​Kembara Xtra - Medicine - Prostatitis

​Kembara Xtra - Medicine - Prostatitis  
Significant impact on quality of life 10% bacteria-proven infection Painful or inflammatory disorder affecting the prostate gland with or without bacterial origin, frequently marked by urogenital pain, voiding symptoms, and/or sexual dysfunction Classification of bacterial prostatitis by the National Institutes of Health (NIH): Class I: Acute Bacterial Prostatitis, characterized by fever, perineal pain, dysuria, and obstructive symptoms; polymorphonuclear leukocytes (PMNL) and bacteria in urine; Class II: Chronic Bacterial Prostatitis, characterized by pain and voiding disturbances; PMNL and bacteria in expressed prostatic secretions (EPS), Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a Class III condition. Chronic symptoms with PMNL in EPS/urine following prostate massage or in semen are indicative of inflammation (subtype IIIA). Class IV: asymptomatic inflammatory prostatitis: incidental detection after prostate biopsy; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen. Noninflammatory (subtype IIIB): persistent symptoms without the presence of PMNL in EPS/urine after prostate massage or in semen. impacted system(s): genitourinary, renal, and reproductive


Epidemiology Incidence: 2 million cases each year in the United States; bimodal peaks in ages 20 to 40 and >60; chronic disease is more prevalent in individuals over 50.
 More common bacterial prostatitis with HIV.
Prevalence
8.2% of males are affected, and the lifetime probability of diagnosis is over 25%.
 Represents 8% of urologist visits and 1% of visits to primary care doctors Cases as a percentage by class:
1% for class I, 5% for class II, 80% for class III, and 10% for class IV.

Pathophysiology and Etiology 

(NIH class I) Acute bacterial prostatitis - Ascending urethral infection with intraprostatic reflux of infected urine into prostatic ducts is most likely the cause, which is frequently linked to cystitis. - Can happen after prostate instrumentation
Escherichia coli is the most prevalent gram-negative bacteria, followed by Proteus, Klebsiella, Serratia, and Enterobacter species, as well as Pseudomonas aeruginosa. Gram-positive bacteria, such as Staphylococcus aureus, Streptococcus, and Enterococcus species, are uncommon. - If staphylococcal prostatitis is confirmed, hematogenous spread, including endovascular sources, should be examined.
- Chlamydia trachomatis, Trichomonas vaginalis, Ureaplasma urealyticum, Mycobacterium tuberculosis, and fungal etiologies are examples of atypical bacteria that can affect immunosuppressed hosts.
- Think about C. trachomatis or Neisseria gonorrhoeae in sexually active men under 35.
Chronic bacterial prostatitis (NIH class II) is characterized by recurrent episodes of the same organism, similar infections, and a potential larger prevalence of gram-positive bacteria than in acute prostatitis.
- Although the progression of acute prostatitis to CP is not fully understood, it may be caused by subpar acute prostatitis care.
CP/CPPS (NIH class III) - Uncertain cause; no recent evidence to establish an infectious source - The provoking factor may produce neurologic or muscle pain in the pelvic floor as well as inflammation surrounding the prostate.
Patients with chronic inflammation on histology have a shorter time to symptomatic development. However, there is no relationship between prostate histologic inflammation and the presence or absence of symptoms.

Urinary tract infections, including STIs, HIV infection, prostatic calculi, urethral stricture, indwelling intermittent catheterization, genitourinary instrumentation, such as prostate biopsy (especially in patients who have previously taken quinolones), transurethral resection of the prostate (TURP), cystoscopy, urinary retention, benign prostatic hypertrophy, unprotected sexual contact, and prostate cancer are risk factors.

Prevention 

Antibiotic precautions for prostate biopsy and genitourinary instrumentation

Benign prostatic hypertrophy, cystitis, urethritis, and sexual dysfunction, including erectile dysfunction and premature ejaculation, are associated conditions.

Providing History Class I acute prostatitis:
- Malaise, chills, and fever from an acute illness - Low back pain, myalgias
- Vomiting and nauseous
Urgency, regularity, dysuria, and nocturia
- Perineal pain, pelvic pain, and enlarged prostate
- Cloudy pee - Recent prostate instrumentation - Poor stream, hesitation, retention, and urge incontinence are signs of obstructed voiding.
CP (classes II and III) symptoms can include any of the following and vary from patient to patient: - More subtly manifested than in class I - Symptoms for three of the past six months
Low-grade fever (class II only) - High caffeine and alcohol intake
- Perineal pain and prostatitis
- Urgency, frequency, and dysuria
Lower abdominal discomfort
Hematospermia, penile, and/or testicular pain, as well as sexual dysfunction and painful ejaculation


clinical assessment 
Vital signs (Sepsis is suggested by unstable vital signs.) Examining the back for CVA discomfort and the abdomen for bladder distension NIH class I prostate examination for acute bacterial prostatitis: The prostate is extremely edematous, heated, sensitive, and hard.
- Chronic bacterial prostatitis, NIH class II: The prostate is frequently normal, but it can sometimes be swollen, painful, edematous, or nodular.
- CP/CPPS: often normal prostate, NIH class III
ALERT
Avoid strong prostate massage in cases of acute bacterial prostatitis; it may cause iatrogenic bacteremia; gentle massage is safe.

