Thursday, August 2, 2012

Prostatitis: a concise review

Prostatitis: a concise review

Bacterial and non-bacterial etiologies

Prostatitis affects up to 50% of men at some point in their lives. Affects men of all ages 
About 8% of all urology visits in United States related to prostatitis 
Only about 6-8% of men with prostatitis will have bacterial prostatitis 

Pathophys: NIH classification and definitions of prostatitis:
I. Acute bacterial prostatitis.
II. Chronic bacterial prostatitis: recurrent infection.
III. Chronic abacterial prostatitis/chronic pelvic pain syndrome: no demonstrable infection
IIIA. Inflammatory chronic pelvic pain syndrome: wbc present in semen/expressed prostatic secretions or voided bladder urine (VB3).
IIIB. Noninflammatory chronic pelvic pain syndrome: no wbc noted in semen/expressed prostatic secretions or VB3.
IV. Asymptomatic inflammatory prostatitis: detected by prostate bx or presence of wbcs in prostatic secretions during evaluation for other disorders.  

Organisms isolated in acute and chronic bacterial prostatitis are same as those causing UTI
E. coli accounts for 80% of prostatic infections; 
Other gram-negative organisms (Pseudomonas aeruginosa, Serratia, Klebsiella proteus) account for 10-15% of infections. 
Enterococci identified in 5-10% cases of prostatitis 
Role of Chlamydia trachomatis in prostatitis is controversial. 

Etiology of acute bacterial prostatitis is often due to reflux of infected urine into prostatic ducts that drain into posterior urethra
Inflammation and edema may lead to occlusion of these ducts, trapping bacteria within, leading to chronic bacterial prostatitis 
Intraprostatic urinary reflux, causing a “chemical” prostatitis, may play a role in etiology of nonbacterial prostatitis  

Urinary frequency and urgency, dysuria, malaise, pain in perineum, groin, testes, back, suprapubic area

Fever/chills if acute bacterial, decreased urine flow rate, nocturia; tender, boggy, or firm prostate on DRE

Differential diagnosis
Distal ureteral calculus, Müllerian remnant, urethral stricture, BPH, seminal vesicle cyst, prostatic cyst, IC, bladder cancer, urachal remnant, hernia, ejaculatory duct cyst, depression/stress, spinal stenosis, mesenteric cyst, fibromyalgia


Meares-Stamey test (4 glass test) is gold standard for diagnosis of bacterial prostatitis. After cleansing and retraction of foreskin, pt voids first 10 mL into sterile container (VB1), then collects midstream 5-10 mL (VB2), then prostatic massage performed, collect expressed prostatic secretions and review under microscope and collect first 10 mL of urine after massage (VB3). 
Modification of Nickels allows for simple testing with 91% sens and specif compared to Meares-Stamey technique.
Modified Nickels technique: Collect midstream urine and perform prostatic massage, then collect postmassage urine and perform UA, C&S on both. 
Future studies include immunologic techniques to allow for ab screening of the expressed prostatic secretions or VB3 specimen for common prostatic pathogens and molecular biologic techniques using PCR to id bacterial gene products  

Bladder scanner PVR to ensure complete bladder emptying. Uroflow helpful in pts with voiding complaints.
Cystoscopy not indicated in most pts.
Videourodynamics in pts with nonbacterial chronic prostatitis may demonstrate spastic dysfunction of bladder neck and prostatic urethra


Acute bacterial prostatitis with abx; typically fluoroquinolones for 6-12 wk. TMP/SMX may be used.

Chronic bacterial prostatitis rx with abx for extended periods; in pts with frequent recurrent infections long-term prophylactic abx may be employed. 

Chronic nonbacterial prostatitis may be treated as follows:
Category IIIA: Trial of broad-spectrum abx, alpha-blocker therapy, anti-inflammatory agents, finasteride or other 5-alpha reductase inhibitor if enlarged prostate, prostatic massage (2-3 ×/wk), supportive therapy (counseling), transurethral microwave therapy or phytotherapy.
Category IIIB: Alpha-blocker therapy, muscle relaxant, analgesics, biofeedback, relaxation exercises, supportive therapy (counseling).

Other Therapies: Sitz baths; avoidance of spices, caffeine, and alcohol. Biofeedback has encouraging results in pts with noninflammatory chronic pelvic pain syndrome



atef soliman said...

how can we do this type of therapy

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