Acute Bacterial Prostatitis Workup
- Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS more...
Approach Considerations
In patients with acute bacterial prostatitis (ABP), prostatic secretions contain large numbers of leukocytes and fat-laden macrophages. However, prostatic massage to obtain secretions should not be performed as it is rarely necessary for diagnosis.
Because prostatitis may cause irritative and obstructive voiding symptoms that mimic other primary causes of those symptoms, the use of urodynamics may possibly be helpful to avoid misdiagnosis of prostatitis. However, this is more the situation in chronic prostatitis; in acute prostatitis, this should not be necessary.
The presence of a prostatic abscess is confirmed with transrectal ultrasonography and noncontrast computed tomography (CT) scanning of the pelvis.
Occasionally, blood culture results are positive.
Urine Studies
Urinalysis, which shows leukocytes, and a positive result on urine culture are essential for the diagnosis of acute bacterial prostatitis (ABP). The urine specimen should include midstream premassage and postmassage of the prostate; this test is known as the 2-glass test.[7]
If the patient is febrile or exhibits signs of acute bacterial prostatitis, only the midstream urine is collected for urine culture. The prostatic massage is contraindicated.
Urethral swab culture and postmassage urine culture as well as microscopic examination may be an alternative standard protocol to simplify the evaluation of prostatitislike syndrome in the clinical practice.[8]
The evaluation for chronic prostatitis may include first voided urine, midstream urine, urine after prostatic massage, and expressed prostatic secretions to localize the nidus of infection, as described by Meares and Stamey.[9]
Serum PSA Levels
Serum prostate-specific antigen (PSA) levels are also increased in prostatitis but should not be used as a screening test for this condition. In the setting of acute bacterial prostatitis (ABP), PSA has little to no clinical value. If the PSA level is obtained and is found to be elevated, the study should be repeated 30-60 days after adequate treatment. Studies have shown that a 2- to 4-week treatment with antibiotics decreased the PSA levels in approximately half of patients with PSA levels in the gray zone who did not have prostatitis symptoms.[10]
CT Scanning/Transrectal Ultrasonography
Imaging studies, including computed tomography (CT) scanning of the pelvis or transrectal ultrasonography, should be reserved for cases in which findings from laboratory analyses are equivocal or when no improvement is observed following medical therapy.
Ruling out complications of prostatitis (eg, prostatic abscess) is a strong indication to proceed to imaging studies. Transrectal ultrasonography and CT scanning of the pelvis can be very useful in diagnosing and draining prostatic abscesses.[11] However, transrectal ultrasonography should be performed as gently as possible to prevent bacteremia.
Biopsy and Histology
Histologically, the normal prostate gland is composed of tubuloalveolar glands. The glandular spaces are lined by epithelium, which is composed of 2 layers of cells—a basal layer of low cuboidal epithelium covered by a layer of columnar mucus-secreting cells. The glands have a distinct basement membrane and are separated by a fibromuscular stroma.
Prostate biopsy is contraindicated in patients with suspected acute bacterial prostatitis (ABP) because of the potential complication of seeding the bacterial infection in adjacent organs. Furthermore, prostate biopsy is extremely painful without a prostatic nerve block. The current practice is to anesthetize the area before core biopsy sampling. Biopsy in the face of acute bacterial prostatitis may result in gram-negative sepsis.
In prostatitis, a stromal leukocytic infiltrate may be accompanied by increased prostatic secretion or leukocytic infiltration within gland spaces (see image below). When complicated by abscess formation, focal or larger areas of the prostate become necrotic.
Leukocytic infiltration of the stroma and glandular lumina during acute bacterial prostatitis (ABP). Nickel JC. Inflammatory conditions of the male genitourinary tract: prostatitis and related conditions, orchitis, and epididymitis. In: Wein. AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: WB Saunders: 2005; Chapter 9.
