Prostatitis syndromes are some of the most common urologic problems in men, accounting for about 25 percent of physician visits for genitourinary complaints. Chronic prostatitis affects quality of life much in the way that coronary artery disease or Crohn's disease does. Lipsky reviews the diagnosis and treatment of the four major types of prostatitis: acute bacterial, chronic bacterial, chronic nonbacterial (inflammatory) and chronic pelvic pain syndrome. For summary information about the presentation, examination results and response to antibiotics of each of these conditions, see the accompanying table.
|Type||Typical presentation||Prostate examination||Prostatic fluid WBC*||Bacterial cultures||Antibiotic response||Percentage of all cases|
|Acute bacterial||Acute illness; 40 to 60 years of age||Tender, warm||Contraindicated†||Positive||Predictable and prompt||1 to 5|
|Chronic bacterial||Recurrent urinary tract infections; 50 to 80 years of age||Enlarged, “boggy”||Always||Positive 4-cup test (prostatic specimens)||Usual, but slow||5 to 10|
|Chronic nonbacterial (inflammatory)||Genitourinary and voiding discomfort; 30 to 50 years of age||Highly variable||Always||Negative||Occasional||40 to 65|
|Chronic pelvic pain syndrome||Pain, voiding problems, 30 to 40 years of age||Usually normal||Rarely||Negative||None||20 to 40|
WBC = white blood cells.
*—At least 10 white blood cells per high power field.
†—Prostatic massage is contraindicated; examination and culture of urine will suffice.
Adapted with permission from Lipsky BA. Prostatitis and urinary tract infection in men: what's new; what's true? Am J Med 1999;106:327–34.
Both types of bacterial prostatitis are typically caused by Escherichia coli, Proteus or Provedentia species. The pathogenesis of this type of prostatitis is not well known, but it may be caused by reflux of infected urine or by ascending urethral infection. Host defenses against these types of infection include urination and ejaculation. Prostatic antibacterial factor, a zinc-containing polypeptide secreted by the prostate gland, may also play a role. Common signs and symptoms of acute infection include fever, chills and pain in the rectal, low back or perineal areas. Chronic infection is characterized by recurrent urinary tract infections, dysuria, pain on ejaculation, genital pain and hemospermia, but some men are asymptomatic. Digital rectal examination reveals firmness, warmth, tenderness and swelling of the prostate gland with acute infection but is not helpful in patients with chronic infection. Prostatic massage should be avoided because it is painful and may cause bacteremia. Results of a urine culture usually reveal the bacterial cause. Evaluation of prostatic fluid usually shows more than 10 leukocytes per high-power field.
Chronic nonbacterial prostatitis and chronic pelvic pain syndrome tend to affect younger men but are similar in presentation to chronic bacterial infection. Dysuria is not usually a prominent symptom of these syndromes; rather, chronic pelvic and ejaculatory pain are the most common. Digital rectal examination and urine cultures usually are not helpful in confirming the diagnosis, nor are semen specimens, as they may be contaminated after passage through the urethra.
Treatment of both types of infectious prostatitis frequently includes therapy with trimethoprim/sulfamethoxazole, even though the U.S. Food and Drug Administration has not labeled it for this use. Penicillins and cephalosporins usually are not as effective because of their low prostatic concentrations. Duration of treatment varies on the type of syndrome. Acute infection needs only four weeks of treatment, whereas chronic infection requires between six and 12 weeks. The shorter course is adequate for acute bacterial prostatitis because its characteristic inflammation enables more effective antibiotic penetration. Use of fluoroquinolones for chronic infection is successful in up to 90 percent of patients. Recurrences should be treated for at least three months. The effectiveness of antibiotics in treating nonbacterial prostatitis is not well-defined. Other proposed treatments for this type of prostatitis, including nonsteroidal anti-inflammatory drugs, alpha-blockers, allopurinol, nutritional supplements and lifestyle changes, lack scientific evidence of effectiveness. However, transurethral microwave thermotherapy or transurethral incision of the bladder neck may relieve symptoms.
The author concludes that despite the fact that urologic problems in men, particularly prostatitis, have been studied less than those in women, a useful classification system for diagnosis and proposed treatment has been developed. This classification scheme allows for a more systematic approach to patient care.