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Prostatitis T I N Daniel A C Diagnosis and Management of O N Acute and Chronic Prostatitis T I N Daniel A. Shoskes Floyd Katske U Sun Kim I N G rostatitis syndromes pre- Prostatitis syndromes are some of the most poorly understood yet sent an interesting con- prevalent problems in urology. There is little controversy over acute trast in incidence and prostatitis, a urinary tract infection with systemic symptoms and E understanding. Acute and signs that typically responds to antimicrobial therapy. By contrast, D Pchronic bacterial prostatitis are the chronic prostatitis syndromes have so far eluded attempts to relatively uncommon, but well- U understand their pathophysiology and design effective therapies, C understood urinary tract infec- resulting in great frustration among patients and health care tions caused by established providers. An accurate diagnosis and a multidisciplinary approach A uropathogens. They are typically T responsive to appropriate antimi- are essential to assist men with this often debilitating condition. crobial therapy. By contrast, the I much more common nonbacteri- O Objectives al prostatitis and prostatodynia N syndromes remain an enigma, This educational activity is designed for nurses and other health both in etiology, appropriate care professionals who care for and educate patients regarding acute workup, and therapy. The rough- and chronic prostatitis. The multiple choice examination that follows ly 2 million annual outpatient is designed to test your achievement of the following educational objec- visits for chronic prostatitis in tives. After studying this offering, you will be able to: the United States (Collins, 1. Define acute and chronic prostatitis. Stafford, O’Leary, & Barry, 1998) 2. Discuss the diagnosis of acute and chronic prostatitis. usually lead to antimicrobial 3. Describe the therapeutic options for treating acute and chronic pro- therapy without an attempt to statitis. document the presence of pro- static infection. This results in very low durable response rates. symptoms for years to decades, suprapubic tenderness and an Despite this, non-antimicrobial leading to depression, job loss, extremely tender prostate. It is alternatives with documented and even suicide. By objective important to avoid vigorous pal- scientific benefit are limited, measures the impact of chronic pation or intentional prostatic often leading to a defeatist pos- prostatitis on quality of life is massage in patients with pre- ture by both patient and doctor. similar to that of Crohn’s disease sumed acute prostatitis, as it may Some patients have persistent (Wenninger, Heiman, Rothman, provoke bacteremia and septic Berghuis, & Berger, 1996). shock. Urinalysis usually reveals elevated WBC and RBC counts Acute Prostatitis and urine culture will be represen- Daniel A. Shoskes, MD, FRCS(c), is Director for Renal Transplant, Acute prostatitis is an acute tative of intra-prostatic organisms. Cleveland Clinic Florida, Fort systemic illness usually caused by Blood analysis should include a Lauderdale, FL. uropathogenic bacteria in the CBC and blood cultures, but not a prostate leading to a febrile uri- PSA, which will be elevated in Floyd Katske, MD, is Assistant nary tract infection. Patients com- most patients due to the acute Clinical Professor, Department of plain of a sudden onset of fever, inflammation. Urology, UCLA School of Medicine, chills, perineal pain, and lower For patients with signs of sep- Torrance, CA. urinary tract symptoms such as sis, therapy for acute prostatitis frequency, urgency, dysuria, noc- begins with appropriate fluid Sun Kim, MD, is a Urology Resident, turia, and even urinary retention. resuscitation and systemic antibi- Department of Urology, UCLA School of Medicine, Torrance, CA. Physical examination may reveal otics, such as ampicillin and an UROLOGIC NURSING / August 2001 / Volume 21 Number 4 255 C aminoglycoside, targeted at gram- age of presentation in the mid prognosis or response to therapy. O negative pathogens. For patients 40s. Onset may be gradual or Indeed, fewer than 50% of urolo- in urinary retention, a suprapubic sudden, but few patients give a gists or primary care physicians N catheter is preferable to a urethral history of prior acute prostatitis. surveyed even examine ex- T Foley catheter, which may be dif- History of urethral discharge or pressed prostatic secretions let I ficult to place and produce penile lesions may indicate ure- alone perform the entire protocol intense pain. Effective empirical thritis or other sexually transmit- (Moon, 1997). The classification N choices for oral antimicrobial ted disease (STD). Patients often system is based upon the culture U therapy (until culture with sen- have a strong belief that they and examination of first voided