PROSTATITIS
Prostatitis is the term given to a complex constellation of symptoms and findings related to the prostate. Currently, there are four general categories of clinically defined prostatitis. They are differentiated based on symptoms and the urinalysis findings of bacteruria and pyuria. The categories are acute bacterial (NIH Class I), chronic bacterial (NIH Class II), inflammatory (NIH Class IIIA) or noninflammatory (NIH Class IIIB), and asymptomatic inflammatory prostatitis (NIH Class IV). Class III prostatitis is also termed chronic nonbacterial prostatitis/chronic prostatitis and pelvic pain syndrome (CPPS).
Acute bacterial prostatitis
typically presents with acute urinary tract infection (UTI) symptoms and
infected urine, typically with gram-negative organisms. It is unusual but may
be related to urologic instrumentation and chronic catheter use. Clinically, it
involves the acute onset of irritative voiding symptoms, dysuria, pelvic and
perineal pain, fever, and hematuria. Not uncommonly, a rectal exam reveals a
tender, “boggy” prostate. Cloudy, infected urine is a feature that
differentiates it from prostatic infarction. Histologically, prostatic acini
are filled with exudate, and the stroma is infiltrated with leukocytes. When
severe, urinary retention may result, which is treated with urethral or
suprapubic catheter drainage. The infection requires broad-spectrum,
gram-negative antibiotics that are later adjusted to bacterial sensitivity.
Chronic bacterial prostatitis can occur with or without an antecedent acute
form and is characterized by acute or chronic symptoms and infected urine.
Patients experience recurrent episodes of bacterial UTI caused by the same
organism, usually Escherichia coli, another gram-negative organism, or
enterococcus. Between symptomatic episodes, lower urinary tract cultures can
document an infected prostate gland as the focus of recurrent infections.
Indwelling catheters, instrumentation, recurrent UTIs, bladder stones, or
spread from distant infections such as abscessed teeth, bronchitis, pneumonia,
or sinusitis may underlie this diagnosis. Chronic prostatitis can be
asymptomatic but is usually associated with complaints of scrotal, penile, low
back, inguinal, or perineal pain; sexual dysfunction; and irritative or
obstructive urinary symptoms. The finding of a boggy or fluctuant prostate on
rectal examination is unusual. Histologically, prostatic acini contain increased
leukocytes and the stroma is infiltrated with plasma cells and varying degrees
of fibrosis. Prostatic ducts can also be chronically inflamed and dilated,
indicating an infection that extends from the urethra.
Class III inflammatory or
noninflammatory prostatitis is not primarily a disease of the prostate or the
result of an inflammatory process but is a moniker for a symptom complex
suggestive of bacterial prostatitis but in the absence of bacteruria. More than
90% of symptomatic patients fall into this category of prostatitis. Symptom
duration and intensity can be significant and can be associated with profound
impacts on patient quality of life. Pyuria can be present (IIIA) or absent
(IIIB) in the urine, semen, or in the urethral fluid obtained after expressed
prostatic massage. Urologic pain complaints are the primary component of this
syndrome, and exclusion criteria include the presence of active urethritis,
urogenital cancer, urinary tract disease, functionally significant urethral
stricture, or neurologic disease affecting the bladder. This prostatitis
category recognizes the limited understanding of the causes of this syndrome
and the possibility that organs other than the prostate gland may be causally important.
Asymptomatic inflammatory
prostatitis is diagnosed in patients without a history of genitourinary tract
pain complaints. The diagnosis is made during evaluation of other genitourinary
tract issues, including (1) the finding of inflammation on a prostate biopsy for
possible prostate cancer because of an elevated serum prostate-specific antigen
(PSA) level and (2) elevated leukocytes in the seminal fluid of infertility
patients (pyospermia). Treatment is aimed at decreasing PSA levels or restoring
normal semen quality, as pain is not a component of this diagnosis.
Prostatic abscess as a
consequence of acute prostatitis is unusual with modern antibiotic therapy.
Abscess can occur with metastasis from
distant infectious foci or as a complication of immunosuppressive disease.
Symptoms are similar to those of acute prostatitis, but stranguria and tenesmus
are more common, along with acute urinary retention. Prostatic abscess can
sometimes be detected on rectal examination with the finding of a boggy and
tender gland. If untreated, the abscess usually spares rectal involvement due
to Denonvilliers fascia posteriorly, but rupture and drainage into the
posterior urethra is possible. Treatment with incision and drainage through
endoscopic unroofing or transrectal or perineal drainage may be required along with appropriate antibiotics.
