Introduction
Background
Prostatitis is an infection or inflammation of the prostate gland that presents as several syndromes with varying clinical features. The term prostatitis is defined as microscopic inflammation of the tissue of the prostate gland, which spans a broad range of clinical conditions.
The National Institutes of Health (NIH) has recognized and defined a classification system for prostatitis in 1999. The 4 syndromes of prostatitis are as follows:
- I -Acute bacterial prostatitis
- II -Chronic bacterial prostatitis
- III - Chronic prostatitis and chronic pelvic pain syndrome (CPPS)
- Inflammatory
- Noninflammatory
- IV - Asymptomatic inflammatory prostatitis.
Acute and chronic bacterial prostatitis are defined by documented bacterial infections of the prostate.
Chronic pelvic pain syndrome (CPPS) is characterized primarily by urological pain complaints in the absence of urinary tract infection. This syndrome includes several exclusion criteria, such as presence of active urethritis, urogenital cancer, urinary tract disease, functionally significant urethral stricture, or neurological disease affecting the bladder. It is subdivided into inflammatory and noninflammatory subtypes. Inflammatory CPPS is defined by the presence of white cells in the semen, expressed prostatic secretions, or voided bladder urine post-prostatic massage. Noninflammatory CPPS is defined by the absence of white cells.1
Asymptomatic inflammatory prostatitis is characterized by the incidental discovery of prostatic inflammation without any genitourinary complaints. These patients do not present to the emergency department but rather are diagnosed while undergoing workup for infertility or elevated prostate-specific antigen (PSA) level.
Pathophysiology
In bacterial prostatitis, sexual transmission of bacteria is common, but hematogenous, lymphatic, and contiguous spread of infection from surrounding anatomy must also be considered. Although various routes have been postulated, none have been firmly substantiated.
A history of sexually transmitted diseases is associated with an increased risk for prostatitis symptoms. Prostatitis symptoms may increase a man's risk for benign prostatic hyperplasia (BPH), lower urinary tract symptoms, and prostate cancer.2
The presence of acute inflammatory cells in the glandular epithelium and lumens of the prostate, with chronic inflammatory cells in the periglandular tissue, characterizes prostatitis. However, the presence and quantity of inflammatory cells in the urine or prostatic secretions does not correlate with the severity of physical symptoms.
A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.
Chronic pelvic pain syndrome is diagnosed based on pain in the setting of negative culture results of the urine and prostatic secretions. Neuromuscular dysfunction or congenital reflux of urine into the ejaculatory and prostatic ducts may be a precipitating factor.
Viral and granulomatous prostatitis may be associated with HIV infection and is another cause of culture-negative disease. A common viral pathogen of prostatitis in HIV-infected patients is cytomegalovirus (CMV). Mycobacteria, such as Mycobacterium tuberculosis, and fungi, such as Candida albicans, have also been associated with culture-negative disease in this population.
Frequency
United States
Prostatitis is one of the most common diseases seen in urology practices in the United States, accounting for nearly 2 million outpatient visits per year, with chronic bacterial prostatitis and chronic pelvic pain syndrome being most frequently diagnosed. The diagnosis of prostatitis is made in approximately 25% of male patients presenting with genitourinary symptoms. Autopsy studies have revealed a histologic prevalence of prostatitis of 64-86%.
Approximately 8.2% of men have prostatitis at some point in their lives.1 Of the 4 categories of prostatitis, the most common is chronic prostatitis/chronic pelvic pain syndrome, accounting for 90-95% of cases of prostatitis. Acute bacterial prostatitis and chronic bacterial prostatitis each make up another 2-5% of cases.
International
The incidence of mycobacterial prostatitis, concomitant with disseminated disease, is increased in underdeveloped countries. Areas with widespread sexually transmitted disease (STD) rates and prostitution have a higher incidence of acute bacterial prostatitis.
Mortality/Morbidity
- Particularly susceptible patients include those with diabetes mellitus, patients on dialysis for chronic renal failure, patients who are immunocompromised, and postsurgical patients who have had urethral instrumentation. In these patients, prostatitis can lead to urosepsis with significant associated mortality. Do not overlook the prostate gland when searching for a source of sepsis in these patients.
- In the United States, the long-term prognosis of the first occurrence of acute bacterial prostatitis is good with antibiotic therapy in compliant patients.
Sex
- Prostatitis is a disease of men only.
Age
- In patients younger than 35 years, the most common variant of the syndrome is acute bacterial prostatitis.
- HIV-related disease is also predominantly seen in younger patients.
