Prostatitis Prostatitis

Prepared byPrepared by

Dr.sarwar N mahmoodDr.sarwar N mahmood

F.I.C.M.S( urology),F.E.B.U, E.A.UF.I.C.M.S( urology),F.E.B.U, E.A.U

Traditional National Institutes of Health Description

Acute bacterial prostatitis Category I Acute infection of the prostate gland

Chronic bacterial prostatitis Category II Chronic infection of the prostate gland

  Category III Chronic Pelvic Pain Syndrome (CPPS)

Chronic genitourinary pain in the absence of uropathogenic bacteria localized to the prostate gland employing standard methodology

Nonbacterial prostatitis Category IIIA (Inflammatory CPPS)

Significant number of white blood cells in expressed prostatic secretions, post–prostatic massage urine sediment (VB3), or semen

Prostatodynia Category IIIB (Noninflammatory CPPS)

Insignificant number of white blood cells in expressed prostatic secretions, post–prostatic massage urine sediment (VB3), or semen

  Asymptomatic Inflammatory Prostatitis (AIP)

White blood cells (and/or bacteria) in expressed prostatic secretions, post–prostatic massage urine sediment (VB3), semen, or histologic specimens of prostate gland

PROSTATE INFECTIONPROSTATE INFECTION

Acute Bacterial Prostatitis Acute bacterial prostatitis refers to inflammation of the prostate

It is thought that infection results from:

– ascending urethral infection

– or reflux of infected urine from the bladder into the prostatic ducts,

– may be haematogenous

PRESENTATION AND FINDINGSPRESENTATION AND FINDINGS

• uncommon in prepubertal boys but frequent affects adult men.

• It is the most common urologic diagnosis in men younger than 50 years

• usually present with an abrupt onset of – constitutional (fever, chills, malaise, arthralgia, myalgia, lower back/rectal/

perineal pain), Nausea and vomiting, and even frank septicemia with hypotension

– urinary symptoms:

• (frequency, urgency, dysuria).

• hesitancy, poor interrupted stream, even acute urinary retention

Approximately 5% of patients with acute bacterial prostatitis may progress to chronic bacterial prostatitis

• Digital rectal examination reveals

– The prostate itself is usually described as hot, boggy, and exquisitely

tender

• leukocytosis.

• PSA are often elevated.

• A urine culture is the only laboratory evaluation of the lower urinary tract

required. It has been suggested that the vigorous prostatic massage

necessary to produce EPS can exacerbate the clinical situation,.

• A midstream urine specimen will show significant leukocytosis and

bacteriuria microscopically, and culturing usually discloses typical

uropathogens.

• Blood cultures may show the same organism

• Culture of urine usually identifies a single organism, but occasionally, polymicrobial infection may occur.

• E. coli is the most common causative organism

• Other gram-negative bacteria

– (Proteus, Klebsiella, Enterobacter, Pseudomonas, and Serratia spp.) and enterococci are less frequent pathogens.

– Anaerobic and other gram-positive bacteria are rarely a cause of acute prostatitis.

RADIOLOGIC IMAGINGRADIOLOGIC IMAGING

• Radiologic imaging is rarely indicated in patients with acute

prostatitis.

• Bladder ultrasonography may be useful in determining the amount

of residual urine.

• Transrectal ultrasonography is only indicated in patients who do not

respond to conventional therapy.

MANAGEMENTMANAGEMENT

• Empiric therapy directed against instituted immediately, while awaiting the culture results.

• Trimethoprim and fluoroquinolones have high drug penetration into prostatic tissue and are recommended for 4–6 weeks.

• The long duration of antibiotic treatment is to allow complete sterilization of the prostatic tissue to prevent complications such as chronic prostatitis and abscess formation.

• Patients who have sepsis, are immunocompromised or in acute urinary

retention, or have significant medical comorbidities

– hospitalization

– parenteral antibiotics. Ampicillin and an aminoglycoside provide effective therapy against both gram-negative bacteria and enterococci.

• Patients with urinary retention secondary to acute prostatitis should

be managed with a suprapubic catheter because transurethral

catheterization or instrumentation is contraindicated.

Chronic Bacterial ProstatitisChronic Bacterial Prostatitis

In contrast to the acute form, chronic bacterial prostatitis has a more

– insidious onset

– characterized by relapsing, recurrent UTI caused by the persistence of pathogen in the prostatic fluid despite antibiotic therapy.

– The prevalence of bacterial prostatitis ranges from 5% to 15% of prostatitis cases.

PRESENTATION AND FINDINGSPRESENTATION AND FINDINGS

• history of documented recurrent or relapsing UTI, urethritis, or epididymitis

caused by the same organism. (25%-43%)

• asymptomatic between acute episodes,

• long history

– dysuria,

– urgency,

– frequency,

– nocturia,

– and low back/perineal pain.

• Others are asymptomatic, but the diagnosis is made after investigation for

bacteriuria.

• digital rectal examination of the prostate is often

normal.

• occasionally, tenderness, firmness, or prostatic calculi

may be found on examination.

• Urinalysis demonstrates a variable degree of WBCs and bacteria in the

urine, depending on the extent of the disease.

