eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions
Nonbacterial Prostatitis
Updated: Mar 18, 2008
Introduction
Background
Nonbacterial prostatitis refers to a condition that affects patients who present with symptoms of prostatitis without a positive result after urine culture or expressed prostate secretion (EPS) culture. Bacterial causes and their presentations can be reviewed in Acute Bacterial Prostatitis and Prostatic Abscess, Chronic Bacterial Prostatitis, and Prostatitis, Bacterial.
Prior to 1995, the diagnosis of prostatitis was based on the classification of Meares and Stamey, which classified prostatitis into 4 categories: acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia.
In 1995, the US National Institutes of Health (NIH) convened a workshop on prostatitis and developed a new classification scheme. The first 2 categories remained the same, ie, acute and chronic bacterial prostatitis. Nonbacterial prostatitis and prostatodynia were combined as category III, ie, chronic abacterial prostatitis/chronic pelvic pain syndrome (CPPS). Category III was further subdivided into IIIa, ie, inflammatory CPPS, and IIIb, ie, noninflammatory CPPS. Category IV encompasses asymptomatic inflammatory prostatitis. See Image 2 for a comparison of the old and new categories of prostatitis.
Prostate specimens often reveal evidence of category IV prostatitis after a biopsy. However, patients with category IV prostatitis have no symptoms. Some physicians treat these patients with antibiotics in an effort to lower their prostate-specific antigen (PSA) level.
The rationale for the new diagnostic classification was to promote additional research to find effective forms of treatment for a symptom complex that cannot always be attributed to a bacterial infection.
Pathophysiology
Of all men evaluated for prostatitis, only 5-10% actually have a true bacteriologic condition as evidenced by a positive urine culture. However, approximately 50% of these men actually receive antibiotics for treatment of the prostatitis symptom complex. Evidence suggests that despite negative culture findings, some patients with nonbacterial prostatitis in the traditional sense may have a bacterial infection. Recent studies found bacterial ribosomal ribonucleic acid (rRNA) by reverse transcriptase-polymerase chain reaction (RT-PCR) in the prostatic fluid of patients with prostatitis symptoms. In addition, some fastidious organisms that do not grow in standard culture media may be the cause of the symptom complex. Some of these organisms are Chlamydia trachomatous, Ureaplasma urealyticum, and Neisseria gonorrhoeae. Despite having nonbacterial prostatitis by the classic definition, these patients improve with an appropriate course of antibiotics.
The pathophysiology of chronic abacterial prostatitis has not been fully elucidated, emphasizing the lack of understanding of this disease complex. However, chronic abacterial prostatitis may involve an etiology similar to that of chronic bacterial prostatitis. The peripheral zone of the prostate is composed of a system of ducts, which possess a poor drainage system that prevents the dependent drainage of secretions. As the prostate enlarges with increasing age, patients develop obstructive symptoms and urine refluxes into the prostatic ducts.
Urine reflux may also occur in patients with urethral stricture disease, voiding dysfunction, or benign prostatic hyperplasia. Refluxing urine, even when it is sterile, may lead to chemical irritation and inflammation. Tubule fibrosis is initiated, and prostatic stones form and lead to intraductal obstruction and stagnation of intraductal secretions. This obstruction initiates an inflammatory response, and prostatitis symptoms develop. A fastidious organism may cause an infection by ascending up the urethra or through reflux of infected urine into the prostatic ducts. Additionally, many men with prostatitis are also more prone to having allergies. Thus, these men may also have autoimmune-mediated inflammation caused by a preceding true infection.
Frequency
United States
Prostatitis symptoms are very common in men aged 35-50 years. These symptoms are the most common urologic problem in men younger than 50 years and the third most common urologic problem in older men. Recent studies using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) (see Image 1) found the prevalence of prostatitis symptoms to be approximately 10% in a population of men aged 20-74 years. The most common form of prostatitis (90%) is category III, ie, chronic abacterial prostatitis and CPPS.
