What is prostatitis?
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Prostatitis refers to an inflammation of the prostate gland that can be manifested in a variety of ways. Symptoms of acute bacterial prostatitis include urinary frequency, urgency dysuria or painful urination, nocturia, perineal pain, low back pain, fever, and/or chills. Some men with acute bacterial prostatitis may present with inability to urinate and will require a catheter or supra-pubic tube placement until the inflammation and pain have resolved. Some men with acute prostatitis may develop a prostatic abscess that will require drainage. Chronic bacterial prostatitis may present in a similar manner, but men are typically less toxic in appearance.
Prostatitis normally does not occur in children or adolescents, but can occur in adult men of any age. The diagnosis can be elusive and treatment is often empiric.
What types of prostatitis are there?
The National Institutes of Health (NIH) has recently defined the different prostatitis syndromes:
Prostatitis syndromes: NIH classification
I. Acute bacterial prostatitis II. Chronic bacterial prostatitis
III. Chronic prostatitis/chronic pelvic pain syndrome (CPPS)
B. Noninflammatory Asymptomatic inflammatory prostatitis
Acute bacterial prostatitis is usually a sudden illness with irritative urinary symptoms and can be associated with fever. Urinary and/or prostatic secretions are often positive for bacteria. Some patients with acute prostatitis will have a transient elevation of their PSA. A PSA should not be done during an episode of acute prostatitis. If a PSA is inadvertently drawn during an episode of acute prostatitis and comes back elevated, a repeat PSA should be obtained after a course of antibiotics has been administered. Chronic bacterial prostatitis tends to be a more indolent condition. Irritative urinary symptoms are typical; however, fever is rare, and positive cultures are uncommon.
How is prostatitis diagnosed?
The patient's clinical history, general appearance, and urinalysis are often suggestive of acute bacterial prostatitis. A urine culture is commonly positive for a urinary tract infection. A digital rectal examination will usually identify a very tender prostate. In rare cases, fluctuance may be palpable in the prostate, if there is a prostatic abscess. In men who appear toxic or who fail to improve with antibiotic therapy, a transrectal ultrasound may be obtained to rule out a prostatic abscess. An assessment of postvoid residual is performed. The classic diagnostic maneuver for bacterial prostatitis is the three-glass test. The patient is asked to void and collect his first 10 ml of urine. This is sent for culture and is known as VB1. Then the patient is asked to collect a midstream urine sample after he voids about 200 ml. This urine sample is sent for culture and is known as VB2. Then the urologist performs a digital rectal exam and massages the patient's prostate in an attempt to express prostatic secretions (EPS) into a sterile container. A prostatic massage is not always successful in producing sufficient secretions, and for some men, it can be quite uncomfortable. After the prostatic massage, the patient is asked to void again into a container, referred to as VB3, and this sample is sent for culture. If there is an increase in the number of bacterial colonies seen in either EPS or VB3, a diagnosis of bacterial prostatitis is made, and treatment is based on the antibiotic sensitivities of the organisms that were isolated. If there are no bacteria present, but white blood cells are present in the VB3 collection, it is suggestive of nonbacterial inflammatory prostatitis.
How is prostatitis treated?
The treatment of bacterial prostatitis is with antibiotics. Patients with acute bacterial prostatitis may require a short stay in the hospital for intravenous antibiotics and then continue on antibiotics for 2 to 4 weeks. Men with chronic bacterial prostatitis may require a longer course of antibiotics. In those men with recurrent chronic bacterial prostatitis, the doctor may prescribe a low dose of antibioctics for 6 months to prevent recurrent infections. Often bacterial prostatitis is treated with a class of antibiotics called quinolones (for example, ciprofloxacin, norfloxacin, ofloxacin). For men who are allergic to quinolones alternative antibiotics may be used, depending on the sensitivity results of the urine culture. Such alternative antibiotics include doxycycline, minocycline, trimethoprim-sulfamethoxazole, and trimethoprim.
Because nonbacterial prostatitis is also recognized and is often thought to be caused by Chlamydia trachomatis, some urologists will give the patient a course of doxycycline, an antibiotic that covers Chlamydia particularly well.