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Prostatitis Diagnosis and Treatment Gretchen Dickson CLINICAL Prostatitis Diagnosis and treatment Gretchen Dickson gland following intraprostatic reflux of urine Prostatitis is a spectrum of disorders that impacts a significant number of men. infected with organisms such as Escherichia coli, Acute bacterial prostatitis may be a life-threatening event requiring prompt Enterococcus and Proteus species.5,6 Men with recognition and treatment with antibiotic therapy. Chronic bacterial prostatitis has chronic indwelling catheters, diabetes mellitus, a more indolent course and also requires antibiotic therapy for resolution. Chronic immunosuppression, or who intermittently prostatitis/chronic pelvic pain syndrome is the most common manifestation of prostatitis and may be the most difficult to treat. Asymptomatic inflammatory perform self-catheterisation, are at higher risk prostatitis is an incidental finding of unclear significance. Understanding the of developing ABP due to their increased risk of diagnostic and management strategies for each of these entities is critical for bacterial colonisation of the urethra.6,7 There is general practitioners in caring for their male patients. no evidence that perineal trauma from bicycle or horseback riding, dehydration or sexual abstinence Keywords are risk factors for ABP. prostatitis; bacterial infections; pelvic pain The clinical presentation of ABP may be highly variable with symptoms ranging from mild to severe.6 Classic symptoms include: Up to 8% of Australian men report having • fever urogenital pain at any given time, with • chills 15% of men suffering from symptoms • perineal or lower abdominal pain of prostatitis at some point during their • dysuria lives.1,2 In addition to causing impaired • urinary frequency quality of life, men who have a history of • urinary urgency prostatitis have increased rates of benign • painful ejaculation prostatic hyperplasia, lower urinary tract • hematospermia.8 symptoms and prostate cancer.1,3 Acute bacterial prostatitis should be considered in the differential diagnosis of any male presenting Prostatitis encompasses four distinct clinical with urinary tract symptoms. While gentle entities, which can be described using the National palpation of the prostate gland on physical Institutes of Health International Prostatitis examination will often reveal a pathognomonic Collaborative Network classification system. The finding of an exquisitely tender, boggy prostate four categories of prostatitis are: gland, care should be taken to avoid vigorous • acute bacterial prostatitis prostate massage as this may precipitate • chronic bacterial prostatitis bacteremia and sepsis.9 • chronic prostatitis/chronic pelvic pain syndrome Acute bacterial prostatitis can be diagnosed – inflammatory subtype clinically, although both urine Gram stain and – non-inflammatory subtype urine culture are recommended to identify • asymptomatic inflammatory prostatitis.4 causative organisms and guide treatment. While blood cultures and C-reactive protein may prove Acute bacterial prostatitis useful, a prostate specific antigen (PSA) test is not Acute bacterial prostatitis (ABP) accounts indicated. Prostate specific antigen elevations are for approximately 5% of cases of prostatitis common in the setting of infection and may take cases.1 Although rare, ABP requires prompt up to 1 month postinfection to resolve. Imaging recognition and treatment as it may result in is only indicated when prostatic abscess is sepsis. Acute bacterial prostatitis results from suspected in a patient with ABP who is failing to proliferation of bacteria within the prostate improve with treatment. 216 Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 42, NO. 4, APRIL 2013 Prostatitis – diagnosis and treatment CLINICAL Antibiotic therapy for ABP should be based Table 1. Treatment of acute and chronic bacterial prostatitis40 on the acuity of the patient and the known or suspected causative organism. Table 1 outlines Acute bacterial Mild or moderate disease while awaiting culture the Australian Therapeutic Guidelines current prostatitis • Trimethoprim 300 mg orally daily for 14 days, or treatment recommendations. While ABP is • Cephalexin 500 mg orally twice daily for 14 days, or usually caused by urinary pathogens, sexually • Amoxicillin and clavulanic acid 500 mg + 125 mg orally twice transmissible infections such as chlamydia and daily for 14 days gonorrhoea should be considered, particularly Appears septic or unable to tolerate oral therapy in young men. If chlamydia is thought to be • Admit to hospital, offer parenteral therapy with ampicillin and gentamycin or ceftriaxone as per severe pyelonephritis the causative agent, azithromycin 1 g orally treatment stat or doxycycline 100 mg orally twice daily for 7 days is