- Rare causes should be noted. According to case reports of Wegener granulomatosis in the fourth and fifth decades of life, prostatitis can be a presenting feature of Wegener granulomatosis and a clinical manifestation of relapse. Fungal infection with C albicans and Coccidioides immitis and mycobacterial infection with M tuberculosis have also been reported.
Clinical
History
- Acute bacterial prostatitis
- Fever
- Chills
- Malaise
- Arthralgias
- Myalgias
- Perineal prostatic pain
- Dysuria
- Obstructive urinary tract symptoms, including frequency, urgency, dysuria, nocturia, hesitancy, weak stream, and incomplete voiding
- Low back pain
- Low abdominal pain
- Spontaneous urethral discharge
- Chronic bacterial prostatitis
- Intermittent dysuria
- Intermittent obstructive urinary tract symptoms
- Recurrent urinary tract infections1
- Systemic symptoms typically absent
- Chronic prostatitis and chronic pelvic pain syndrome
- Pelvic pain or discomfort including perineal, suprapubic, coccygeal, rectal, urethral, and testicular/scrotal pain for more than 3 of the previous 6 months without documented urinary tract infections from uropathogens.1
- Obstructive urinary tract symptoms, including frequency, dysuria, and incomplete voiding
- Ejaculatory pain
- Erectile dysfunction
- Asymptomatic inflammatory prostatitis - This diagnosis is defined by its lack of symptoms.
Physical
- Acute bacterial prostatitis
- Tender, nodular, hot, boggy, or normal-feeling gland on digital rectal examination
- Suprapubic abdominal tenderness
- Enlarged tender bladder due to urinary retention
- Chronic bacterial prostatitis
- Normal examination findings between acute episodes
- Tender, nodular, or normal gland on digital rectal examination
- Suprapubic tenderness during acute episodes
- Chronic prostatitis and chronic pelvic pain syndrome
- Mildly tender or normal prostate on digital rectal examination
- Tight anal sphincter on digital rectal examination
- Asymptomatic inflammatory prostatitis - Normal or calcified prostate on digital rectal examination
Causes
- Consider Neisseria gonorrhoeae and Chlamydia trachomatis infection in any male younger than 35 years presenting with urinary tract symptoms.
- Acute bacterial prostatitis may be caused by the following:
- Ascending infection through the urethra
- Refluxing urine into prostate ducts
- Direct extension or lymphatic spread from the rectum
- Approximately 80% are gram-negative organisms (eg, Escherichia coli, Enterobacter, Serratia, Pseudomonas, Enterococcus, and Proteus species). Mixed bacterial infections are uncommon. One case report of prostatitis caused by methicillin-resistant Staphylococcus aureus was documented in a diabetic patient.
- Chronic bacterial prostatitis may be due to the following:
- A primary voiding dysfunction, either structurally or functionally
- E coli is responsible for 75-80% of chronic bacterial prostatitis cases. Enterococci and gram-negative aerobes such as Pseudomonas are usually isolated the remainder of the time.
- C trachomatis, Ureaplasma species, Trichomonas vaginalis
- Uncommon organisms, such as M tuberculosis and Coccidioides, Histoplasma, and Candida species , must also be considered. Tuberculous prostatitis may be found in patients with renal tuberculosis.
- Human immunodeficiency virus
- Cytomegalovirus
- Inflammatory conditions such as sarcoidosis
- Chronic prostatitis and chronic pelvic pain syndrome
- About 5-8% of men with this syndrome eventually have a bacterial pathogen isolated from their urine or prostatic fluid.
Bacterial prostatitis. Expressed prostatic fluid contains more than 10 white blood cells per high-power field, indicating prostatitis.
- Etiology is poorly understood but may result from an infectious or inflammatory initiator that results in neurologic injury and eventually results in pelvic floor dysfunction in the form of increased pelvic tone.1
- Functional or structural bladder pathology, such as primary vesical neck obstruction, pseudodyssynergia (failure of the external sphincter to relax during voiding), impaired detrusor contractility, or acontractile detrusor muscle
- Ejaculatory duct obstruction
- Increased pelvic side wall tension
- Nonspecific prostatic inflammation
- Asymptomatic inflammatory prostatitis - Causes are similar to chronic inflammatory prostatitis without symptoms.
More on Prostatitis |
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| Follow-up: Prostatitis |
| Multimedia: Prostatitis |
| References |
| Next Page » |
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Further Reading
Keywords
prostatitis, acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, prostatodynia, prostate gland, bacterial prostatitis, chronic pelvic pain syndrome, CPPS, asymptomatic inflammatory prostatitis, prostatic inflammation
