Prostatitis

Prostatitis can be bacterial or, more commonly, nonbacterial. However, differentiating bacterial and nonbacterial causes can be difficult, particularly in chronic prostatitis.

Bacterial prostatitis can be acute or chronic and is usually caused by typical urinary pathogens (eg, Klebsiella, Proteus, Escherichia coli) and possibly by Chlamydia. How these pathogens enter and infect the prostate is unknown. Chronic infections may be caused by sequestered bacteria that antibiotics have not eradicated.

Nonbacterial prostatitis can be inflammatory or noninflammatory. The mechanism is unknown but may involve incomplete relaxation of the urinary sphincter and dyssynergic voiding. The resultant elevated urinary pressure may cause urine reflux into the prostate (triggering an inflammatory response) or increased pelvic autonomic activity leading to chronic pain Chronic Pain Chronic pain is pain that persists or recurs for > 3 months, persists > 1 month after resolution of an acute tissue injury, or accompanies a nonhealing lesion. Causes include chronic disorders... read more without inflammation.

Prostatitis is classified into 4 categories (see table NIH Consensus Classification System for Prostatitis ). These categories are differentiated by clinical findings and by the presence or absence of signs of infection and inflammation in 2 urine samples. The first sample is a midstream collection. Then digital prostate massage is done, and patients void immediately; the first 10 mL of urine constitutes the 2nd sample. Infection is defined by bacterial growth in urine culture; inflammation is defined by the presence of white blood cells in urine. The use of the term prostatodynia for prostatitis without inflammation is discouraged.

Symptoms vary by category but typically involve some degree of urinary irritation or obstruction and pain. Irritation is manifested by frequency and urgency, a sensation of incomplete bladder emptying, a need to void again shortly after voiding, or nocturia. Pain is typically in the perineum but may be perceived at the tip of the penis, lower back, or testes. Some patients report painful ejaculation.

Acute bacterial prostatitis often causes such systemic symptoms as fever, chills, malaise, and myalgias. The prostate is exquisitely tender and focally or diffusely swollen, boggy, indurated, or a combination. A generalized sepsis syndrome may result, characterized by tachycardia, tachypnea, and sometimes hypotension.

Chronic bacterial prostatitis manifests with recurrent episodes of infection with or without complete resolution between bouts. Symptoms and signs tend to be milder than in acute prostatitis.

Chronic prostatitis/chronic pelvic pain syndrome typically has pain as the predominant symptom, often including pain with ejaculation. The discomfort can be significant and often markedly interferes with quality of life. Symptoms of urinary irritation or obstruction also may be present. On examination, the prostate may be tender but usually is not boggy or swollen. Clinically, inflammatory and noninflammatory types of chronic prostatitis/chronic pelvic pain syndrome are similar.

Asymptomatic inflammatory prostatitis causes no symptoms and is discovered incidentally during evaluation for other prostate diseases when white blood cells are present in the urine.

Diagnosis of type I, II, or III prostatitis is suspected clinically. Similar symptoms can result from urethritis Urethritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more , perirectal abscess Anorectal Abscess An anorectal abscess is a localized collection of pus in the perirectal spaces. Abscesses usually originate in an anal crypt. Symptoms are pain and swelling. Diagnosis is primarily by examination... read more , or urinary tract infection Introduction to Urinary Tract Infections (UTIs) Urinary tract infections (UTIs) can be divided into upper tract infections, which involve the kidneys ( pyelonephritis), and lower tract infections, which involve the bladder ( cystitis), urethra... read more . Examination is helpful diagnostically only in acute bacterial prostatitis.

Febrile patients with typical symptoms and signs of acute bacterial prostatitis usually have white blood cells and bacteria in a midstream urine sample. Prostate massage to obtain a postmassage urine sample is thought to be unnecessary and possibly dangerous in these patients (although danger remains unproved) because bacteremia can be induced. For the same reason, rectal examination should be done gently. Blood cultures should be obtained in patients who have fever and severe weakness, confusion, disorientation, hypotension, or cool extremities. For patients without these findings, urine samples before and after massage are adequate for diagnosis.

For patients with acute or chronic bacterial prostatitis who do not respond favorably to antibiotics, transrectal ultrasonography and sometimes cystoscopy may be necessary to rule out prostatic abscess or destruction and inflammation of the seminal vesicles.

For patients with types II, III, and IV (nonacute prostatitis) disease, additional tests that can be considered are cystoscopy and urine cytology (if hematuria is also present) and urodynamic measurements (if there is suspicion of neurologic abnormalities or detrusor-sphincter dyssynergia).