appropriate. If gonorrhoea is Chronic bacterial First line treatment suspected, ceftriaxone 500 mg intramuscularly prostatitis • Norfloxacin 400 mg orally every 12 hours for 4 weeks, or and azithromycin 1 g orally is indicated. Contact • Trimethoprim 300 mg orally daily for 4 weeks tracing, notification and treatment is also If chlamydia or ureaplasma noted important in these cases. • Doxycycline 100 mg orally every 12 hours for 2–4 weeks In addition to antibiotic therapy, non-steroidal anti-inflammatory drugs (NSAIDs) may offer spread of rectal bacteria, hematogenous spread of both the right and left sides of the prostate gland. both analgesia and more rapid healing through bacteria from a remote source, undertreated acute More than 20 leucocytes per high powered field liquefaction of prostatic secretions.6 bacterial prostatitis or recurrent urinary tract on the post-massage urine sample is diagnostic Urine culture 48 hours post-treatment is infection with prostatic reflux. Causative agents of CBP.19 If urine cultures show no growth, useful combined with review after 7 days of of CBP are similar to those of ABP include Gram consider a nucleic acid test for C. trachomatis antibiotic treatment to assess clinical response to negative rods, fungi, mycobacterium, Ureaplasma and culture of prostatic fluid for ureaplasmas. treatment. urealyticum, Chlamydia trachomatis14 and Occasionally, Mycoplasma genitalium is found in If the patient fails to improve with antibiotics, Trichomonas vaginalis.15 However, Escherichia prostatic secretions, although its role in prostatitis a prostatic abscess should be suspected, coli is believed to be the causative organism in is unclear. If these tests are also negative, an particularly in men who are immunocompromised, 75–80% of CBP cases.14 alternative diagnosis should be considered. have diabetes mellitus or who have had recent Recognising CBP can be difficult, as the Limited comparative trials exist to guide instrumentation of the urinary tract.10 Both history and examination are highly variable. All antibiotic regimens for CBP. Table 1 lists current computed tomography (CT) and transrectal patients note some degree of genitourinary pain recommendations. Patients should be warned ultrasound may be used to detect a prostate or discomfort. Common presentations include about the common side effects of extended abscess.11 If perineal puncture of the abscess is recurrent urinary tract infections with no history duration of antibiotic use, such as Achilles tendon planned, ultrasound may guide the procedure.12 of bladder instrumentation, dysuria and frequency rupture with fluoroquinolones. However, if surgical debridement of the abscess is with no other signs of ABP or new onset sexual In addition to antibiotics, NSAIDs may planned, a CT scan may be more helpful to define dysfunction without other aetiology.16,17 alleviate pain symptoms. Alpha-blockers may borders of the abscess, plan the surgical approach Often the physical examination, including diminish urinary obstruction and reduce future and to investigate for other abnormalities in the prostate examination, is normal. Prostate occurrences.20 Although less well studied, saw genitourinary system.12 examination should be performed to document palmetto, quercetin, daily sitz baths, perianal Acute urinary retention may develop as a any abnormalities such as prostatic calculi, which massage and frequent ejaculation may also complication of ABP. Suprapubic tap should can serve as a reservoir of infection. Prostate help to clear prostatic secretions and lessen be performed to alleviate retention as urethral stones may be difficult to palpate, but if found, discomfort. If prostatic stones are present, catheterisation may worsen infection and is may impact management decisions. prostatectomy may eliminate the nidus of contraindicated. In addition to acute urinary Although the Meares-Stamey four glass infection. retention and prostatic abscess, ABP can lead test is the gold standard to diagnose CBP, it is to sepsis, chronic bacterial prostatitis, fistula rarely used in practice due to time constraints Chronic prostatitis/chronic formation or spread of infection to the spine or and the difficulty obtaining samples.18 Instead pelvic pain syndrome sacroiliac joints.6,13 pre- and post-prostatic massage urine samples Chronic prostatitis/chronic pelvic pain syndrome for analysis and culture may be useful and can (CP/CPPS) is more common than either acute Chronic bacterial prostatitis guide antibiotic therapy.19 A prostate massage bacterial or chronic bacterial prostatitis.4 Up to Chronic bacterial prostatitis (CBP) may result is performed by stroking the prostate with firm 18% of Australian men may experience some from ascending urethral infection, lymphogenous pressure from the
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