Differential diagnoses include: Pyelonephritis, bacterial or interstitial cystitis, urethritis, epididymitis, proctitis, prostatic abscess, acute or chronic urinary retention, benign or malignant prostatic hypertrophy, obstructive calculi, and foreign bodies.

Initial test results from the laboratory and imaging
Urinalysis, urine culture, and sensitivity tests for suspected acute prostatitis (NIH class I) 
Prostate-specific antigen (PSA) is not advised unless there are particular indications. Complete blood count with differential, blood culture if immunocompromised or evidence of SIRS/sepsis are present.
- Imaging is optional and performed when needed to rule out problems, such as a pelvic ultrasound or bladder scan if signs of urine retention are present, or a transrectal prostatic ultrasound (TRUS) to rule out an abscess. Prostate imaging at first is not advised.
- STI testing (riskier in men aged 35 or older who engage in risky sexual conduct); Suspected chronic bacterial prostatitis (NIH class II) - Lower urinary tract microbiologic localization cultures Pre- and post-massage urine culture, 4- or 2-glass test - Semen cultures should not be performed.
TRUS is not suggested.
- Urodynamics investigations are optional but may be useful in identifying blockage or bladder issues.
 CP/CPPS suspected (NIH class III) - Making an exclusionary diagnosis (particularly to rule out a STI or urinary tract infection with a history, physical exam, and appropriate laboratory testing, as needed) - The use of the NIH Chronic Prostatitis Symptom Index (NIH-CPSI), a nine-question symptom survey, is helpful for symptom evaluation (not diagnosis) both at the time of diagnosis and throughout treatment.
- Pre- and post-massage tests using 4 or 2 glasses, with urine microscopy as an optional extra (prostatic massage is infrequently and anecdotally linked to sepsis; proceed with caution). - Urodynamic tests are optional but may be useful in determining the cause of obstructive symptoms.
- Semen cultures should not be performed.
- Cystoscopy may be necessary for some individuals, such as those who have hematuria or obstructive symptoms that are resistant to treatment.
TRUS is not suggested.
- It is not advisable to have serum PSA levels unless there are specific reasons (such as abnormal DRE, age >45, family history of prostate cancer, or risk factors). - Psychological evaluation - If hematuria is present: urine cytology, cystoscopy, and contrast-enhanced CT urography - Urinary swab for urethral symptoms (dysuria, discharge, penile discomfort) Testicular pain: scrotal US; concurrent stomach pain: CT scan
- MRI of the spine for lumbar radiculopathy

Tests in the Future & Special Considerations
Failure to react to initial antibiotic therapy: prostate imaging by US, CT, or MRI and referral to urology  If prostatic calculi, cancer, or an abscess are suspected, a TRUS, CT scan, or MRI may be ordered.
If symptoms continue after receiving the recommended course of treatment, repeat a urinalysis and/or a culture for acute bacteria.
To guarantee that the infection has cleared up following antibiotic therapy, think about repeating the urine culture after 7 days.

Diagnostic procedures/other include cystoscopy (to look for bladder cancer, interstitial cystitis if hematuria is present, or obstructive symptoms resistant to treatment), needle biopsy or aspiration for culture, urodynamic testing, and cytoscopy.

Treatment options include: NSAIDs for analgesia; 1-Blockers for symptoms of the lower urinary tract (obstructive/voiding symptoms); antipyretics/stool softeners; hydration; Sitz baths to ease pain and spasm; urinary drainage for urine retention; and, as needed, anxiolytics and antidepressants.

