eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Prostatitis, Bacterial: Differential Diagnoses & Workup

Author: Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center
Coauthor(s): Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Contributor Information and Disclosures

Updated: Oct 8, 2009

Differential Diagnoses

Chronic Pelvic Pain
Prostatitis, Tuberculous
Perianal Abscess
Ureteral Stricture
Prostate Hyperplasia, Benign
Urinary Tract Infection, Males
Prostatitis, Bacterial
Urinary Tract Obstruction

Other Problems to Be Considered

Pelvic floor tension myalgia
Acute prostatitis
Bacteriuria
Cystitis
Prostatic abscess
Chronic prostatitis
Urethral stricture
Urethritis

Workup

Laboratory Studies

The various prostatitis syndromes have been classified based on EPS and culture findings. This classification system is important for therapy because the various categories are treated differently. The presence of 10 or more WBCs/HPF in the EPS is considered clinically significant inflammation.

  • EPS findings are detailed as follows:
    • Chronic bacterial prostatitis: The EPS usually contains greater than 10 WBCs/HPF and should be obtained. Unlike patients with acute bacterial prostatitis, these patients are not acutely ill.
    • Acute bacterial prostatitis: EPS should not be obtained because of the risk of potentiating bacteremia. If the EPS is obtained inadvertently, sheets of WBCs are present. The voided urine reveals significant bacterial growth due to accompanying cystitis.
    • Nonbacterial prostatitis: The prostate is significantly inflamed, as revealed by more than 10 WBCs/HPF. However, routine bacterial culture does not demonstrate growth of organisms. Cultures for fungi, Chlamydia, Ureaplasma, and Mycoplasma rarely demonstrate growth.
    • Prostatodynia: No inflammation in the EPS or bacterial growth in culture is present. Pelvic-perineal pain appropriately describes the symptoms of this condition.
  • Historically, the criterion standard for diagnosis is the 3-cup bacterial localization study. This test represents the classic method for the diagnosis of bacterial prostatitis. The technique was described initially by Meares and Stamey in 1968.4 Clinically, the 3-cup test has proven time-consuming and cumbersome; thus, its use as a diagnostic tool is declining. Obtaining urine cultures prior to and following prostatic massage have arisen as clinically useful alternatives to the 3-cup test. More recently, Magri et al (2009) conducted a retrospective study of semen cultures and found them to be a useful adjunctive diagnostic tool.5 However, further studies are needed to confirm these findings and to determine if semen culture alone may represent a reasonable diagnostic alternative.
  • The 3-cup test is performed best when the bladder urine is sterile. If the bladder urine is not sterile, an oral antibiotic such as nitrofurantoin may be prescribed to sterilize the bladder urine. Nitrofurantoin achieves excellent bladder concentrations but does not produce significant intraprostatic levels. The method for performing a 3-cup test is described below.
    • VB1 represents any bacterial growth within the urethra. The patient is asked to retract the foreskin, if present, and cleanse the meatus. The VB1 is the first 5-10 mL of voided urine and should be collected in a sterile cup.
    • After the VB1 collection, the patient urinates another 100-150 mL of urine. The next 10-15 mL is collected in a sterile cup and represents VB2, the bladder component of any bacterial growth.
    • The EPS represents the prostate contribution. The EPS is obtained by massaging and compressing the prostate gland until a drop of fluid is obtained. The EPS is examined under high power in a microscope. More than 10 WBCs/HPF is abnormal and consistent with prostatic inflammation. In addition to WBCs, the EPS may contain oval bodies, which are fat-containing macrophages; these also indicate inflammation.
    • The VB3 represents a mixture of prostatic fluid and bladder urine. The VB3 is the first 5-10 mL of urine obtained after the prostate massage for the EPS. Similarly, this VB3 is sent for culture.

