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Infectious Disease and Microbiology – Prostatitis
The term prostatitis encompasses several infectious and noninfectious disorders affecting the prostate gland. These include acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis with inflammatory and noninflammatory subtypes, asymptomatic inflammatory prostatitis, and granulomatous prostatitis. The most common form is chronic prostatitis/chronic pelvic pain syndrome, accounting for approximately 90% of cases. Overall prevalence of prostatitis ranges from 2–16% in the general population.
Genitourinary procedures are an important risk factor for acute bacterial prostatitis. Effective management of acute prostatitis reduces the risk of recurrent or chronic bacterial prostatitis. Bacterial prostatitis is associated with secretory dysfunction of the prostate. Prostatic secretions become more alkaline, affecting local antibiotic penetration, and there is a reduction in prostatic antibacterial factor, a zinc-containing antimicrobial polypeptide normally present in prostatic fluid.
Acute bacterial prostatitis is most commonly caused by typical uropathogens including Escherichia coli, other Enterobacteriaceae, Pseudomonas aeruginosa, and enterococci. Chronic bacterial prostatitis is usually caused by the same organisms. The inflammatory subtype of chronic prostatitis has an uncertain etiology, although some cases are associated with Chlamydia or Mycoplasma species. Leukocytes are present in expressed prostatic secretions. The noninflammatory subtype also has an unclear cause, though some patients demonstrate voiding dysfunction related to dyssynergy between bladder detrusor and internal sphincter muscles. Granulomatous prostatitis is rare and may follow acute bacterial prostatitis or result from infections such as tuberculosis, nontuberculous mycobacteria, cryptococcosis, blastomycosis, coccidioidomycosis, or histoplasmosis. In patients with AIDS, the prostate may serve as a persistent focus of cryptococcal infection.
Acute bacterial prostatitis should be suspected in any man presenting with symptoms consistent with urinary tract infection accompanied by perineal, pelvic, or lower back pain. Urinary frequency, dysuria, urgency, fever, and chills are common. Chronic bacterial prostatitis often presents with recurrent urinary tract infections caused by the same organism. Patients are frequently asymptomatic between episodes, although some report symptoms similar to chronic nonbacterial prostatitis.
Chronic prostatitis commonly presents with persistent or intermittent perineal, pelvic, lower back, scrotal, or inguinal pain. Urinary symptoms such as frequency, hesitancy, dribbling, urgency, and dysuria may occur. Erectile dysfunction and ejaculatory complaints are also common. Patients with asymptomatic inflammatory prostatitis have no genitourinary pain and are usually diagnosed incidentally during evaluation for infertility or elevated prostate-specific antigen levels.
Physical examination findings vary according to the type of prostatitis. In acute bacterial prostatitis, digital rectal examination performed gently may reveal an enlarged, tender prostate; vigorous examination should be avoided to prevent bacteremia. In chronic prostatitis, the prostate is generally normal on examination. Granulomatous prostatitis produces a firm, indurated prostate.
Laboratory evaluation includes urinalysis, urine culture, blood urea nitrogen, and creatinine measurements before initiating antibiotics. The classic diagnostic method is the four-glass Meares-Stamey test, which compares cultures from urethral urine (VB1), bladder urine (VB2), expressed prostatic secretions (EPS), and postmassage urine (VB3). Elevated bacterial colony counts in EPS or VB3 compared with VB1 suggest bacterial prostatitis. Presence of leukocytes in EPS or VB3 indicates prostatic inflammation. A simplified two-glass pre- and post-prostatic massage test is also commonly used. Imaging studies such as transrectal ultrasonography and CT scanning are useful for detecting prostatic stones and abscesses. Elderly patients with chronic prostatitis symptoms but no infection should undergo evaluation for bladder cancer with urine cytology, bladder ultrasonography, and cystoscopy if indicated.
Granulomatous prostatitis demonstrates granulomas with lipid-laden histiocytes, plasma cells, and multinucleated giant cells on histopathology. The differential diagnosis of prostatitis includes benign prostatic hyperplasia, bladder neck dysfunction, urethral stricture, prostatic calculi, and prostate cancer.
