Management of Acute and Chronic Prostatitis

John D. Goodson

Prostatitis, both acute and chronic, represents an important source of discomfort and impaired quality of life in men, causing lower urinary tract symptoms, pelvic or perineal pain, and ejaculatory problems. Acute prostatitis is the more straightforward condition, typically associated with urinary tract infection and responsive to antibiotic therapy. Chronic prostatitis is the more common variety, with an estimated prevalence ranging from 2% to 9% of males over the age of 18 years; however, its pathogenesis remains elusive, leading to the designation of chronic prostatitis-chronic pelvic pain syndrome for the vast majority of cases where there is no evidence of infection; treatment can be challenging.

The tasks for the primary care physician include ruling out important conditions that may mimic prostatitis, prompt identification and treatment of infection when present, and thoughtful supportive care that protects the patient from the many ineffective treatments often promoted for use, especially to men with chronic symptoms.

CLASSIFICATION, PATHOPHYSIOLOGY, CLINICAL PRESENTATION, AND COURSE (1, 2, 3, 4, 5 and 6)

To facilitate study and understanding of prostatitis, a classification system has been introduced to categorize patients according to findings on evaluation, particularly with regard to evidence of infection and inflammation (see Table 139-1).

Acute Prostatitis

Infection appears to be the major source of symptoms in acute prostatitis, presumably ensuing from ascending urethral infection, reflux of infected urine, extension of rectal infection, or hematogenous spread. Gram-negative bacilli (predominantly Escherichia coli, Proteus, Klebsiella, and Pseudomonas) and enterococci account for most of the single isolates obtained from culture. Occasionally, Chlamydia, Ureaplasma, a virus, or Trichomonas may be the etiologic agent, sexually transmitted from an untreated urethritis (see Chapter 136). In the immunecompromised patient, infection with fungi, such as Aspergillus, may be responsible. At times, small numbers of organisms not usually considered urinary tract pathogens (e.g., Staphylococcus epidermidis and Corynebacterium species) are recovered; their significance is unclear.

The condition is readily identified by the onset of diminished urine flow, perineal pain, dysuria, and fever. On gentle rectal examination, the gland is found to be enlarged, exquisitely tender, and sometimes boggy. Abdominal examination occasionally
reveals striking bladder distention. Some patients may appear toxic at the time of presentation.

TABLE 139-1 Classification and Definition of Prostatitis

Category I		Acute Bacterial Prostatitis	Acute Infection
Category II		Chronic bacterial prostatitis	Persistent infection
Category III		Chronic abacterial prostatitis	No infection
	IIIA	Inflammatory	WBCs in postmassage urine
	IIIB	Noninflammatory	No WBCs in postmassage urine
Category IV		Asymptomatic inflammatory prostatitis	WBCs in postmassage urine or on biopsy specimen, but no symptoms
WBC, white blood cell; EPS, expressed prostatic secretion; VB, voided bladder. From Atter Nickel JC. Prostatitis: myths and realities. Urology 1998;51:363, with permission from Elsevier. Copyright 1998, Elsevier.

The acutely infected gland may lead to renal parenchymal infection or bacteremia if untreated. Rarely, acute infection will progress to a well-defined abscess. Timely treatment usually results in full resolution of symptoms.

Chronic Prostatitis-Chronic Pelvic Pain Syndrome

While a few cases involve obvious urinary tract infection or inflammation, most do not. Previously labeled as “prostatodynia,” the symptom constellation of recurrent pelvic or perineal pain, lower urinary tract symptoms, and ejaculatory discomfort in the absence of evidence for prostatic infection or inflammation (classified as IIIB disease—see Table 139-1) is now designated as chronic prostatitis-chronic pelvic pain syndrome when symptoms are present for 3 of the past 6 months. It accounts for over 90% of cases of chronic prostatitis. Sometimes, the picture may be dominated by pain or by lower urinary tract symptoms such as frequency, urgency, decreased stream flow, or decreased bladder capacity; ejaculatory pain or other difficulties may be reported. Overlap in some patients with the urinary tract and pelvic symptoms seen in chronic interstitial cystitis in women suggests a component of nociceptive pathophysiology.

In older men, urinary frequency, dribbling, loss of stream volume and force, double voiding, hesitancy, and urgency in conjunction with perineal pain may dominate the clinical presentation. Younger men more often complain of dysuria and dribbling in conjunction with intermittent discomfort in the perineum, low back, or testicles. Some patients present initially with painful ejaculations. Rectal examination may reveal an enlarged prostate with a variable amount of asymmetry, bogginess, or tenderness. Recurrent symptomatic exacerbations separated by asymptomatic intervals are typical.

