Nonbacterial Prostatitis Workup
- Author: Sunil K Ahuja, MD; Chief Editor: Edward David Kim, MD, FACS more...
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.
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.
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.
Krieger JN, Nyberg L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999 Jul 21. 282(3):236-7. [Medline].
Litwin MS, McNaughton-Collins M, Fowler FJ Jr, Nickel JC, Calhoun EA, Pontari MA, et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol. 1999 Aug. 162(2):369-75. [Medline].
Sandhu JS. Use of empiric antibiotics in the setting of an increased prostate specific antigen: con. J Urol. 2011 Jul. 186(1):18-9. [Medline].
Loeb S. Use of empiric antibiotics in the setting of an increased prostate specific antigen: pro. J Urol. 2011 Jul. 186(1):17-9. [Medline].
Weidner W. Treating chronic prostatitis: antibiotics no, alpha-blockers maybe. Ann Intern Med. 2004 Oct 19. 141(8):639-40. [Medline].
Forrest JB, Schmidt S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity. J Urol. 2004 Dec. 172(6 Pt 2):2561-2. [Medline].
Collins MM, Stafford RS, O'Leary MP, Barry MJ. How common is prostatitis? A national survey of physician visits. J Urol. 1998 Apr. 159(4):1224-8. [Medline].
Nickel JC, Downey J, Hunter D, Clark J. Prevalence of prostatitis-like symptoms in a population based study using the National Institutes of Health chronic prostatitis symptom index. J Urol. 2001 Mar. 165(3):842-5. [Medline].
Dalhoff A, Shalit I. Immunomodulatory effects of quinolones. Lancet Infect Dis. 2003 Jun. 3(6):359-71. [Medline].
Shoskes DA, Nickel JC, Rackley RR, Pontari MA. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis. 2009. 12(2):177-83. [Medline].
Anderson R, Wise D, Sawyer T, Nathanson BH. Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. Clin J Pain. 2011 Nov-Dec. 27(9):764-8. [Medline].
Barbalias GA, Nikiforidis G, Liatsikos EN. Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. 1998 Mar. 159(3):883-7. [Medline].
Kaplan SA, Volpe MA, Te AE. A prospective, 1-year trial using saw palmetto versus finasteride in the treatment of category III prostatitis/chronic pelvic pain syndrome. J Urol. 2004 Jan. 171(1):284-8. [Medline].
Schneider H, Ludwig M, Horstmann A, et al. The efficacy of cernilton in patients with chronic pelvic pain syndrome (CP/CPPS) type NIH III: a randomized prospective, double blind, placebo controlled study. J Urol. 2006. 175(suppl);34:Abstract 105.
Nickel JC, Sorensen R. Transurethral microwave thermotherapy for nonbacterial prostatitis: a randomized double-blind sham controlled study using new prostatitis specific assessment questionnaires. J Urol. 1996 Jun. 155(6):1950-4; discussion 1954-5. [Medline].
Bassotti G, Whitehead WE. Biofeedback, relaxation training, and cognitive behaviour modification as treatments for lower functional gastrointestinal disorders. QJM. 1997 Aug. 90(8):545-50. [Medline].
Kaplan SA, Santarosa RP, D'Alisera PM, Fay BJ, Ikeguchi EF, Hendricks J, et al. Pseudodyssynergia (contraction of the external sphincter during voiding) misdiagnosed as chronic nonbacterial prostatitis and the role of biofeedback as a therapeutic option. J Urol. 1997 Jun. 157(6):2234-7. [Medline].
Chang SC, Hsu CH, Hsu CK, Yang SS, Chang SJ. The efficacy of acupuncture in managing patients with chronic prostatitis/chronic pelvic pain syndrome: A systemic review and meta-analysis. Neurourol Urodyn. 2016 Jan 6. 61(6):1156-9; discussion 1159. [Medline].
Yang ZX, Chen PD, Yu HB, Pi M, Luo WS, Zhuo YY. Study strategies for acupuncture treatment of chronic nonbacterial prostatitis. Zhong Xi Yi Jie He Xue Bao. 2012 Mar. 10(3):293-7. [Medline].
Öztekin İ, Akdere H, Can N, Aktoz T, Arda E, Turan FN. Therapeutic Effects of Oligonol, Acupuncture, and Quantum Light Therapy in Chronic Nonbacterial Prostatitis. Evid Based Complement Alternat Med. 2015. 2015:687196. [Medline].
Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005 Jul. 174(1):155-60. [Medline].
Chen X, Hu C, Peng Y, Lu J, Yang NQ, Chen L, et al. Association of diet and lifestyle with chronic prostatitis/chronic pelvic pain syndrome and pain severity: a case-control study. Prostate Cancer Prostatic Dis. 2016 Mar. 19 (1):92-9. [Medline].