A. Types of Prostate Disease and Prostatitis [5]

1. Types of Prostate Disease
   1. Benign prostatic hyperplasia (BPH)
   2. Prostate Cancer
   3. Prostatitis (acute and chronic)
   4. Prostatodynia (prostate pain / pelvic pain syndrome)
2. Types of Prostatitis [2,5]
   1. Category I: Acute Bacterial (Type I)
   2. Category II: Chronic Bacterial (Type II)
   3. Category III: chronic pelvic pain syndrome
   4. Noninfectious (Type IIIA with inflammation)
   5. Prostatodynia (Type IIIB: prostate pain and urgency without inflammatory cells)
   6. Category IV: Asymptomatic inflammatory prostatitis
3. Bacterial Prostatitis (~10% of cases)
   1. More common in older men
   2. Usually with BPH
4. Non-Bacterial (Abacterial) Prostatitis
   1. Cause of prostatitis is unknown in ~90% of cases
   2. Inflammatory cells present in prostatic fluid
   3. No inflammatory cells found in prostatic fluid
   4. More common in younger men
5. Non-bacterial prostatitis without inflammatory cells may be prostatodynia
6. Bacterial prostatitis is discussed first

B. Presentation of Bacterial Prostatitis

1. Acute or gradual onset of severe back/rectal pain
2. Worse when sitting, often relieved by standing
3. Hematuria or dysuria
4. Dyspareunia may occur
5. Usually in older men
   1. BPH
   2. Prostate cancer
   3. Instrumentation - catheterization, post-surgical

C. Causes of Bacterial Prostatitis

1. Usually enteric Gram negative rods
2. Partially treated patients may redevelop infection with pseudomonas or enterobacter etc.
3. Mixed infections very common with BPH
4. Failure to treat adequately will result in severe chronic prostatitis
5. Chlamydia trachomatis and Ureaplasma urealyticum are common causes in sexually active men (usually younger) with urethritis
6. Autoimmune prostatitis - may play a role in chronic prostatitis and pelvic pain [3]

D. Diagnosis

1. Severe pain on rectal exam in prostate area
2. Fluctuant prostate - avoid prostatic massage if frank bacterial prostatitis is suspected
3. Three or four stage Urinalysis + Culture (include chlamydia) [2,5]
   1. Initial void specimen
   2. Do prostatic massage (via rectal exam)
   3. Secondary void specimen
   4. Tertiary void specimen
   5. In 4-stage test, an additional prostatic fluid specimen is obtained
   6. Prostatitis will have high WBC and organisms with Third>Second Specimen
   7. The overall sensitivity and specificity of this diagnostic strategy is not known
   8. A two stage (pre- and post-void urine) test is about as accurate and easier to do [5]
   9. Also called Meares-Stamey 4-Glass Urine Test
4. Prostate ultrasound to rule out abscess
5. PSA will be elevated in bacterial prostatitis as well as in BPH and prostate cancer

E. Treatment of Prostatitis Categories I and II

1. A prolonged course (4 weeks) of a prostate-penetrating drug is absolutely essential
2. Fluoroquinolones
   1. Often first line therapy
   2. Ciprofloxacin (Cipro®) - 500 mg po bid
   3. Ofloxacin (Oflox®) - 300-400 mg po bid
   4. Levofloxacin - 500 mg po qd
3. TMP/SMX (Bactrim®, Septra®)
   1. Alternative first choice for bacterial prostatic infections
   2. Excellent penetration into prostate and inexpensive
   3. Dose is 1 double strength (DS) tablet po bid
4. Doxycycline 100mg po bid or Azithromycin (500mg qd) for atypical organisms [1]
5. Aggressive treatment of candidal infections with po fluconazole 3-4 weeks
6. Recurrent bacterial prostatitis may be treated by sub-total prostate resection
7. In non-responsive to antibiotics, consider non-bacterial prostatitis and prostadynia

F. Non-Bacterial (Abacterial) Prostatitis [5]

1. The etiology of this syndrome is largely unclear
2. Unlikely due to persistent atypical organisms such as chlamydia or ureaplasma
3. Syndrome complex consists of:
   1. Abdominal, pelvic, perineal, or rectal pain
   2. Disturbance of sexual function
   3. Absence of bacteria in urine (and prostatic massage) specimen
4. Pain is the hallmark of this condition
5. Evaluation
   1. This is a diagnosis of exclusion (no definitive diagnostic test exists)
   2. Therefore, common problems must be ruled out
   3. Urine culture for bacteria
   4. Prostate Specific Antigen (PSA) to rule out prostate cancer
   5. Rectal / prostate exam to rule out distal rectal cancers and prostate anomalies
   6. Ultrasonography - transabdominal to rule out prostatic abscess
   7. Prostate secretion - evaluation for inflammatory cells, but unclear clinical relevance
   8. Prostate secretions can also be cultured for bacteria
   9. Prostatic massage should NOT be done if frank bacterial prostatitis is suspected
6. Pain Control
   1. Anti-inflammatory agents (NSAIDs) are typically used but of moderate benefit
   2. Narcotics should only be used in selected cases
   3. Prostatic Massage may be effective in some patients
   4. Sitz baths and/or warm baths in a tub may help relieve symptoms
   5. Alpha-adrenergic blockers may be of some utility in this disease
7. Antibiotics
   1. Even with negative cultures, antibiotics are used in this condition
   2. TMP/SMX is usually first line
   3. Fluoroquinolones, doxycycline, or azithromycin are reasonable second choices
   4. A 10-30 day course of antibiotics may be used even in absence of clear infection
   5. Some patients with culture negative prostatitis will have clinical benefit
8. Other Medications
   1. Treatment of BPH symptoms may be helpful
   2. Medications for interstitial cystitis may be helpful
   3. Reducing urate concentrations with allopurinol has shown some success [4]
9. Other Modalities
   1. Stress management appears to be helpful in this syndrome
   2. Acupuncture may be beneficial in this condition
   3. Various herbel extracts have not demonstrated benefits in placebo-controlled trials
   4. However, the bioflavonoid quercetin showed some benefit in a 30 days study [6]

References

1. Pewitt EB and Schaeffer AJ. 1997. Infect Dis Clin North Am. 11(3):623
2. Schaeffer AJ. 2006. NEJM. 355(16):1690
3. Alexander RB, Brady F, Ponniah S. 1997. Urology. 50(6):893
4. Nickel JC, Siemens DR, Lundie MJ. 1996. Lancet. 347:1711
5. Collins MN, MacDonald R, Wilt TJ. 2000. Ann Intern Med. 133(5):367
6. Shoskes DA, Zeitlin SJ, Shahed A, Rajfer J. 1999. Urology. 54:960