What is Acute Prostatitis?

Acute Prostatitis is the inflammation of the prostate of abrupt onset caused by urinary tract pathogens. The more common bacteria organisms include Proteus spp, Escherichia Coli, Klebsiella spp, Pseudomonas spp, enterococci, staphylococcus aureus and rarely anaerobes like bacteroides spp.
Clinical Presentation of Acute Prostatitis

Acute prostatitis can present as a severe systemic infection. They may present as:

i)Urinary tract infection presenting with pain on urination (dysuria), urine frequency and urgency.

ii)Prostatitis symptoms involving inflammation of prostatitis. Patients will experience pain over the penile, perineal area, rectal area and lower back pain.

iii)Systemic infection (bacteremia) symptoms include fever, chills, rigors, tachycardia (increased heart rate), myalgia (painful muscles) and arthralgia (painful joints).

Clinical examination will reveal a tender, swollen and tense smooth prostate which feels warm to touch.

If the prostate is swollen and edematous, it may cause acute retention of urine. Prostate massage should be avoided as it is very painful and it may precipitate spread of infection to rest of body (bacteremia). 
Diagnostic Tests for Acute Prostatitis

1.Blood cultures: Blood should be taken for bacteria cultures and sensitivity to antibiotics to aid treatment.

2.Urine Sample: Mid-stream urine should be taken and send for urine full examination and microscopy as well as urine cultures for bacteria and antibiotic sensitivity. 

Management of Acute Prostatitis

General measures include analgesics to relieve pain, sufficient rest and adequate hydration. If there is acute retention of urine, catheterization maybe necessary.

Empirical treatment should be started immediately and then adjusted according to the culture result and antibiotic sensitivity. Oral antibiotics can be started for mild cases however intravenous antibiotic maybe necessary for severe cases.

Oral antibiotics that can be started include: oral ciprofloxacin 500 mg twice daily for 28 days or oral ofloxacin 200 mg twice daily for 28 days. If patients are allergy to quinolones group of antibiotics, they can take co-trimoxazole (trimethoprim/sulfamethoxazone) 160/800 mg 2 tablets twice daily for 28 days.

For patients with severe prostatitis, they require intravenous injections of high dose cephalosporins antibiotics like cefotaxime, cefuroxime, ceftriaxone plus gentamicin. When they improve, they can be switched to oral forms of antibiotics according to the culture antibiotic sensitivity results.

Follow up plan for Acute Prostatitis

Always suspect a prostate abscess (collection of infective pus in the prostate) if patient fails to respond fully to treatment. Confirmation of the diagnosis of prostate abscess can be made by a CT scan of prostate and trans-rectal ultrasound scan of the prostate. If confirmed, surgical drainage of the abscess is the treatment of choice.

At least 4 weeks of antibiotics is required to prevent chronic bacterial prostatitis. When managed correctly, acute prostatitis prognosis is good. The urinary tract should also be investigated to rule out any structural cause for the infection.

As acute prostatitis is caused by urinary tract bacteria, treatment of sexual partners is not required.
What is Chronic Bacterial Prostatitis?

Chronic Bacterial Prostatitis is a longstanding bacterial infection of the prostate. It is characterized by a significant numbers of pathogenic bacteria from the prostatic fluid in the absence of concomitant urinary infection. The most common bacteria are Escherichia Coli. Others include Staphylococcus Aureus, streptococcus faecalis and enterococci.
What is Chronic Abacterial Prostatitis?

This condition is also sometimes known as chronic pelvic pain syndrome in man. It is also formerly known as prostatodynia (painful prostate). It can be caused by inflammatory and non-inflammatory processes. The exact etiology of these conditions is unknown. Unlike chronic bacterial prostatitis, pathogenic bacteria are rarely found.

Clinical presentation of Chronic Prostatitis?

Chronic prostatitis is characterized by chronic pelvic pain over the perineal area, penile area, lower abdomen area, rectal area, testicular area, painful urination and ejaculation pain. The symptoms must be present for at least 6 months to diagnose chronic prostatitis.

Clinical examination of the prostate gland may or may not reveal diffuse or localized tenderness on palpation.
Diagnostic tests for chronic prostatitis

The test involves a prostatic massage to collect urine and expressed prostatic secretions to determine the number of polymorphonuclear leucocytes present under microscopic examination.

Prior to prostatic massage procedure, patient should have a full but not distended bladder, should not ejaculate the last 2 days and no antibiotics should be taken for 1 month.

Prostatic massage is carried out by retracting the foreskin and cleaning the genitalia area to avoid contamination. Then the first void urine (VB1) of 5-10 ml is collected. The patient then urinates another 100-200 ml and then a further 5-10 ml mid-stream bladder urine sample (VB2) is collected. By digital rectal examination, the prostate gland is vigorously massaged for one minute and the expressed prostatic secretions sample (EPS) is collected. Immediately after massage 5-10 ml post massage urine (VB3) is collected.

All the 3 urine samples are sent for culture studies and microscopy examination. The expressed prostatic secretions are sent for microscopic examination.

For prostatic inflammation > 10 polymorphonuclear leucocytes / high power field is diagnostic of chronic prostatitis. An expressed prostatic secretions’ PH > 8 suggests prostatitis but not diagnostic. Presence of clumping polymorphonuclear leucocytes and lipid-laden macrophages also suggest prostatitis but not diagnostic.

Transrectal ultrasound should also be conducted to rule out abscesses or cysts in the prostate gland which require surgical intervention. 
Treatment of Chronic Bacterial Prostatitis

Most antibiotics penetrate the prostate gland poorly. Quinolones are first line treatment of choice for chronic bacterial prostatitis. Antibiotics choice is also determined by the cultures antibiotic sensitivity results.

Patients can be treated with oral ofloxacin 200 mg twice daily for 28 days or oral ciprofloxacin 500 mg twice daily for 28 days or oral norfloxacin 400 mg twice daily for 28 days.

For those who are allergic to quinolones, they can be treated with oral doxycycline 100 mg twice daily for 28 days or co-trimoxazole 160/800 mg (2 tablets) twice daily for 28 days. Minocycline can also be used however it has side effects hence seldom used for treatment.

Treatment of Chronic Abacterial Prostatitis

Currently there are no treatment guidelines for chronic Abacterial prostatitis as the etiology is unknown. Treatment is usually trial and error.  Despite negative bacteria cultures, some clinicians try antibiotics to cover for occult infections.

Other possible treatments include:
  • Trial of Terazosin 2-10 mg for 28 days
  • Transurethral microwave thermotherapy
  • Nsaids (Non-Steroidal Anti-Inflammatory drugs) to control chronic pain
  • Alfuzosin 2.5mg twice daily for 42 days for patients with confirmed urodynamic abnormalities.
  • Bioflavonoid/Quercetin for 28 days
  • Stress management
Follow up

Chronic prostatitis is a long-standing, relapsing condition that is difficult to manage. Patient will be following up with urologist for a long period of time. 
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