Treatment depends on the specific subtype. Mild acute bacterial prostatitis without nausea or vomiting is treated with oral fluoroquinolones such as levofloxacin or ciprofloxacin, or with trimethoprim-sulfamethoxazole (TMP-SMX), generally for 2–4 weeks. Moderate or severe illness requires parenteral antibiotics such as ampicillin plus gentamicin or intravenous fluoroquinolones until fever resolves, followed by oral therapy to complete a four-week course. Persistent infection may require retreatment for up to 12 weeks.
Chronic bacterial prostatitis requires antibiotics with good prostatic penetration. Preferred regimens include oral fluoroquinolones for four weeks or TMP-SMX for six weeks. Approximately one-third of patients achieve complete response, while others experience partial or no response. Extended antibiotic courses up to 12 weeks may be required. Suppressive therapy with daily TMP-SMX may be necessary in patients with recurrent infections.
There is no consistently effective therapy for chronic inflammatory prostatitis because the etiology is uncertain. A short trial of doxycycline or a macrolide is reasonable to target possible Chlamydia or Mycoplasma infection. If improvement occurs, treatment may continue for an additional 2–4 weeks. In noninflammatory prostatitis associated with voiding dysfunction, alpha-blockers such as tamsulosin, terazosin, or alfuzosin may provide benefit. Antibiotic therapy is not indicated for asymptomatic inflammatory prostatitis.
Supportive management of acute bacterial prostatitis includes stool softeners, analgesics, and antipyretics. Transurethral catheterization should be avoided because it may obstruct drainage of prostatic secretions; suprapubic catheterization is preferred if urinary retention occurs. In chronic prostatitis, hot sitz baths, anti-inflammatory medications, reassurance, and encouragement of sexual activity may improve symptoms. Some patients with pelvic floor tension myalgia benefit from pelvic floor exercises, diathermy, or diazepam. Prostatic massage, oral zinc, and vitamin supplements have unproven benefit.
Surgical intervention may be necessary in chronic bacterial prostatitis complicated by recurrent urinary tract infections despite suppressive therapy or by infected prostatic calculi. Transurethral or open prostate resection may be considered in selected patients.
Follow-up urine cultures should be obtained approximately 14 days after completing treatment for acute bacterial prostatitis. Complications of acute bacterial prostatitis include prostatic abscess, prostatic infarction, bacteremia, progression to chronic bacterial prostatitis, and granulomatous prostatitis.
The term prostatitis encompasses several infectious and noninfectious disorders affecting the prostate gland. These include acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis with inflammatory and noninflammatory subtypes, asymptomatic inflammatory prostatitis, and granulomatous prostatitis. The most common form is chronic prostatitis/chronic pelvic pain syndrome, accounting for approximately 90% of cases. Overall prevalence of prostatitis ranges from 2–16% in the general population.
Genitourinary procedures are an important risk factor for acute bacterial prostatitis. Effective management of acute prostatitis reduces the risk of recurrent or chronic bacterial prostatitis. Bacterial prostatitis is associated with secretory dysfunction of the prostate. Prostatic secretions become more alkaline, affecting local antibiotic penetration, and there is a reduction in prostatic antibacterial factor, a zinc-containing antimicrobial polypeptide normally present in prostatic fluid.
Acute bacterial prostatitis is most commonly caused by typical uropathogens including Escherichia coli, other Enterobacteriaceae, Pseudomonas aeruginosa, and enterococci. Chronic bacterial prostatitis is usually caused by the same organisms. The inflammatory subtype of chronic prostatitis has an uncertain etiology, although some cases are associated with Chlamydia or Mycoplasma species. Leukocytes are present in expressed prostatic secretions. The noninflammatory subtype also has an unclear cause, though some patients demonstrate voiding dysfunction related to dyssynergy between bladder detrusor and internal sphincter muscles. Granulomatous prostatitis is rare and may follow acute bacterial prostatitis or result from infections such as tuberculosis, nontuberculous mycobacteria, cryptococcosis, blastomycosis, coccidioidomycosis, or histoplasmosis. In patients with AIDS, the prostate may serve as a persistent focus of cryptococcal infection.
Acute bacterial prostatitis should be suspected in any man presenting with symptoms consistent with urinary tract infection accompanied by perineal, pelvic, or lower back pain. Urinary frequency, dysuria, urgency, fever, and chills are common. Chronic bacterial prostatitis often presents with recurrent urinary tract infections caused by the same organism. Patients are frequently asymptomatic between episodes, although some report symptoms similar to chronic nonbacterial prostatitis.
