Definition
Prostatitis is an acute or chronic infection of the prostate gland. Prostatitis is the most important cause of urinary infection in men.
A.Patients can be considered to be in the early stages of the disease if they have experienced persistent, recurrent symptoms for less than 6 months and are antibiotic-naïve.
B.Patients can be considered in the later stages of the disease if they have persistent, recurrent symptoms for ≥3 of the previous 6 months and are refractory to initial lines of pharmacotherapy (Table 15.3).
TABLE 15.3 National Institutes of Health Classification of Prostatitis
aDuring CP/CPPS, it is possible for patients to switch between the two subcategories (IIIa and IIIb), but this has little effect on subsequent clinical management.
CBP, chronic bacterial prostatitis; CP, chronic prostatitis; CPPS, chronic pelvic pain syndrome; EPS, expressed prostatic secretions;
VB, voided bladder; VB3, postprostatic massage voided bladder urine.
Source: Rees, J., Abrahams, M., Doble, A., Cooper, A., & the Prostatitis Expert Reference Group. (2015). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU International, 116(4), 509–525. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008168/
Incidence
A.About 50% of adult men in the United States will be treated for prostate conditions during their lifetime.
B.Acute and chronic bacterial prostatitis (CBP) occurs in about 1 in 10 men.
C.Nonbacterial prostatitis occurs in about 6 in 10 men.
D.Prostatodynia occurs in about 3 in 10 men.
Pathogenesis
A.Nonbacterial prostatitis is an inflammatory condition with an unknown etiology. Infection results in prostatitis in four ways:
1.Ascending infection of urethra.
2.Reflux of infected urine into the prostate through ejaculatory and prostatic ducts that empty into the prostatic urethra.
3.Hematogenous spread causing bacterial prostatitis.
4.Invasion by rectal bacteria through direct extension or lymph system spread.
B.Causative organisms: Escherichia coli, Klebsiella, Pseudomonas, Enterococci, Ureaplasma, Gardnerella vaginalis, Trichomonas vaginalis, Chlamydia trachomatis, Chlamydia, Mycoplasma, or Neisseria gonorrhoeae. Cytomegalovirus (CMV), Mycobacterium tuberculosis, and fungi have been associated with prostatitis in HIV-infected patients.
C.Incubation period depends on pathogen.
Predisposing Factors
A.More common in younger and middle-aged men.
B.Sexual transmission of bacteria.
C.Neuromuscular dysfunction.
D.Structural voiding dysfunction.
E.Benign prostatic hypertrophy (BPH).
F.History of allergies and asthma (increase in nonbacterial prostatitis).
Common Complaints
A.Dysuria.
B.Perineal, rectal, or suprapubic pain (chronic pain syndrome).
C.Less urine flow.
D.Spiking fever.
E.Back pain.
F.Sexual dysfunction symptoms:
1.Erectile dysfunction (ED).
2.Ejaculatory dysfunction (premature, delayed, or pain during or after ejaculation).
3.Decreased libido.
Other Signs and Symptoms
A.Acute bacterial prostatitis:
1.Fever and chills, malaise.
2.Acute onset of dysuria.
3.Hesitancy.
4.Urinary frequency and low back pain.
5.Pain with intercourse and with defecation.
6.Initial or terminal hematuria and edema with acute urinary retention.
7.Arthralgia or myalgia.
8.Nocturia.
9.Neuropathic pain.
B.CBP:
1.Usually presents with recurrent urinary tract infection (UTI).
2.May be asymptomatic between acute episodes; some men have large fluctuation in symptom severity.
3.Perineal, inguinal, or suprapubic pain, or irritative symptoms on voiding such as frequency and urgency.
4.Hematuria, hematospermia, or painful ejaculations.
5.Prostatic calculi.
C.Nonbacterial prostatitis (most common):
1.Vague discomfort to pain: Prostatic, lower back, perineum, groin, scrotum, or suprapubic pain; ejaculatory pain.
