Prostatitis
Background
Prostatitis means inflammation of the prostate and comes in several different forms including:
Non-infectious prostatitis.
Infectious prostatitis - bacterial and other.
Acute: of short duration.
Chronic: of prolonged duration (more than about 6 weeks).
The diagnosis of prostatitis is most commonly given to men who do NOT have an infectious cause (i.e. non-infectious prostatitis). In practice, non-infectious prostatitis is a term used to describe irritative urinary symptoms where a definable cause cannot be identified. That is, causes such as infection, cancer, benign prostatic hyperplasia, neurogenic bladder disorders and others have not been identified. This implies that an evaluation for all of these other causes has actually taken place.
Bacterial prostatitis is usually a very straight forward diagnosis to make. In addition to symptoms consistent with invasive infection (high fever, chills and rigors), there will also be prominent urinary symptoms and virtually always test results to support the diagnosis including bacteria and pus on urine testing.
Unfortunately, many patients and physicians gloss over the critical distinction between infectious and non-infectious prostatitis. This may result in ineffective treatment or delay in diagnosing a serious condition.
Causes
Generally acute prostatitis is caused by an acute bacterial infection. Chronic prostatitis or chronic pelvic pain often is an inflammatory problem and is not necessarily associated with bacterial infection.
The types of bacteria that cause bacterial prostatitis are the same as those which cause urinary tract infections in other circumstances. Escherichia coli, Enterococcus faecalis Proteus mirbelis and Pseudomonas aeruginosa are common culprits. Viral and parasitic organisms are much less common.
Diagnosis & Evaluation
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The symptoms of bacterial cystitis are typically so severe that patients present to the emergency department.
Urinary symptoms: burning, urinary frequency, urinary urgency (inability to empty), slow stream, straining, pain above the bladder or in the perineum. Some patients may be unable to void.
Systemic symptoms: fever, chills, rigors.
The symptoms of non-bacterial prostatitis are often a mixture of voiding or storage symptoms but do not have the severity or the associated systemic symptoms of fever, chills and the like.
The exam in patients with bacterial prostatitis are usually very striking as well - patients look very unwell. Most are in distress. The prostate is usually so tender that exam is challenging. The prostate may be swolloen and tender.
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Most patients with bacterial prostatitis are presenting to the emergency department or are so acutely ill that many of the tests applied to men with non-infectious prostatitis are not immediately relevant. The converse is also true.
Bacterial prostatitis:
Urine analysis and cultures.
Blood cultures (sometimes).
Complete blood counts, creatinine.
Blood tests for measures of sepsis (e.g. CRP)
Prostate specific antigen (PSA) may be done with caution - it may be extremely elevated as a result of infection and this may cause patients to worry about cancer.
Non-infectious prostatitis:
Urine analysis and cultures.
Prostate specific antigen (PSA).
Cystoscopy.
Urodynamics.
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Imaging tests may not immediately be necessary in men with bacterial prostatitis with the exception of checking for urinary retention (a PVR measurement). Imaging studies are necessary to if men do not initially respond to treatment (in bacterial infections) or if a non-prostatic condition is possible (for non-infectious causes).
Ultrasound.
CT.
MRI.
Treatment
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The mainstay of treatment for bacterial prostatitis is antibiotics. Initial treatment is based on the best guess of the infectious agent and often with an intravenous antibiotic. Urine testing (culture and sensitivity) will help direct treatment and often allow for transition to oral antibiotics but the results usually take 2-3 days.
Duration of therapy may be as short as 7-10 days but several weeks of infection may be necessary in severe infections.
Supportive care may require admission to hospital, temporary placement of a urethral catheter or medications to assist with urination. Drainage of prostatic abscess may be necessary.
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Management of non-infectious prostatitis is usually symptom directed. Alpha blockers may be used.
Antibiotics do not have any role for non-infectious prostatitis.
On the Web
General Urology Websites
Canadian Urological Association Extensive library of downloadable pamphlets on a wide range of urological conditions
Medline Plus Produced by the US National Institutes of Health with information on virtually every health topic and extensive list of links
UrologyHealth.org The patient information site of the American Urological Association.