• Serum does not show any evidence of leukocytosis.

• Prostate-specific antigen levels may be elevated.

• Diagnosis is made after identification of bacteria from prostate expressate or

urine specimen after a prostatic massage, using the 4-cup test. The

causative organisms are similar to those of acute bacterial prostatitis

RADIOLOGIC IMAGINGRADIOLOGIC IMAGING

Radiologic imaging is rarely indicated in patients with chronic prostatitis.

Transrectal ultrasonography is only indicated if a prostatic abscess is suspected.

MANAGEMENTMANAGEMENT

• the duration of antibiotic therapy may be 3–4 months.

• Using fluoroquinolones,

• The addition of an alpha blocker to antibiotic therapy has been shown to reduce symptom recurrences.

• Despite maximal therapy, cure is not often achieved due to poor penetration of antibiotic into prostatic tissue and relative isolation of the bacterial foci within the prostate.

• When recurrent episodes of infection occur despite antibiotic therapy, suppressive antibiotic– (TMP-SMX 1 single-strength tablet daily, – nitrofurantoin 100 mg daily, – ciprofloxacin 250 mg daily) may be used.

Transurethral resection of the prostate has been used to treat

patients with refractory disease; however, the success rate has

been variable and this approach is not generally recommended .

Tuberculosis of the prostateTuberculosis of the prostate

• Tuberculosis of the prostate is rare and associated with renal tuberculosis

• in 1/3 of cases there is a history of pulmonary tuberculosis within 5 years of the onset of the genital tubeculosis.

• rectal examination reveals nodules in one or both lateral lobes.

• Patients usually present with the following– Urethral discharge

– painful and sometime blood stained ejaculation

– perineal pain, infertility,

– dysuria,

– abscess formation.

• Radiography sometimes displays area of calcification in the prostate and

seminal vesicles.

• Prostate expressate, seminal fluid and sometime prostate biopsy

bacteriological examination yields positive cultures for tubercle bacilli.

Treatment :

The general Rx is that for tuberculosis. If the prostatic abscess forms it

should be drained transurethrally.

Prostate AbscessProstate Abscess

Most cases of prostatic abscess result from complications of acute bacterial prostatitis that were

inadequately or

inappropriately treated.

Prostatic abscesses are often seen in patients with

• diabetes;

• those receiving chronic dialysis.

• patients who are immunocompromised. undergoing urethral

instrumentation. who have chronic indwelling catheters.

PRESENTATION AND FINDINGSPRESENTATION AND FINDINGS

Patients with prostatic abscess present with similar symptoms to those with

acute bacterial prostatitis.

Typically, these patients were treated for acute bacterial prostatitis

previously and had a good initial response to treatment with antibiotics.

However, their symptoms recurred during treatment, suggesting

development of prostatic abscesses.

– On digital rectal examination, the prostate is usually tender and swollen.

– Fluctuance is only seen in 16% of patients with prostatic abscess.• .

RADIOLOGIC IMAGINGRADIOLOGIC IMAGING

Imaging with transrectal ultrasonography or pelvic CT scan is crucial for diagnosis and treatment

MANAGEMENTMANAGEMENT

• Antibiotic therapy in conjunction with drainage of the abscess is required.

• Transrectal ultrasonography or CT scan can be used to direct transrectal

drainage of the abscess .

• Transurethral resection and drainage may be required if transrectal

drainage is inadequate.

• When properly diagnosed and treated, most cases of prostatic abscess

resolve without significant sequelae.

Chronic Pelvic Pain Syndrome CPPSChronic Pelvic Pain Syndrome CPPS

• The presenting symptoms of inflammatory category IIIA CPPS (chronic nonbacterial Prostatitis) are indistinguishable from those of patients with noninflammatory category IIIB disease prostatodynia.

• The predominant symptom is pain,localized to

– perineum, suprapubic area, and penis but can also occur in the testes, groin, or low back.

• Pain during or after ejaculation is one of the most prominent, important, and bothersome feature in many patients .

• Irritative and obstructive voiding symptoms

• Erectile dysfunction and sexual disturbances

• By definition, the syndrome becomes chronic after 3 months' duration.

• The symptoms tend to wax and wane over time; approximately one third of

patients improve over 1 year (usually patients with shorter duration and

fewer symptoms) .

• The impact of this condition on health status is significant. The quality of life

of many patients diagnosed with CP/CPPS is impaired

• The differentiation of the two subtypes of category III CPPS depend on

cytologic examination of the urine or EPS or both.

MEDICAL THERAPYMEDICAL THERAPY

• Antibiotics• α-adrenergic blockers• anti-inflammatory agents• hormonal therapies• phytotherapies  

The following medical therapies have shown benefits in placebo controlled studies in CPPS:  

– Marked benefit—none – Moderate benefit—α-adrenergic blockers – Modest benefit—anti-inflammatory agents, phytotherapies

Minimal invasive surgeryMinimal invasive surgery

• transurethral needle ablation (TUNA) of the prostate.

• Microwave Hyperthermia and Thermotherapy.

• TURP or even radical prostatectomy