Prostatitis

• Prostatitis refers to an infection or inflammatory process of the prostate gland and is the most common urological diagnosis in men less than 50 years old
• It is most commonly caused by bacteria, but it can also be abacterial. Acute prostatitis can normally be successfully treated with antibiotics
• The prostate is a gland surrounding the urethra at the neck of the bladder that is part of the male reproductive system, and its main function is to produce fluid for semen
• In the acute setting, prostate inflammation is most commonly associated with organisms entering the gland due to urinary tract infections (UTI), so is most often due to Escherichia coli. 
• Atypical organisms may cause infection in immunosuppressed patients such as Candida. Rarely, it can be a complication of sexually transmitted infections (STI)
• Conditions which cause men to suffer reflux of urine into the prostatic ducts increase the likelihood of bacteria ascending and causing infection. Therefore, instrumentation/trauma to the area can also induce an episode of acute prostatitis.
• The most common risk factor is UTI, but other risk factors can include:

  • Benign prostatic hyperplasia/enlargement (BPH/BPE)
  • Urinary catheters, recent biopsy or transurethral surgery/instrumentation
  • General risk factors for infections may also include poor general health, immunosuppression, smoking, alcohol and genetic facotrs
• Typical symptoms of prostatitis include:

  • Genital pain
  • Perineal/rectal/suprapubic pain
  • Lower back pain
  • Lower urinary tract symptoms (e.g. dysuria, frequency, poor stream & urinary retention)
  • Systemic signs (e.g. fever, chills, malaise & features of sepsis)
• Typical clinical findings of prostatitis include:

  • Digital rectal examination (DRE): ‘boggy’ prostate (warm/soft), exhibiting tenderness 
  • Abdominal examination: palpable, distended and tender bladder if urinary retention is present
  • Signs of sepsis: fever, tachycardia, hypotension & poor peripheral perfusion
• DREs should be performed gently so as not to induce the release of bacteria into the bloodstream.
• Relevant bedside investigations for prostatitis include:

  • Basic observations: to assess for pyrexia and signs of sepsis
  • Urinalysis: leucocytes may be present
  • Mid-stream urine sample (MSU): to be sent for microbiology, cultures & sensitivities
• Relevant laboratory investigations for prostatitis include:

  • Baseline bloods including FBC, CRP and U&Es: inflammatory markers may be raised, and renal function may be impaired 
  • Blood cultures
  • Venous blood gas (VBG): to identify raised lactate (sepsis)
  • STI screening can be considered
  • PSA can be considered in more chronic setting to look for underlying cancer diagnosis if symptoms do not improve
• Radiological investigations are not normally indicated but can include:

  • Transrectal ultrasound to rule out abscess/cyst if refractory to management
• Other investigations to consider in the chronic setting if symptoms refractory/diagnostic uncertainty include:

  • Cystoscopy
  • Transperineal prostate biopsy 
• Prostatitis is a clinical diagnosis formed from a combination of history and examination findings supported by urine testing. Inflammatory markers and high white cell counts may also indicate infection
• . The suspicion should be high if the patient is experiencing a combination of signs and symptoms of:

  • UTI: frequency & dysuria
  • Bacteraemia: fever, rigors & myalgia
  • Prostatitis: perineal/penile/rectal/low back pain, retention or obstructive urinary symptoms and tender, warm & swollen prostate
• Chronic prostatitis should be suspected if a patient is experiencing pain and lower urinary tract symptoms (LUTS) for more than 3 months. These patients will not usually be systemically unwell like acute prostatitis patients.
• Hospital admission is advisable if there are severe symptoms, signs of sepsis or urinary retention. In septic patients, the sepsis 6 should be initiated as per guidelines. Patients with urinary retention should be catheterised. 
• Medical management:

  • Antibiotics - most commonly a fluoroquinolone (ciprofloxacin) for 14 days
  • Antibiotic choice can be guided by the results of cultures. As the patient improves, IV antibiotics can be stepped down to oral for a total for 2-4 weks
  • Analgesia
  • Sexual health clinic referral if STI suspected
  • Tamsulosin in chronic prostatitis
• Surgical management:

  • Incision and drainage of pus via transrectal or perineal aspiration may need to be performed if an abscess has developed
  • If there are signs of un-resolving sepsis, a transurethral resection of the prostate may need to be performed
• If not treated promptly, complications of prostatitis can include:

  • Sepsis
  • Urinary retention
  • Prostatic abscess
  • Epididymitis & pyelonephritis if the infection becomes more widespread
  • Chronic prostatitis
• Chronic Prostatitis:

  • Most commonly inflammatory in nature (non-infective)
  • Presents with chronic, low-grade perineal and suprapubic pain, urinary frequency, urgency, dysuria and poor flow
  • Non infective = chronic pelvic pain syndrome
  • Treatment is with antibiotics according to culture and sensitivity if infective cause
  • Anti-inflammatory drugs
  • Tamulosin and 5-alpha reductase inhibitors