment of acute bacterial prostatitis. If the patient is having systemic symptoms, then admission is warranted for intravenous antibiotics, hydration, and analgesia. If the patient has signs of urinary retention or obstruction, then placement of a Foley catheter is indicated.

Therapy for chronic bacterial prostatitis varies in regards to type and duration of antibiotics used as well as adjunctive medications. Treatment typically consists of 4-8 weeks of prostate-penetrating antibiotics, such a fluoroquinolone or trimethoprim-sulfamethoxazole.

Chronic prostatitis, chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis may be treated with alpha-blocking agents or diazepam with sitz baths. Some studies have shown that a longer course of antibiotics has been shown to result in a decrease in PSA values in patients with category IV prostatitis.

Drug Category: Antibiotics

Empiric antibiotics should be tailored toward treating gram-negative pathogens. STDs, where N gonorrhoeae and C trachomatis are the primary suspected pathogens, must also be considered, especially in patients younger than 35 years. 

In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information see, the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.
 
For the treatment of chronic bacterial prostatitis, where Enterobacteriaceae, enterococci, and P aeruginosa are common pathogens, consider trimethoprim/sulfamethoxazole (Bactrim) or fluoroquinolones for 28 days or more as empiric agents.

For nonbacterial prostatitis caused by Chlamydia and Ureaplasma species, which are difficult to culture, an empiric trial of doxycycline or erythromycin should be instituted.

Drug Category: Alpha-adrenergic antagonists

These agents are used in the treatment of benign prostatic hypertrophy.

Studies suggest that combining alpha-blockers with antibiotics may reduce the risk of prostatitis recurrence in chronic prostatitis. Alpha-blockers improve bladder outlet obstruction and thus improves voiding dysfunction that may be associated with the pathogenesis of prostatitis.

Alpha-blockers may also have role in chronic pelvic pain syndrome to improve symptoms.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Carefully treat associated septicemia in acutely ill patients.
• Carefully monitor for bladder outlet obstruction and renal failure.

Further Outpatient Care

• After primary management and stabilization, care of the patient is appropriately transferred to a urologist, as aggressive treatment of acute prostatitis can lessen the chance of developing chronic prostatitis.
• After initial improvement with parental antibiotics, acute bacterial prostatitis may be managed with outpatient care with a 2- to 4-week course of oral antibiotics and urologic follow-up.
• Management strategies for category II prostatitis, chronic bacterial prostatitis, include intraprostatic antibiotic injection, transurethral resection of the prostate (TURP), and long-term antimicrobial suppression.
• Additional therapeutic modalities studied for category III prostatitis include anti-inflammatories, phytotherapy, biofeedback, thermal therapy, and pelvic floor exercises.
• Although no clear connection between elevated PSA level in prostatitis and cancer have been established, patients found to have elevated PSA levels should be followed up by their primary care-physicians, urologists, or both.

Deterrence/Prevention

• Protection against STDs also provides protection against many of the organisms associated with acute bacterial prostatitis, development of chronic prostatitis, and suspected causes of nonbacterial prostatitis.
• Psychological stress has been associated with men who report symptoms of chronic prostatitis. Recognition of underlying psychosomatic disease in chronic cases and appropriate psychiatric referral and treatment lessens the recurrence rate.

Complications

• Chronic prostatitis - Approximately one third of patients with chronic bacterial prostatitis experience recurrence following initial treatment.
• Bladder outlet obstruction/urinary retention
• Abscess - Typically in immunocompromised patients
• Infertility due to scarring of the urethra
• Recurrent cystitis
• Pyelonephritis
• Renal damage
• Sepsis

Prognosis

• The prognosis of the first occurrence of acute bacterial prostatitis is good with aggressive antibiotic therapy and good patient compliance.
• In cases of recurrent chronic prostatitis that may present with acute exacerbations, causative underlying factors must be determined to affect outcome.

Patient Education

• For excellent patient education resources, visit eMedicine's Prostate Health Center. Also, see eMedicine's patient education article Prostate Infections.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider diagnosis in sexually active adolescents
• Performing prostatic massage in patients with acute bacterial prostatitis
• Failure to recognize acute urinary retention

Special Concerns

• Acute bacterial prostatitis is a recognized complication after sclerotherapy for rectal prolapse.
• Nursing home patients with indwelling urethral catheters may be at increased risk.
• Patients with an elevated PSA value must be referred to their primary care physician or a urologist for PSA recheck and follow-up.
• Chronic prostatitis and asymptomatic inflammatory prostatitis have not been scientifically linked to prostate cancer.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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• Parks RW, Henry PG, Abram WP, Best BG. Primary non-Hodgkin's lymphoma of the prostate mimicking acute prostatitis. Br J Urol. Sep 1995;76(3):409. [Medline].
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Article Last Updated: Nov 5, 2007