A Clinical Guide To Prostatitis The term prostatitis is often used to cover a multitude of ills. Ye it is important to have a working knowledge of this condition to ensure patients receive adequate treatment.

Prostatitis is frequently used as a descriptive rather than diagnostic term. It is commonly used to describe men with atypical, often bizarre symptoms referable to the genito-urinary tract, but it is important to identify patients who have a treatable cause.

The American National Institutes of Health (NIH)classification of prostatitis is useful and has distinct management implications.

The NIH classifies prostatitis into several categories; acute bacterial, chronic bacterial prostatitis and chronic abacterial prostatitis. The latter condition is also known as chronic pelvic pain syndrome, prostatosis or prostatodynia.

Excluding men with treatable conditions identifies men whose pelviperineal symptoms cannot be readily eliminated; these men are in need of ongoing management and supportive counselling.

This is an obvious diagnosis. The patient presents with acute symptoms of fevers, rigors, irritative voiding and myalgia. On examination the patient looks "toxic", with a high temperature and a palpably tender indurated swollen prostate gland. Appropriate management usually requires hospital admission for rehydration, parenteral broad spectrum antibiotic therapy and observation to exclude urinary retention. Analgesics and stool softeners are recommended.

It the patient is not systemically unwell and has no vomiting or diarrhoea, they can be managed as outpatients using ciprofloxacin, which has good oral absorption.

There is no place for prostatic massage in the management of acute bacterial prostatitis.

For inpatients, the antibiotics of choice are an aminoglycoside plus ampicillin if there is no penicillin allergy. Gentamicin 240mg daily IVI is recommended with ampicillin 1gm IVI tds. Creatinine and gentamicin levels need to be carefully monitored. In cases of penicillin allergy, a third generation cephalosporin can be substituted for ampicillin. If urinary retention occurs, a suprapubic catheter should be inserted under general anaesthetic.

It is important that antibiotic therapy is not discontinued prematurely; 3-4 weeks of oral outpatient antibiotic treatment is needed using either trimethoprim or fluoroquninolone - either ciprofloxacin or norfloxacin. These antibiotics achieve adequate prostate parenchymal levels and are generally effective against the causative organisms. The most common organism is Escherichia coli, less common is Klebsiellas proteus, enterobacter and pseudomonas; whereas gram positive organisms are uncommon. Using this combination of parenteral and oral antibiotic therapy the cure rate of acute bacterial prostatitis is 95%.

A prostatic abscess should be suspected in patients with acute bacterial prostatitis who fail to respond to parenteral antibiotic therapy. If there is no improvement in forty eight hours, the patient should be assessed with an abdomino-pelvic CT scan. Should a prostatic abscess be present consideration should be given to transurethral or transperineal drainage.

Chronic bacterial prostatitis is a relatively rare condition characterised by asymptomatic periods between episodes of recurrent bacteruria. The organisms involved are usually coliforms unless the patient is immuno-suppressed.

Chronic bacterial prostatitis is one of the most common causes of relapsing urinary tract infections in men although its cause is poorly understood. The diagnosis should be suspected in men with recurrent bacteruria whose IVP or urinary tract ultrasound excludes other causes of urinary tract sepsis. Symptoms of chronic prostatitis include mild to moderate irritative voiding symptoms, perineal and low back pain. Most men with chronic bacterial prostatitis do not experience acute bacterial prostatitis before the onset of the chronic condition.

Ideally, localisation studies such as the Stamey test should be performed to identify the prostate as the source of the bacteria. This test is complex and involves examining a first voided urinary sample for evidence of urethritis, a mid-stream urine to exclude cystitis, prostatic secretions for culture and a final urine specimen for culture.

In clinical practice, however the Stamey localisation study is seldom done as it is awkward and uncomfortable for patients and time consuming for the treating physician. An empirical trial of either ciprofloxacin or norfloxacin is safe and effective for the management of chronic refractory bacterial prostatitis. The cure rate is in the order of 75% if the antibiotic therapy is continued for a duration of 4-6 weeks.

Patients whose symptoms recur and are often benefited by long-term, low dose suppressive antibiotic therapy with either trimethoprim, nitrofurantoins or tetracyclines.

In cases of chronic bacterial prostatitis it is important to exclude significant bladder neck obstruction as a potential underlying cause of the condition. Video urodynamics is the diagnostic strategy of choice in this regard.

However, a three week course of an antibiotic can be tried empirically first and referral for further investigation reserved for non-responders. In the absence of proven bladder neck obstruction, transurethral prostatectomy has a limited role in the management of patients with chronic bacterial prostatitis. It is curative only if all foci of infective tissue and calculi are removed. As the inflammation is predominantly in the peripheral zone, the ducts of which empty into the urethral distally, surgery carries with it an increased risk of post-operative urinary incontinence and should only be proceeded to with great caution.

Asymptomatic prostatic calculi occur in the majority of men over 50. These calculi are generally contained within the prostatic ductal acini and are generally not colonised by bacteria. In the absence of chronic infection, they do not require treatment.

Occasionally in men with chronic bacterial prostatitis, prostatic calculi are colonised and an attempt to remove the infected calculi is justifiable using transurethral resection.

The majority of men labelled with prostatitis fit into the category better described as non-bacterial prostatitis or prostatosis. This symptoms complex includes diffuse pelvi-perineal pain involving the low back, pelvis and perineal regions. These men have negative urine cultures and negative localisation studies when the latter are performed. There is no unambiguous information to assert a causative role for either chlamydia or ureaplasma urealyticum infections in this condition.

Because the aetiology of prostatosis is poorly understood, treatment is empiric. Some patients respond in variable ways to non-steroidal anti-inflammatory medication in either oral or in suppository form. In the absence of obstructive urinary symptoms, transurethral prostatectomy is not indicated. Patients with prostatosis are frequently depressed, which may be the cause or the result of their chronic pain.

Many of these men are also cancerphobic and it is important that prostate cancer is excluded and the patients reassured.

Prostatodynia, or chronic prostatic pain, particularly occurs in the younger male who experiences variable symptoms associated with restricted urinary flow and irritative voiding dysfunction. The voiding dysfunction may be associated with pain in the perineum or low back. Recent evidence suggests a possible neuromuscular dysfunction as a cause for this symptom complex. These men are frequently "stressed" by life events, such as divorce or pending occupational redundancy, and are generally emotionally tense.

Identifiable pathology needs to be excluded, such as bladder neck dyssynergia, urethral stricture, lower tract infection or carcinoma insitu.

Initial investigations include urine culture, voided urinary cytology to access for carcinoma insitu, PSA and digital rectal examination. If these examinations are normal, reassurance is appropriate.

When local pathology is suspected, assessment with urinary tract ultrasonography, video urodynamics and cysto-urethroscopy may be necessary.

Young men with idiopathic pelvi-perineal pain syndrome should be empirically trialled with selective alpha one blockers such as terazosin.

The patient with prostatitis or prostatosis should be carefully evaluated for acute or chronic urinary tract infection and sexually transmitted diseases where the patient is known to be at risk. Lower urinary tract pathology must be excluded, particularly benign bladder neck obstruction or urethral stricture disease.

The patient's underlying fear of prostate caner should be addressed by diagnostic PSA testing and digital rectal examination. Where either is abnormal, Transrectal ultrasound with guided biopsy is needed.

Men with idiopathic prostatic pain should be provided with supportive counselling and empirical trials of non-steroid anti-inflammatory medication and where appropriate selected alpha blocker medication.