Prostatitis

Prostatitis is the third most significant prostate pathology after prostate cancer and benign prostatic hyperplasia.

With the development of a new prostatitis classification system in 1995 at the National Institutes of Health (NIH) conference, promising ongoing research may change the way men with prostatitis are managed.

NIH category Name
I Acute bacterial prostatitis
II Chronic bacterial prostatitis
III Chronic prostatitis/chronic pelvic pain syndrome ( Inflammatory or non-inflammatory )
IV Asymptomatic inflammatory prostatitis

• Category I ( Acute bacterial prostatitis )
  

It is characterized by local symptoms of dysuria, urgency and urinary frequency which can be associated with suprapubic or perianal pain and urinary retention.

These symptoms can be preceded by systemic symptoms such as fever and rigors.

Per rectal digital examination will show an exquisitely
tender, warm, boggy prostate.

Urine cultures, blood cultures and routine blood tests (including full blood count and electrolytes, urea and creatinine measurements) should be performed.

Treatment initially includes intravenous penicillin with aminoglycosides, followed by oral fluoroquinolone antibiotics (e.g. ciprofloxacin) for four to six weeks.

• Category II ( Chronic Bacterial Prostatitis )

It tends to occur in older men.

It classically present with recurrent, symptomatic urinary tract infections, usually caused by the same organism.

In addition to symptoms related to urinary tract infection, they may also experience perineal, lower back or testicular pain, or painful ejaculation.

• Category III (Chronic prostatitis/chronic pelvic pain syndrome)

The hallmark is ‘pelvic’ pain or discomfort which lasts for at least three months. It is a diagnosis of exclusion after careful evaluation of all other causes of pain in the area.

In general practice, evaluation should at least include a detailed history, physical examination including DRE, urinalysis and urine culture.

A renal tract ultrasound with postvoid urine measurement is
reasonable to determine bladder emptying and screen for any obvious bladder pathology, including tumours or bladder stones.

Treatment of CP/CPPS

A multimodality approach to treatment should be adopted for men with CP/CPPS.

Medical treatment has traditionally been based around the three As – antibiotics, alpha blockers and anti-inflammatories.

Antibiotics:
Even though there is no evidence of infective aetiology, there is enough support to use 4 - 6 weeks course of antibiotic therapy initially. However, repeated course of antibiotics therapy is not justified.

Fluoroquinolones such as ciprofloxacin are the antibiotics of choice due to excellent penetration into the prostrate. Norfloxacin can be used but it does not concentrate as effectively in the prostatic fluid as ciprofloxacin.

Trimethoprim is the second line agent.

Alpha blockers: should be used for a minimum duration of three months, and some symptoms may be relieved in about 50 to 60% of patients.

Anti-inflammatories: Ibuprofen and naproxen are generally well tolerated and readily available examples of these drugs.

Hormone therapy: Finasteride is a 5alpha-reductase inhibitor for which there is some evidence of benefit in terms of voiding symptoms and pain in patients with CP/CPPS. In men with concurrent lower urinary tract symptoms and enlarged prostates, this may provide a dual benefit.

Referral to a urologist should be considered for:

• significant pelvic pain
• a history of pelvic pain with bothersome lower urinary tract symptoms
• recurrent urinary tract infections
• microscopic or macroscopic haematuria with pelvic pain, or lower urinary tract symptoms
• a tender prostate or an abnormal DRE
• an abnormal serum prostate specific antigen measurement