prostatitis
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Introduction
Inflammation/infection of the prostate gland. A common cause of urinary tract infection (UTI) in men.
Classification
- class 1: acute bacterial prostatitis
- class 2: chronic bacterial prostatitis
- class 3: no infection
- class 3A: inflammatory chronic pelvic pain syndrome
- class 3B: non-inflammatory chronic pelvic pain syndrome
- asymptomatic inflammatory prostatitis
Etiology
- mechanisms
- ascending urethral infection
- reflux of infected urine
- contiguous spread from rectum
- hematogenous spread
- etiologic agents
- gram-negative bacilli (Escherichia coli) (older patients)
- Enterococci (older patients)
- Chlamydia trachomatis (younger patients)
- Neisseria gonorrhoeae (younger patients)
- Ureaplasma
- idiopathic (chronic prostatitis/chronic pelvic pain syndrome)[4]
- > 80% of patients with chronic prostatitis[9]
Epidemiology
- acute prostatitis is uncommon
- chronic prostatitis is more common
Pathology
- repeated urinary tract infections caused by the same pathogen
- antimicrobial agents diffuse poorly into the prostate
- pain does not correlated with histological inflammation[5]
- some evidence for neuropathic pain[7]
Clinical manifestations
- constitutional:
- urogenital:
- oliguria, dysuria, nocturia, hesitancy, dribbling
- prostate tenderness, enlargement, bogginess on rectal exam
- prostate massage contraindicated in acute prostatitis; may result in sepsis[6]
- digital rectal examination may be normal especially between episodes of urinary tract infection or during treatment[17]
- bladder distention (suprapubic pressure)
- peritoneal pain may present as abdominal pain in any quadrant (acute)
- pelvic pain
- obstructive uropathy
- low back pain (acute)
- rectal pressure
- sexual dysfunction
- may rarely present as septic shock[6]
Laboratory
- urinalysis
- expressed prostatic secretions or semen analysis
- microscopy:
- culture of semen, culture of urine after prostate massage
- helpful for chronic prostatitis[16]
- avoid in patients with acute bacterial prostatitis
- may potentially cause bacteremia & sepsis[6]
- neither urine culture after prostate massage nor semen culture useful after 6 week trial of antibiotics
- urine culture
- blood culture
- serum prostate-specific antigen (serum PSA)
- may be elevated with prostate inflammation
- recheck serum PSA after resolution of prostatitis
- cystoscopy
- prostate biopsy if acute bacterial prostatitis suspected
Diagnostic procedures
- transrectal ultrasonography
- deterioration after initiation of antibiotic therapy[15]
- post-void residual volume if suggestion of urinary retention
Complications
Differential diagnosis
- benign prostatic hypertrophy
- prostatic carcinoma
- urethral stricture
- bladder cancer
- neurogenic bladder
- interstitial cystitis
- chronic pelvic pain syndrome
Management
- transrectal ultrasonography if deterioration after initiation of antibiotics[15]
- antibiotic therapy for acute bacterial prostatitis
- IV therapy, hospitalized patients with acute prostatitis
- ampicillin* plus aminoglycoside
- cephalosporin plus aminoglycoside
- ceftriaxone alone in elderly[6]
- piperacillin tazobactam (Zosyn)
- meropenem for fluroquinolone resistance*
- oral therapy for 3-4 weeks[1] (4 weeks[2][6]), 2-6 weeks[2]
- fluoroquinolone for 4-6 weeks treatment of choice[6]
- ciprofloxacin or levofloxacin 500 mg BID
- do not use if recent urogenital instrumentation
- many/most strains of E coli resistance to fluoroquinolones[6]
- Bactrim DS BID for 4 weeks is another treatment of choice[6]
- ampicillin* 500 mg QID
- tetracycline 500 mg QID
- doxycycline 100 mg BID
- carbenicillin 1 g QID
- cephalexin for gram positive cocci[6]
- fluoroquinolone for 4-6 weeks treatment of choice[6]
- ceftriaxone 250 mg IM + doxycycline 100 mg BID for 10 days if sexually-transmitted disease suspected[6]