Chronic prostatitis commonly presents with persistent or intermittent perineal, pelvic, lower back, scrotal, or inguinal pain. Urinary symptoms such as frequency, hesitancy, dribbling, urgency, and dysuria may occur. Erectile dysfunction and ejaculatory complaints are also common. Patients with asymptomatic inflammatory prostatitis have no genitourinary pain and are usually diagnosed incidentally during evaluation for infertility or elevated prostate-specific antigen levels.
Physical examination findings vary according to the type of prostatitis. In acute bacterial prostatitis, digital rectal examination performed gently may reveal an enlarged, tender prostate; vigorous examination should be avoided to prevent bacteremia. In chronic prostatitis, the prostate is generally normal on examination. Granulomatous prostatitis produces a firm, indurated prostate.
Laboratory evaluation includes urinalysis, urine culture, blood urea nitrogen, and creatinine measurements before initiating antibiotics. The classic diagnostic method is the four-glass Meares-Stamey test, which compares cultures from urethral urine (VB1), bladder urine (VB2), expressed prostatic secretions (EPS), and postmassage urine (VB3). Elevated bacterial colony counts in EPS or VB3 compared with VB1 suggest bacterial prostatitis. Presence of leukocytes in EPS or VB3 indicates prostatic inflammation. A simplified two-glass pre- and post-prostatic massage test is also commonly used. Imaging studies such as transrectal ultrasonography and CT scanning are useful for detecting prostatic stones and abscesses. Elderly patients with chronic prostatitis symptoms but no infection should undergo evaluation for bladder cancer with urine cytology, bladder ultrasonography, and cystoscopy if indicated.
Granulomatous prostatitis demonstrates granulomas with lipid-laden histiocytes, plasma cells, and multinucleated giant cells on histopathology. The differential diagnosis of prostatitis includes benign prostatic hyperplasia, bladder neck dysfunction, urethral stricture, prostatic calculi, and prostate cancer.
Treatment depends on the specific subtype. Mild acute bacterial prostatitis without nausea or vomiting is treated with oral fluoroquinolones such as levofloxacin or ciprofloxacin, or with trimethoprim-sulfamethoxazole (TMP-SMX), generally for 2–4 weeks. Moderate or severe illness requires parenteral antibiotics such as ampicillin plus gentamicin or intravenous fluoroquinolones until fever resolves, followed by oral therapy to complete a four-week course. Persistent infection may require retreatment for up to 12 weeks.
Chronic bacterial prostatitis requires antibiotics with good prostatic penetration. Preferred regimens include oral fluoroquinolones for four weeks or TMP-SMX for six weeks. Approximately one-third of patients achieve complete response, while others experience partial or no response. Extended antibiotic courses up to 12 weeks may be required. Suppressive therapy with daily TMP-SMX may be necessary in patients with recurrent infections.
There is no consistently effective therapy for chronic inflammatory prostatitis because the etiology is uncertain. A short trial of doxycycline or a macrolide is reasonable to target possible Chlamydia or Mycoplasma infection. If improvement occurs, treatment may continue for an additional 2–4 weeks. In noninflammatory prostatitis associated with voiding dysfunction, alpha-blockers such as tamsulosin, terazosin, or alfuzosin may provide benefit. Antibiotic therapy is not indicated for asymptomatic inflammatory prostatitis.
Supportive management of acute bacterial prostatitis includes stool softeners, analgesics, and antipyretics. Transurethral catheterization should be avoided because it may obstruct drainage of prostatic secretions; suprapubic catheterization is preferred if urinary retention occurs. In chronic prostatitis, hot sitz baths, anti-inflammatory medications, reassurance, and encouragement of sexual activity may improve symptoms. Some patients with pelvic floor tension myalgia benefit from pelvic floor exercises, diathermy, or diazepam. Prostatic massage, oral zinc, and vitamin supplements have unproven benefit.
Surgical intervention may be necessary in chronic bacterial prostatitis complicated by recurrent urinary tract infections despite suppressive therapy or by infected prostatic calculi. Transurethral or open prostate resection may be considered in selected patients.
Follow-up urine cultures should be obtained approximately 14 days after completing treatment for acute bacterial prostatitis. Complications of acute bacterial prostatitis include prostatic abscess, prostatic infarction, bacteremia, progression to chronic bacterial prostatitis, and granulomatous prostatitis.
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