2.Dysuria, urinary frequency, urgency, hesitancy, and decreased urine flow.
3.Penile discharge, especially noted during the first bowel movement (BM) of the day.
4.Sexual difficulty.
5.Low sperm count.
6.Blood or urine in ejaculate.
D.Asymptomatic inflammatory prostatitis is found when looking for causes of infertility and testing for prostate cancer.
E.Prostatodynia (cause is unknown):
1.Prostate irritation.
2.Pain and discomfort in the prostate, testicles, penis, and urethra.
3.Difficulty urinating.
Subjective Data
A.Ask the patient to complete the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) self-evaluation form (see Table 15.4). The assessment tool evaluates pain, urinary symptoms, and the impact on quality of life. An online NIH symptom index that self-scores is available at www.prostatitis.org/symptomindex.html.
1.Mild = 0 to 14 total score.
2.Moderate = 15 to 29 total score.
3.Severe = 30 to 43 total score.
B.Review the onset, duration, and course of symptoms.
C.Are there any other symptoms such as discharge, pain, hematuria, hesitancy, back pain, or weight loss?
D.Has the patient ever had the same symptoms? If so, how were they treated?
E.Does any sexual partner(s) have any symptoms, lesions, or known sexually transmitted infections (STIs)?
F.Does the patient engage in anal intercourse?
G.Has the patient noted any impaired urinary flow?
H.Has the patient required any recent urethral catheterization or instrumentation?
Physical Examination
A.Check temperature and blood pressure (BP).
B.Inspect:
1.Examine the patient generally for discomfort before and during examination.
2.Check the urethral meatus for discharge.
3.Retract foreskin (if present) and assess for hygiene and smegma.
4.Check the shaft of the penis, glans, and prepuce for lesions.
C.Palpate:
1.Palpate testes and epididymides for inflammation, tenderness, and masses; palpate scrotum for hydrocele or varicocele.
2.Check back for costovertebral angle (CVA) tenderness.
3.Evaluate for an enlarged, tender bladder caused by urinary retention.
4.Palpate the abdomen for masses, urinary distension, suprapubic tenderness, and organomegaly.
5.Palpate inguinal lymph nodes, check the inguinal and femoral areas for bulges and hernias, have the patient bear down and cough, and reexamine him.
6.Rectal exam:
a.Prior to the rectal examination, have the patient obtain a clean-catch urine specimen for culture. Check for symmetry, swelling, tenderness, and enlarged prostate.
b.In acute prostatitis, rectal examination reveals the prostate gland to be exquisitely tender and boggy.
c.A fluctuant prostatic mass suggests an abscess that may require surgical intervention.
d.Perform prostate massage for postmassage urine sample (see Section II: Procedure for Prostatic Massage Technique: 2-Glass Test
).
Diagnostic Tests
A.Acute infection:
1.Complete blood count (CBC) with differential.
2.Urinalysis and urine culture.
3.Culture for STIs.
4.The four-glass test is considered the diagnostic standard but is not practiced in a clinical setting; the two-glass premassage and postmassage test is more commonly used.
5.Gram stain, culture of expressed prostatic specimen (EPS):
a.Avoid vigorous massage when obtaining specimen because of the risk of inducing bacteremia.
b.Gram stain of EPS demonstrates infectious organisms or white blood cells (WBCs) typical of an immune response (>10 WBC/high-power microscope field (HPF) is abnormal). Patients with abnormal WBC but no bacterial growth may have chlamydial or Ureaplasma infection and need to be tested or treated empirically.
B.Chronic infection:
1.Blood urea nitrogen (BUN).
2.CBC with differential.
3.Creatinine.
4.Uroflowmetry, retrograde urethrography, or cystoscopy to exclude BOO, urethral stricture, or bladder neck stenosis.
C.CBP:
1.If recurrent infections are confirmed, evaluate for structural or functional abnormality with CT scan.
2.Measure residual urine after voiding.
3.If no urologic abnormalities are found and repeated cultures indicate the same bacterial strain, CBP is likely.