By definition, symptoms must be of at least 3 months’ duration. The clinical course is chronic, typically waxing and waning with periodic remissions; in some, there is improvement over time. In a large prospective natural history study, 31% of men considered themselves moderately or markedly improved over 2 years, often after the first 3 months; no predictors of clinical course could be identified.

The majority of patients are white, well educated, and affluent, but lower income and unemployment are associated with more severe symptoms. Psychological state and quality of life are often adversely affected.

DIFFERENTIAL DIAGNOSIS (1,4,7,8)

Acute prostatitis is readily evident by the clinical presentation and exquisitely tender prostate found on rectal examination. However, chronic prostatitis presents a more difficult diagnostic problem, often resembling in clinical presentation other common forms of lower urinary tract pathology, such as benign prostatic hyperplasia (see Chapter 138), prostatic carcinoma (see Chapter 143), and urethral stricture (see Chapter 134). The lower urinary tract irritative symptoms associated with chronic prostatitis may be seen with urethritis (see Chapter 136), bladder carcinoma (see Chapter 143), sphincter dyssynergy, and neurogenic bladder (see Chapter 134).

WORKUP (1,4,7, 8, 9, 10, 11 and 12)

Approach to Diagnosis

Diagnosis of prostatitis rests largely on history, physical examination, and urinalysis/urine culture (pre- and postprostatic massage for patients with chronic symptoms) as well as ruling out other conditions that may present in similar fashion. Diagnosis of acute prostatitis is aided by finding an exquisitely tender prostate gland on examination, but the diagnosis of chronic prostatitis can be more problematic, given that most cases are due to chronic prostatitis-chronic pelvic pain syndrome, with its vague symptoms and absence of definitive physical examination or laboratory findings. The National Institutes of Health sponsored the development of the Chronic Prostatitis Symptom Index to facilitate research in men with chronic prostatitis-chronic pelvic pain syndrome, but this tool, which focuses mainly on pain (testicular, ejaculatory, perineal, pubic, urinary), is best used as a symptom index because it does not adequately distinguish between chronic prostatitis and other urogenital conditions that may present with similar symptoms. Keys to the diagnosis of chronic prostatitis include careful attention to the history, with its constellation of chronic waxing and waning urinary symptoms, pelvic/perineal pain complaints, and ejaculatory difficulties in the absence of other urogenital pathology—in essence, a diagnosis of exclusion.

History and Physical Examination

For suspected acute prostatitis, one needs to check for acute onset of fever, perineal pain, dysuria, and diminished urine flow. A urethral discharge is sometimes reported. On rectal examination, the prostate should be examined gingerly for tenderness (which may be exquisite) and fluctuance (suggestive of an abscess). Palpation and any massage should proceed cautiously to avoid precipitating bacteremia. The abdomen should be checked for bladder distention.

For suspected chronic prostatitis, one should inquire into any recurrent perineal, back, pelvic, penile, or testicular discomfort, as well as concurrent urinary symptoms (e.g., dribbling, slow stream, dysuria) and ejaculatory problems (e.g., pain, premature ejaculation). The duration of symptoms (at least 3 of the previous 6 months) and clinical course (waxing and waning with periods of remission) should be noted for characteristic features. Digital rectal examination may reveal a boggy or slightly tender, enlarged prostate, but such findings are nonspecific. Careful examination of the prostate, anorectal area, genitalia, back, spine, and bladder for other causes of urogenital and neurologic symptoms and pelvic/perineal pain is essential (see Chapters 125, 131, 138, and 140).

Laboratory Studies

The urine should be checked for leukocytes and sent for culture. In persons with suspected chronic prostatitis, urologists traditionally massaged the prostate to obtain expressed prostatic sections for examination and culture (performing the so-called 4-glass test). The usefulness of this gold standard but time-consuming diagnostic effort has been called into question by study results finding no significant difference between this procedure and the mucheasier-to-perform pre- and postmassage urine test with regard to rates of bacterial recovery and localization. Moreover, study findings of high prevalences of white blood cells (WBCs) and positive bacterial cultures in the asymptomatic control populations cast some doubt on the significance of results from postmassage testing overall, but the search for evidence of inflammation with or without infection may help inform diagnosis and treatment (see later discussion). Urine testing remains essential to checking for other etiologies such as urinary tract infection and hematuria-associated conditions (see Chapters 129 and 140).

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