- IV therapy, hospitalized patients with acute prostatitis
- antibiotics are less effective for chronic prostatitis
- alpha blocker such as tamsulosin +/-antibiotics for 6 weeks + [6]
- cure can be expected in < 50% of patients
- see chronic pelvic pain syndrome for non-infectious prostatitis
- treat benign prostatic hyperplasia[6]
- patient education
- discontinue over-the-counter decongestants
- sitz baths may help difficulty voiding
- diet
- avoid spicy foods if they cause exacerbation of symptoms
- avoid caffeine
- activity: no restrictions
- follow-up
- acute prostatitis: re-evaluation 48-72 hours
- chronic prostatitis:
- within 2-3 weeks & 1 month after completion of antibiotics
- pharmacotherapy not helpful[4]
- referral to urologist if indicated
- total prostatectomy offers a cure with a high risk to benefit ratio[9]
- TURP is safer, but cure rate is ~33%[9]
* high rate of resistance to ampicillin in community-acquired prostatitis
* floroquinolone resistant E coli (< 90%) after prostate biopsy[6]
More general terms
Additional terms
References
- ↑ 1.0 1.1 Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 554-55
- ↑ 2.0 2.1 2.2 UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ Roberts & Leiber 49:809, 1997
- ↑ 4.0 4.1 4.2 Journal Watch 24(23):173, 2004 Alexander RB, Propert KJ, Schaeffer AJ, Landis JR, Nickel JC, O'Leary MP, Pontari MA, McNaughton-Collins M, Shoskes DA, Comiter CV, Datta NS, Fowler JE Jr, Nadler RB, Zeitlin SI, Knauss JS, Wang Y, Kusek JW, Nyberg LM Jr, Litwin MS; Chronic Prostatitis Collaborative Research Network. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial. Ann Intern Med. 2004 Oct 19;141(8):581-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15492337
- ↑ 5.0 5.1 Nickel JC et al, Examination of the relationship between symptoms of prostatitis and histological inflammation: Basline data from the REDUCE chemoprevention trial. J Urol 2007, 178:896 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17632164
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 7.0 7.1 Pontari MA et al. Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: A randomized controlled trial. Arch Intern Med 2010 Sep 27; 170:1586. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20876412
- ↑ Touma NJ, Nickel JC. Prostatitis and chronic pelvic pain syndrome in men. Med Clin North Am. 2011 Jan;95(1):75-86. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21095412
- ↑ 9.0 9.1 9.2 9.3 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
- ↑ Sharp VJ1, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20704171
- ↑ 11.0 11.1 NEJM Knowledge+ Question of the Week. Dec 15, 2015
- ↑ Schaeffer AJ Clinical practice. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med 2006 Oct 20; 355:1690 PMID: https://www.ncbi.nlm.nih.gov/pubmed/1705089
- ↑ Brede CM, Shoskes DA. The etiology and management of acute prostatitis. Nat Rev Urol. 2011 Apr;8(4):207-12. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21403661
- ↑ Wagenlehner FM, Weidner W, Pilatz A, Naber KG. Urinary tract infections and bacterial prostatitis in men. Curr Opin Infect Dis. 2014 Feb;27(1):97-101. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24253463
- ↑ 15.0 15.1 15.2 15.3 Ackerman AL, Parameshwar PS, Anger JT. Diagnosis and treatment of patients with prostatic abscess in the post-antibiotic era. Int J Urol. 2018 Feb;25(2):103-110. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28944509 Review
- ↑ 16.0 16.1 NEJM Knowledge+ Nephrology/Urology
- ↑ 17.0 17.1 Gill BC, Shoskes DA. Bacterial prostatitis. Curr Opin Infect Dis. 2016;29:86-91. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26555038
- ↑ Prostatitis: Disorders of the Prostate http://kidney.niddk.nih.gov/kudiseases/pubs/prostatitis/index.htm
Chronic Prostatitis Workshop http://kidney.niddk.nih.gov/kudiseases/pubs/chronicprostatitis/index.htm