Mortality/Morbidity
- Approximately half of all men develop symptoms consistent with prostatitis at some time in their lives. This accounts for 25% of men evaluated for a urologic problem and 8% of all visits to urologists. Prostatitis impairs the patient's quality of life to the same degree as coronary artery disease or Crohn disease. Prostatitis has been shown to have the same effect on a patient's mental health as diabetes mellitus and congestive heart failure.
- Nonbacterial prostatitis may be caused by fastidious organisms that cannot be cultured routinely from a urinary specimen. A negative routine urine culture result is the reason the syndrome is called nonbacterial prostatitis. These fastidious organisms include C trachomatous, U urealyticum, Trichomonas vaginalis, N gonorrhoeae, viruses, fungi, and anaerobic bacteria.
- Noninfectious causes of prostatitis have not been proven definitively, but allergies and autoimmune diseases, such as Reiter syndrome, are hypothesized causes. Other purported etiologies are pelvic floor tension myalgia, bladder neck or urethral spasm, and a male variant of interstitial cystitis. One important caveat is that carcinoma in situ of the bladder can also present with irritative urinary symptoms and should be excluded as a cause.
Race
- No racial predilection is found.
Sex
- Nonbacterial prostatitis only occurs in males.
Age
- The common age range for presentation of prostatitis symptoms is 36-74 years.
Clinical
History
Patients with abacterial prostatitis/CPPS (category III in the 1995 NIH prostatitis classification system) have the same symptom complex as those with chronic bacterial prostatitis. The chief symptom reported in patients with abacterial prostatitis/CPPS is pain.
- Genitourinary symptoms include perineal, penile tip, testicular, rectal, lower abdominal, or back pain.
- Patients can also have irritative or obstructive urologic symptoms such as frequency, urgency, dysuria, decreased force of the urinary stream, nocturia, and incontinence.
- Other symptoms are a clear urethral discharge, ejaculatory pain, hematospermia, and sexual dysfunction.
Physical
In most cases, physical examination findings are nonspecific.
- Many patients have normal findings, others may have an exquisitely sensitive prostate, and still others may have an enlarged boggy prostate.
- Uroflowmetry findings may show the patient to have a decreased peak urinary flow.
Causes
- Nonbacterial prostatitis may be caused by fastidious organisms that cannot be cultured routinely from a urinary specimen. A negative result after routine urine culture is the reason the syndrome is referred to as nonbacterial prostatitis. These fastidious organisms include C trachomatis, U urealyticum, T vaginalis, N gonorrhea, viruses, fungi, and anaerobic bacteria.
- Noninfectious causes of prostatitis have not been definitively proven, but allergies and autoimmune diseases, such as Reiter syndrome, are hypothesized causes.
- Other purported etiologies are bladder neck or urethral spasm, a male variant of interstitial cystitis, and pelvic floor tension myalgia.
- See Interstitial Cystitis for more information.
- Pelvic floor tension myalgia is also known as levator ani syndrome. This syndrome often is diagnosed based solely on symptoms of a vague dull ache in the rectal area that often worsens when sitting or lying down. Symptoms can last for hours or days. The prevalence rate is approximately 6.6% in the general population and is higher in women. It is observed in persons aged 30-60 years, but incidence decreases in those older than 45 years. Pelvic floor tension myalgia may result from overly contracted pelvic floor muscles due to psychological stress, tension, and anxiety.
- Carcinoma in situ of the bladder, which can present with irritative urinary symptoms, must be considered and excluded.
More on Nonbacterial Prostatitis |
 Overview: Nonbacterial Prostatitis |
| Differential Diagnoses & Workup: Nonbacterial Prostatitis |
| Treatment & Medication: Nonbacterial Prostatitis |
| Follow-up: Nonbacterial Prostatitis |
| Multimedia: Nonbacterial Prostatitis |
| References |
| Further Reading |
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References
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Keywords
nonbacterial prostatitis, chronic pelvic pain syndrome, CPPS, prostatodynia, abacterial prostatitis, noninflammatory chronic pelvic pain syndrome, noninflammatory CPPS, inflammatory chronic pelvic pain syndrome, inflammatory CPPS, asymptomatic inflammatory prostatitis, prostate pain, prostatitis symptom complex, chronic prostatitis symptom index, CPSI, irritative urologic symptoms, obstructive urologic symptoms
