Introduction

Prostatitis refers to inflammation of the prostate, most commonly a result of infection (either UTI or STI). Prostatitis affects up to 15% of men at some point in the lives.

We can divide prostatic into 4 sub-types:

  • Acute bacterial prostatitis can be life-threatening and requires emergency treatment, but is rare, accounting for about 5% of cases of prostatitis
  • Chronic bacterial prostatitis, causing often non-specific symptoms, usually involving pain in the pelvis or perineal area.
  • Chronic prostatitis – with no evidence of infection – sometimes called Prostate pain syndrome or chronic pelvic pain syndrome. This is the most common type of prostatitis
  • Asymptomatic inflammatory prostatitis is also occasionally seen but is usually symptomatic and an incidental finding of little clinical significance.

Prostatitis is associated with increased rates of benign prostate hyperplasia, prostate cancer and lower urinary tract symptoms (LUTS)

Epidemiology & Aetiology

  • Prevalence of about 5-10%
  • 15% of men will suffer prostatitis at some time in their life
  • Chronic prostatitis is much more common than acute prostatitis
  • Bacterial prostatitis is the most common type in men aged <35
  • Risk factors
    • Hx of STI
    • Hx of UTI
    • Indwelling catheter
    • Post procedure – e.g. post prostate biopsy
    • Risk increases with age
    • Diabetes mellitus
    • Immunosuppression
  • Bacterial Prostatitis
    • Gram negative organisms – such as  E. coli, enterobacter, serrate, pseudomonas, proteus
    • Sexually transmitted organisms – neisseria gonorrhoea, chlamydia
    • Rarely – tuberculosis
  • Non-bacterial
    • Increase prostatic pressure
    • Pelvic floor myalgia
    • Emotional causes

Acute Bacterial Prostatitis

An important diagnosis, as it can lead to sepsis if not treated promptly. The result of infection of the prostate gland by a bacteria.

Presentation

  • On DRE (digital rectal examination) prostate gland may be tender, and feel hot to touch. It may feel normal or be soft and boggy. Vigorous examination of the prostate may cause seeding of septic emboli – so examine carefully
  • Inguinal lymphadenopathy
  • Urethral discharge
  • Urinary retention
  • Signs of UTI
    • Increased uruinary frequency
    • Dysuria
    • Haematuria
  • Signs of systemic infection / sepsis
    • Fever
    • Tachycardia
    • Syncope

Diagnosis

  • Often clinical in the OP setting in a systemically well patient
    • Consider sending urine MC+S and STI screen
  • If acutely unwell – send to emergency department
  • PSA (prostate specific antigen) testing is not useful. It may be elevated in acute infection and can take up to a month to resolve

Management

  • May require admission to hospital
  • Antibiotics – Gram-negative cover
    • e.g. if UTI suspected and septic – gentamicin and ceftriaxone. If systemically well – trimethoprim 300mg orally for 2 weeks or flouroquinolones orally for 4 weeks – e.g. ciprofloxacin 500mg BD. Longer courses may be required if remains symptomatic
    • If STI is suspected:
      • Azithromycin 1g orally stat and/or doxycycline 100mg OD for 7 days – to cover chlamydia
      • Ceftriaxone 500mg IM stat and azithromycin 1g orally stat – to cover gonorrhoea
      • In reality, the causative organism is usually not know, and a stat IM dose of ceftriaxone 500mg, a one week course of doxycycline and a single dose of oral azithromycin 1g is given.
  • Consider CT of prostate or transrectal USS if failing to respond to treatment after one week – may be abscess formation
  • If urinary retention develops, then catheterisation is contraindicated and a suprapubic catheter is required

Chronic bacterial prostatitis

Not time-critical like the acute bacterial prostatitis, and symptoms typically more gradual in onset and may be non-specific. Examination of the prostate is usually normal.

Treatment is often similar to that of acute bacterial prostatitis – with oral antibiotics to cover possible urinary and/or STI causes (based on clinical risk from history).

  • E coli accounts for 80% of cases of chronic bacterial prostatitis

Differentiated from chronic non-bacterial prostatitis by the identification of a causative organism

Chronic non-bacterial prostatitis

Typically presents as pain with or without urinary symptoms – and is associated with a significant impact on quality of life.

May present as a chronic illness with acute exacerbations, or as long terms symptoms with minimal variability. Difficult to treat effectively.

Diagnostic criteria

  • Pelvic discomfort or pain >3 months duration
  • Negative urine and prostatic fluid culture
  • Leukocytes may present in prostatic fluid
    • Prostatic fluid is assessed with pre and post prostatic massage urine samples

Causes

The cause is essentially unknown, but there are multiple possible theories:

  • Infection with unknown organism
  • Immune reaction to antigen from previous infection
  • Pelvic nervous system dysfunction
  • Mechanical issue causing retention of prostatic fluid

Management

  • Simple analgesia – such as paracetamol of ibuprofen or other NSAID)
  • Antibiotics – are often used early in the presentation, but avoid repeated doses
  • Alpha-blockers – e.g. prazosin or tamsulosin  – may be of some benefit but evidence is limited
  • Consider stress management if psychological component is suspected

References

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