I sitivities are available) include have identified the instigating urine (VB1), mid-stream urine TMP-SMX (Septra®, Bactrim®) or cause, usually related to a sexual (VB2), expressed prostatic secre- N a fluoroquinolone (Cipro®, encounter or significant increase tions (EPS), and post-prostatic G Floxin®, Levaquin®). These med- in stress. Symptoms may either massage urine (VB3). Patients ications should be continued for be severe, leading to immediate with positive bacterial cultures E 30 days. In patients not immedi- medical consultation, or so mild that localize to the EPS and/or ately responsive to these thera- that the patient waits months VB3 samples are classified as D pies or with a very fluctuant before seeking care. chronic bacterial prostatitis U prostate, prostatic abscess should A thorough physical exami- (CBP). C be considered and diagnosed by nation focusing on the abdomen Standard teaching requires CT scan or transrectal ultrasound. and pelvis is essential, particular- that the cultured organisms be A While the standard therapy for ly to rule out other pathology that established uropathogens and T prostatic abscess has been may produce urogenital pain (for that patients have recurrent uri- I drainage via transurethral resec- example, inguinal hernia, varico- nary tract infections with these tion, recent reports suggest trans- cele). The rectal examination is prostatic organisms, although the O perineal or transrectal drainage performed with the patient stand- rationale for these latter require- N under guidance of transrectal ing and leaning over the examin- ments has never been scientifi- ultrasound is equally effective ing table and supporting his cally validated. By this defini- and avoids a surgical procedure. weight on one elbow, a position tion, probably fewer than 5% of Immunocompromised patients which aids in relaxation of the chronic prostatitis patients have and diabetics are particularly at buttock and leg muscles. At the CBP. risk for prostatic abscess caused start of the rectal examination, the In patients without positive by atypical organisms including surrounding pelvic muscles localizing cultures, further classi- gram-positive bacteria and fungi. should first be palpated to search fication is based on the number Once therapy is completed and for painful muscle spasm. The of WBCs per high-power field the acute prostatitis resolved, prostate in chronic prostatitis may (40x objective) in a wet mount of patients should be reassessed for be small or enlarged, boggy or EPS. Patients with an excessive risk factors such as significant firm, and mildly uncomfortable to number of WBCs are classified as prostatic hypertrophy or ineffi- excruciatingly painful. Enlarged having nonbacterial prostatitis cient voiding with high residual seminal vesicles may be palpable (NBP) and those without classi- urines. as well, particularly in small and fied as having prostatodynia. thin patients. Prostate massage is While many authors use 10 WBC Chronic Prostatitis accomplished with a rolling per hpf as their upper limit of The chronic prostatitis syn- motion of the examining finger normal for EPS, this number has dromes are characterized by uro- from lateral to medial and then not been firmly established. genital pain, often associated from superior to inferior. Ex- Clearly many patients with chron- with voiding symptoms and erec- pressed fluid is collected into a ic prostatitis fluctuate between tile dysfunction. These symp- sterile container held by the low and high WBC counts over toms may be continuous, inter- patient under the penis. A glass time (Wright, Chmiel, Grayhack, mittent, or relapsing. Pain may slide is touched to the penis to & Schaeffer, 1994), and many be felt in the perineum, penis, collect the last drop for asymptomatic patients have scrotum, lower abdomen, back, microscopy. counts in the abnormal range. or groin. Hematuria is rare, but For the past 30 years, the Realizing that the full “4 hematospermia is more common. classification system devised by glass” test is rarely performed Patients may feel relief after ejac- Meares and Stamey has been the and seldom guides treatment, it ulation, or have severe post-ejac- standard used (see Table 1). is still important to thoroughly ulatory pain as their primary However, this system has never rule out infection in these symptom. Age of onset begins in been validated or shown to dif- patients, at least at the initial late adolescence, with a median ferentiate patients on the basis of consultation. At a minimum 256 UROLOGIC NURSING / August 2001 / Volume 21 Number 4 Table 1. C Classification Systems for Chronic Prostatitis/Chronic Pelvic Pain Syndrome O Acute EPS/VB3 Elevated WBC in Meares-Stamey N UTI? Culture EPS or VB3? Classification NIH Classification
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