First Line of Medicine
NIH class I (outpatient) acute bacterial infection: antibiotic therapy is advised.
- The first-line drugs of preference are fluoroquinolones.
There is no clinically significant difference between levofloxacin 500 to 750 mg PO once day and the fluoroquinolones ciprofloxacin 500 mg PO every 12 hours. Trimethoprim-sulfamethoxazole 160/800 mg PO every 12 hours (Take into account regional E. Coli resistance rates.) - The average length of therapy is two to four weeks, however other experts advocate up to six weeks.
If at risk for STIs, use ceftriaxone 250 mg IM for 1 dose (or cefixime 400 mg PO for 1 dosage) in addition to azithromycin 1 g PO for 1 dose or doxycycline 100 mg PO q12h for 10 days. Obtain both blood and urine cultures in cases of acute bacterial NIH class I (inpatient) urinary drainage (indwelling, intermittent, or suprapubic catheterization).
- First-line IV broad-spectrum antibiotic treatment for critically unwell patients: ○ IV fluoroquinolone + aminoglycoside (ciprofloxacin 400 mg IV q12h or levofloxacin 500 to 750 mg IV q24h + gentamycin 5 mg/kg IV daily) with or without a broad penicillin (ampicillin 1 to 2 g q4-6h) or 2nd-/3rd-generation cephalosporin (cefuroxime IV 1.5 g q8h ceftriaxone 1 to 2 g IV q24h - De-escalate to oral regimen pending blood/urine culture results and with clinical improvement for additional 2 to 4 weeks of therapy.
Fluoroquinolones (ciprofloxacin 500 mg PO q12h or levofloxacin 500 to 750 mg PO daily for 4 to 6 weeks) are preferred first-line antibiotics, followed by trimethoprim-sulfamethoxazole (160/800 mg PO q12h for 8 to 12 weeks).
 If gram-positive bacteria (Enterococcus faecalis) are present and ciprofloxacin or levofloxacin have not been effective, consider moxifloxacin 400 mg PO once day or linezolid 600 mg PO every 12 hours.
- When compared to ciprofloxacin, macrolide (azithromycin) therapy has a better rate of clinical improvement and eradication.
Refractory cases: if all other treatments fail, consider radical TURP, intermittent antimicrobial therapy for acute symptomatic episodes (cystitis), low-dose antimicrobial suppression, or open prostatectomy. - Blockers combined with antimicrobial therapy are best for patients with obstructive symptoms because they lower the high recurrence rate.
CP/CPPS NIH class III - Unknown cause of disease, so little information on effective therapy - therapy choice is patient-centered, focusing on symptom management of four domains: pain, symptoms of the lower urinary tract, psychological stress, and sexual dysfunction.
- Empiric trial of cutting off caffeine and alcohol - 1-Blockers (tamsulosin 0.4 mg PO daily) may be helpful, particularly for males with symptoms of the lower urinary tract, but studies have not found statistically significant differences.
- Fluoroquinolones (ciprofloxacin 500 mg PO BID) may aid patients with their symptoms, however studies do not support this claim statistically.
NSAIDs can aid in treating symptoms.


Referral Urology referral is necessary if antibiotic medication is unsuccessful, symptoms continue (particularly obstructive voiding symptoms), hematuria or increased PSA, or if an abscess does not clear up after less than a week of treatment and requires surgical drainage.

Additional Therapies: Psychotherapy (preferably with cognitive-behavioral therapy [CBT]) for sexual dysfunction or psychosocial stressors; Pudendal nerve block or neurolysis if pudendal nerve entrapment is a contributing factor.

Surgical Techniques 
For refractory cases of recurrent bacterial prostatitis or to empty an abscess, surgical resection may be considered. Procedures including balloon dilatation, neodymium: YAG laser, transurethral needle ablation, microwave hyperthermia, and thermotherapy are currently not advised for CP/CPPS class III (1)[A]. Radical transurethral resection or complete prostatectomy are not advised for CP/CPPS class III.


Healthcare Alternatives 
Acupuncture and extracorporeal shockwave therapy have the strongest evidence of a reduction in prostatitis symptoms without side effects, according to CP/CPPS class III.

Admission - Sepsis - PO intolerance - Urinary retention - Proven or suspected abscess - Risk factors for resistance (recent fluoroquinolone usage or instrumentation of the prostate) - Immunocompromised

Follow-Up Negative urine culture at 7 days following the end of the therapy period is indicative of a cure. If a patient doesn't respond well to treatment, take prostatic abscess into consideration.
Nine items from the Patient Monitoring NIH-CPSI can be used to assess the severity of a patient's symptoms and their response to treatment across three domains:  Urinary symptoms Pain
 Standard of living

The prognosis is that the fever and the dysuria will go away in 2 to 6 days.
Acute infections typically get better within 3 to 4 weeks.
10% of cases of acute bacterial prostatitis may advance to CP. The course of CP is frequently extended. The cure rate for CP ranges from 55 to 97%, depending on the population and the medicine utilized.


Complications include: Pyelonephritis, Gram-negative sepsis, bacteremia, urinary retention, epididymitis, infertility, chronic bacterial prostatitis (following acute prostatitis), metastatic infection (spinal, sacroiliac), erectile dysfunction, and prostatic abscess (frequent in HIV-infected patients).

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