Imaging Studies

  • Imaging studies are not necessary for the diagnosis and treatment of chronic bacterial prostatitis.
  • Transrectal ultrasonography cannot be used to diagnose chronic bacterial prostatitis. Although hypoechoic lesions and calcifications within the prostate may suggest the infection and inflammation associated with chronic bacterial prostatitis, these findings are highly nonspecific.

Other Tests

  • Routine PSA testing during a prostatitis episode is not recommended. Most patients with clinically proven bacterial prostatitis have an elevated PSA value independent of any cancer-related elevation. No prostatitis-adjusted tables are available to indicate which PSA values are inappropriate in this patient population. In patients with bacterial prostatitis who have an elevated PSA value, a re-evaluation of the PSA value 6-8 weeks after appropriate treatment is recommended to ensure the value is decreasing to normal levels. It is also appropriate to review the patient’s recent PSA values as a point of comparison. If values remain elevated after appropriate therapy, prostate biopsy is recommended to rule out concomitant pathology.
  • If a patient with chronic bacteriuria does not have chronic bacterial prostatitis based on the above modalities, referral to a urologist is advisable. Chronic bacteriuria should prompt an investigation for underlying causes, such as urinary stasis, infection, stones, abscess, and/or obstruction.
    • In this situation, evaluation of the upper urinary tract with a radiologic imaging study such as an intravenous pyelography (IVP), renal ultrasonography, or CT scanning is often performed.
    • In addition, chronic bacteriuria in the absence of chronic bacterial prostatitis may prompt evaluation of the bladder with cystoscopy.

Histologic Findings

Prostate biopsy is not used to diagnose chronic bacterial prostatitis. However, prostate biopsy samples collected to evaluate prostate cancer may demonstrate focal areas of inflammation characterized by a lymphocytic response. The pathology report is often described as chronic prostatitis.

Although this type of finding may suggest chronic bacterial prostatitis, it also may represent nonbacterial prostatitis. The history of chronic urinary tract infections provides the clinical diagnosis.

A nonspecific mixed inflammatory infiltrate that ...

A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.

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A nonspecific mixed inflammatory infiltrate that ...

A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.


More on Prostatitis, Bacterial

Overview: Prostatitis, Bacterial
Differential Diagnoses & Workup: Prostatitis, Bacterial
Treatment & Medication: Prostatitis, Bacterial
Follow-up: Prostatitis, Bacterial
Multimedia: Prostatitis, Bacterial
References
Further Reading
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References

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  3. NIH Summary Statement. NIDDK Workshop on Chronic Prostatitis, Bethesda, Md. December 1995.

  4. Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol. Mar 1968;5(5):492-518. [Medline].

  5. Magri V, Wagenlehner FM, Montanari E, Marras E, Orlandi V, Restelli A, et al. Semen analysis in chronic bacterial prostatitis: diagnostic and therapeutic implications. Asian J Androl. Jul 2009;11(4):461-77. [Medline].

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  9. Meares ET. Chronic bacterial prostatitis: role of transurethral prostatectomy (TURP) in therapy. In: Schmiedt E, Alken JE, Bauer HW, eds. Therapy of prostatitis. Munich, Germany: Zuckerschwerdt Verlag; 1986:193-197.

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  31. Wagenlehner FM, Naber KG. Fluoroquinolone antimicrobial agents in the treatment of prostatitis and recurrent urinary tract infections in men. Curr Urol Rep. Aug 2004;5(4):309-16. [Medline].

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Further Reading

For additional information, see Medscape’s Prostatitis Resource Center.

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Keywords

chronic urinary tract infections, UTI, acute bacterial prostatitis, chronic bacterial prostatitis, chronic abacterial prostatitis, asymptomatic inflammatory prostatitis, nonbacterial prostatitis, chronic pelvic pain syndrome, CPPS, prostatodynia, asymptomatic bacteriuria, dysuria, ascending urethral infection, gonococcal prostatitis, intraprostatic urinary reflux

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Contributor Information and Disclosures

Author

Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center
Joe D Mobley III, MD, MPH is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Endourological Society, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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