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Chronic Prostatitis

Essentials

  • Antimicrobials are indicated in selected cases only.

Definition and aetiology

  • Painful condition in the male genital area, perineum or pelvic area that has lasted for more than 3 months without findings of a bacterial urinary tract infection
  • Usually (in more than 90% of the cases) the patient has sterile prostatodynia. The condition tends to recur several times a year.
  • The disease may be caused by bacteria residing in the prostatic ducts.
  • Definite aetiology still remains unclear (multi-aetiological).

Symptoms

  • The symptoms are similar to those of acute prostatitis but milder and recurring.
    • Voiding difficulties and burning on urination, increased urinary frequency, feeling of incomplete emptying of the bladder
    • Aching pain in the lower abdomen, scrotum, perineum, glans, or inner thighs
    • Feeling of pressure in the perineum, anus or anterior to the anus
    • Painful ejaculation
    • Sometimes bloody semen Haematospermia
  • Decreased libido, erectile dysfunction

Findings

  • Tenderness of the prostate on digital examination. However, lack of tenderness does not exclude chronic prostatitis
  • Normal urine test results (urinalysis and bacterial culture)
  • Chronic prostatitis may occur simultaneously with benign prostatic hyperplasia Benign Prostatic Hyperplasia.

Treatment Allopurinol for Chronic Prostatitis, Pregabalin for Chronic Prostatitis

  • Avoidance of cold: warm clothing, warm sitz baths
  • NSAIDs
  • Alpha-blockersAlpha-Blockers for Chronic Abacterial Prostatitis
  • 5-alpha-reductase inhibitors
  • Amitriptyline in gradually increasing doses
  • Massage of the prostate and ejaculations sometimes alleviate the symptoms.
    • There is no standardized prostate massage, but one method is to massage both lobes from the lateral side towards the midline for a couple of minutes.
  • Continuity of the doctor-patient relationship; reassurance of the benign nature of the condition; diagnosis and treatment of possible depression
  • Antimicrobial drugs are not indicated for prostatodynia.
  • A fractionated urine sample is taken in frequently recurring cases.
    • First, a urine sample is collected at the beginning of the stream. Then the prostate is massaged and a new urine sample is taken immediately to be microscoped and cultured.
    • If bacteria are detected, treat with a 1-2-month course of sulpha-trimethoprim or fluoroquinolones (starting with e.g. norfloxacin 400 mg twice daily, lowering the dose later on). Potential adverse effects associated with fluoroquinolones should be carefully considered before using them.
    • In case of inflammatory chronic prostatodynia the post-massage sample usually contains leucocytes.
  • If the patient has pyuria without bacterial growth, treat once with a 1-to-2-month course of an antimicrobial drug. According to a recommendation by the EMAhttp://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products, fluoroquinolones should not be used for the treatment of non-bacterial chronic prostatitis. If this is not beneficial, do not give repeated courses of antimicrobials.

    References

    • Franco JV, Turk T, Jung JH ym. Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev 2019;(10):CD012552. [PubMed]
    • Franco JV, Turk T, Jung JH ym. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Rev 2018;(5):CD012551. [PubMed]