Prostatitis

• Prostatitis is inflammation of the prostate gland.
• It can be a result of bacterial or non-bacterial infection.
• Acute bacterial prostatitis, the least common form, can be serious if the infection is left untreated.
• Whilst not normally life threatening, prostatitis can impact considerably on a man’s quality of life.

Symptoms of prostatitis

• urinary tract infection (UTI)
  • acute dysuria
  • urinary frequency
  • urgency
• systemic features
  • fever [38°C or higher
  • chills
  • sweats
• Obstructive urinary symptoms
  • weak stream
  • dribbling
  • hesitancy
  • urinary retention
• symptoms suggestive of prostatic involvement
  • pelvic or perineal pressure
  • prostate tenderness on gentle digital rectal examination

Acute bacterial prostatitis

• approximately 10% of all cases of prostatitis
• Most acute bacterial prostatitis infections are community acquired, but some occur after transurethral manipulation procedures, such as urethral catheterization and cystoscopy, or after transrectal prostate biopsy.

Clinical

1. Digital rectal examination (DRE):
   1. Should not be performed if you suspect acute severe prostatitis because it can be very painful
   2.  Some tenderness and swelling may accompany sub-acute prostatitis

investigations

1. MSU
   1. First pass urine: Chlamydia urine PCR test
   2. Midstream urine: MC&S 
   3. Urine PCR for STIs should be done if Chlamydia or other STI a likely cause.
2. Blood cultures
   1. are indicated in patients with a body temperature greater 38.4°C), a possible hematogenous source of infection (e.g., endocarditis with Staphylococcus aureus), or complicated infections (e.g., sepsis), and in patients who are immunocompromised.
3. PSA testing
   1. is not indicated in the evaluation of acute bacterial prostatitis
   2. Levels may be dramatically high
   3. PSA velocity: if the PSA level doubles in 12-months it may indicate prostate cancer or prostatitis.
4. USS
   1. Fevers that persist for longer than 36 hours should be evaluated with imaging to rule out prostatic abscess.

Treatment

• Antibiotics (not all antibiotics penetrate the prostate gland).
• empirical therapy (while awaiting the results of culture and susceptibility testing)
  •  Nonsevere acute bacterial prostatitis:
    • trimethoprim 300 mg orally, daily for 2 weeks OR
    • cefalexin 500 mg orally, 6-hourly for 2 weeks.
  • Severe acute bacterial prostatitis
    • gentamicin intravenously
      • PLUS EITHER
    • amoxicillin 2 g intravenously, 6-hourly 
      • OR
    • ampicillin 2 g intravenously, 6-hourly. 
• Young men with confirmed Chlamydia prostatitis:
  • Doxycycline
• Analgesics.
• Non-steroidal anti-inflammatory drugs

Complications

• Prostatic abscesses – 2.7% of patients
  • Risk factors for prostatic abscess include long-term urinary catheterization, recent urethral manipulation, and an immunocompromised state
• Recurrence
  • Approximately 13% of patients with acute bacterial prostatitis experience recurrence necessitating a longer course of antibiotics.
  • After three months of persistent or recurrent symptoms, patients should be evaluated and treated for chronic prostate syndrome
• epidimyo-orchitits
• acute retention
• bacteraemia

Chronic bacterial prostatitis

• rare
• defined as recurrent UTI with culture of a recognised uropathogen from urine or prostatic fluid.
• Clinical
  • history of intermittent symptomatic episodes that resemble acute bacterial prostatitis
    • Mild irritant voiding
    • Perineal/scrotal/suprapubic pain
    • PR may be normal or tender
    • fever is usually absent
• Urine MCS
  • can be negative
  • caused by similar organisms to those associated with other urinary tract infections (eg Escherichia coli, Proteus species, Klebsiella species). 
  • sexually transmitted pathogens (ie Chlamydia trachomatis , Neisseria gonorrhoeae ) may also cause chronic bacterial prostatitis.
  • more sensitive after prostate massage
  • ‘two glass test’: comparing leucocyte count and the results of culture of pre– with post–prostatic massage urine samples
• Recurrence of chronic bacterial prostatitis is common. 
• Management
  • antibiotic choice for chronic bacterial prostatitis, based on the results of culture and susceptibility testing, use:
    • ciprofloxacin 500 mg orally, 12-hourly for 4 weeks  OR
    • norfloxacin 400 mg orally, 12-hourly for 4 weeks  OR
    • trimethoprim 300 mg orally, daily for 4 week 
    • Do not repeat courses of antibiotic therapy unless a recognised uropathogen is found on culture from a symptomatic patient.
  • NSAIDs
  • Massage
  • 5-a-reductase therapy if BPH present
  • Good voiding habits
  • Avoid straining

chronic prostate pain syndrome

• treatment is difficult and cure is often not possible.
• Treatment focus is on symptom management, to improve quality of life. 
• Non-medical therapy is recommended as the initial treatment
• Lifestyle changes:
  • avoid activity that involves vibration or trauma to the perineum (e.g. bike riding, tractor driving, long distance driving, cut out caffeine, spicy foods, alcohol, avoid constipation).
• pelvic floor physiotherapist
  • pelvic floor relaxation techniques and trigger point massage.
  • Prostate massage.
• Supportive therapy:
  • Biofeedback
  • relaxation exercises
  • acupuncture
  • massage therapy
  • chiropractic therapy, Heat therapy