Nonbacterial Prostatitis Workup

A patient with abacterial prostatitis can be evaluated in 2 ways. The first approach is to adhere strictly to the fact that these patients do not have an infection by performing an exhaustive search to exclude an infectious source. This often involves repetitive culturing of expressed prostate secretions (EPS) or prostate biopsy specimens using nonstandard culture media for Chlamydia, Ureaplasma, gonorrheal organisms, or anaerobes. Sophisticated research methods using real time polymerase chain reaction (RT-PCR) techniques can also be employed.

This first approach is very time-consuming and likely only of value in the research setting.

A second method involves examination of expressed prostatic secretions. If inflammatory cells are seen (IIIa), then a short course of antibiotics (2 wk) can be given. A longer course can be given if there is symptomatic improvement, as long as the patient is counseled on increased risks of tendon rupture and the development of antibiotic-resistant bacteria. These patients would likely also benefit from additional other treatment, including alpha-blockers. If no inflammatory cells are seen (IIIb), then other treatments should be tried.

This second method is often the one most commonly used and is used first to treat patients with nonbacterial prostatitis. It succeeds approximately 50% of the time when used over a course of 4 weeks. It should be noted that antibiotics have been shown to have analgesic, antipyretic, and antiinflmmatory effects as well, and this may account for symptom improvement in some patients.^[9]

If the patient does not improve with antibiotics, then another cause of symptoms must be sought and different treatment regimens must be initiated until symptoms are controlled. If the symptoms are mostly irritative (eg, dysuria with urinary urgency and frequency), then carcinoma in situ of the bladder must be excluded using urine cytology studies and cystoscopy.

Category III prostatitis is divided into IIIa and IIIb based on whether greater or fewer than 10 WBCs are seen on microscopic examination of the EPS, respectively. However, the management approaches for these two categories do not differ, so they can be grouped together.

Other causes can also be sought, and they are evaluated in no particular order. Further workup is based on the clinical suspicion of the urologist. In addition, some patients may complain of symptoms that are not life-limiting, whereas others are completely limited in their activities of daily life. The search for a cause to these symptoms may be based on each individual, and the appropriate health care consultant should be used for the more esoteric diagnoses.

Category III prostatitis can be further categorized by using the UPOINT system, which divides a patient’s symptoms into different categories (urinary, psychologic, organ specific, infection, neurologic/systemic, and tenderness of skeletal muscles). By subcategorizing, treatment may be better tailored to each patient’s specific needs.^[10]

Interstitial cystitis requires a more complex workup. See the main article on Interstitial Cystitis for more information.

Voiding cystourethrography findings can aid in the diagnosis of bladder neck dysfunction by demonstrating intraprostatic and ejaculatory duct urinary reflux.

Retrograde urethrography findings may demonstrate a urethral stricture. This test is indicated if the patient demonstrates decreased peak urinary flow on uroflowmetry findings.

Prostatic enlargement can be investigated using uroflowmetry or a pressure flow study and the International Prostate Symptom Score.

Problems such as pelvic floor tension are more difficult to diagnose, but videourodynamic findings may be helpful in diagnosis. Patient symptoms of a dull ache or pressure in the rectal area may also suggest this diagnosis. A consultation with physical medicine and rehabilitation (PM&R) specialist may be beneficial for these patients.