Nickel JC. 5 alpha reductase therapy for chronic prostatitis. In: Nickel JC, ed. Textbook of Prostatitis. Oxford, UK: ISIS Medical Media; 1999:333-7.
Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol. Apr 1998;159(4):1224-8. [Medline].
Kanamaru S, Kurazono H, Terai A, Monden K, Kumon H, Mizunoe Y, et al. Increased biofilm formation in Escherichia coli isolated from acute prostatitis. Int J Antimicrob Agents. Aug 2006;28 Suppl 1:S21-5. [Medline].
Bergman B. On the relevance of gram-positive bacteria in prostatitis. Infection. 1994;22 Suppl 1:S22. [Medline].
Lomberg H, Cedergren B, Leffler H, Nilsson B, Carlström AS, Svanborg-Edén C. Influence of blood group on the availability of receptors for attachment of uropathogenic Escherichia coli. Infect Immun. Mar 1986;51(3):919-26. [Medline]. [Full Text].
Nickel JC. The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol. Spring 1997;3(1):38-43. [Medline].
Magri V, Cariani L, Bonamore R, Restelli A, Garlaschi MC, Trinchieri A. Microscopic and microbiological findings for evaluation of chronic prostatitis. Arch Ital Urol Androl. Jun 2005;77(2):135-8. [Medline].
Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol. Mar 1968;5(5):492-518. [Medline].
Terrone C, Poggio M, Bollito E, Cracco CM, Scarpa RM. [Asymptomatic prostatitis: a frequent cause of raising PSA]. Recenti Prog Med. Jul-Aug 2005;96(7-8):365-9. [Medline].
Granados EA, Riley G, Salvador J, Vincente J. Prostatic abscess: diagnosis and treatment. J Urol. Jul 1992;148(1):80-2. [Medline].
Barbalias GA, Nikiforidis G, Liatsikos EN. Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. Mar 1998;159(3):883-7. [Medline].
Aravantinos E, Kalogeras N, Zygoulakis N, Kakkas G, Anagnostou T, Melekos M. Ultrasound-guided transrectal placement of a drainage tube as therapeutic management of patients with prostatic abscess. J Endourol. Aug 2008;22(8):1751-4. [Medline].
Chou YH, Tiu CM, Liu JY, Chen JD, Chiou HJ, Chiou SY, et al. Prostatic abscess: transrectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management. Ultrasound Med Biol. Jun 2004;30(6):719-24. [Medline].
Barozzi L, Pavlica P, Menchi I, De Matteis M, Canepari M. Prostatic abscess: diagnosis and treatment. AJR Am J Roentgenol. Mar 1998;170(3):753-7. [Medline].
Meares EM Jr. Prostatitis. Med Clin North Am. Mar 1991;75(2):405-24. [Medline].
Kabay S, Kabay SC, Yucel M, Ozden H. Efficiency of posterior tibial nerve stimulation in category IIIB chronic prostatitis/chronic pelvic pain: a Sham-Controlled Comparative Study. Urol Int. 2009;83(1):33-8. [Medline].
Lee SH, Lee BC. Electroacupuncture relieves pain in men with chronic prostatitis/chronic pelvic pain syndrome: three-arm randomized trial. Urology. May 2009;73(5):1036-41. [Medline].
Liu L, Yang J. Physician's practice patterns for chronic prostatitis. Andrologia. Oct 2009;41(5):270-6. [Medline].
Ludwig M. Diagnosis and therapy of acute prostatitis, epididymitis and orchitis. Andrologia. Apr 2008;40(2):76-80. [Medline].
Nickel JC, Shoskes D. Phenotypic approach to the management of chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep. Jul 2009;10(4):307-12. [Medline].
Wagenlehner FM, Naber KG, Bschleipfer T, Brähler E, Weidner W. Prostatitis and male pelvic pain syndrome: diagnosis and treatment. Dtsch Arztebl Int. Mar 2009;106(11):175-83. [Medline]. [Full Text].
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