Prostatitis is the inflammation or infection of the prostate gland and can be presented with different clinical presentations. It refers to a broad group of diseases characterized by microscopic inflammation of the prostate gland tissue.

In 1999, the National Institutes of Health (NIH) introduced a classification system for prostatitis, dividing it into four categories:

Acute bacterial prostatitis

Chronic bacterial prostatitis

Chronic prostatitis / chronic pelvic pain syndrome (CP/CPPS), that in turn is subdivided into inflammatory and non-inflammatory.

Asymptomatic inflammatory prostatitis

Acute and chronic bacterial prostatitis are characterized by confirmed bacterial infections of the prostate and are managed with antibiotics and supportive care.

The most common form of prostatitis is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), contributing to 90% of all prostatitis cases. It is defined as urologic pain not associated with a urinary tract infection and does not include diseases such as active urethritis, uro-genital cancer, urinary tract pathology, major urethral stricture or neurological dysfunction of the bladder. There are inflammatory and non-inflammatory CP/CPPS, which is diagnosed by the presence of white blood cells in semen, prostatic secretions or in urine after the massage.

Prostatitis has been estimated to affect over a million men in the USA alone, with nearly 2 million outpatient visits each year in urology practices. It is diagnosed in about 25% of male patients presenting with genitourinary complaints. A histologic study of prostate articles suggests that chronic canine prostatitis histologically ranges between 64% to 86%.

It is estimated that 8.2% of men will suffer from prostatitis at some point in their lives. Of the four categories of prostatitis, the most prevalent is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), accounting for 90 to 95% of all cases. Acute bacterial prostatitis is rare in comparison to chronic bacterial prostatitis although they both fall under 2-5% cases. It is often encountered incidentally, and so the exact incidence of asymptomatic inflammatory prostatitis cannot be estimated.

International Statistics

Prostatitis is a condition that has an incidence of between 2-10% among men in North America, Europe and Asia.

Age-related Demographics

It is also reported that acute bacterial prostatitis is the most common type in men younger than 35 years. This age group also gets affected with HIV related prostatitis more frequently.

Nonbacterial prostatitis (NIH types II and IV) is seen more frequently in older men. It is necessary to take into consideration that there are rare causes of prostatitis.

The cause of bacterial prostatitis is sexual contact but the bacteria can be transported through the blood stream, lymphatics or from adjacent organs. Men with multiple STD episodes have higher chances of developing prostatitis symptoms. The type of inflammation in prostatitis includes acute inflammatory cells within the glandular epithelial and within the lumen of the prostatic gland as well as chronic inflammatory cells within the periglandular area of the prostate gland. However, the number of inflammatory cells in urine or prostatic secretions does not reflect the severity of the patients’ symptoms. Chronic pelvic pain syndrome is manifested by pain in the pelvically referred areas even if urine and prostatic secretions cultures are negative.

Viral and granulomatous prostatitis are also seen in HIV patients and such cases belong to the culture negative prostatitis. Cytomegalovirus (CMV) is one of the major viruses that cause infections in HIV-infected patients.

Acute Bacterial Prostatitis:

It can be an ascending infection through the prostatic urethra, back flow of urine into the prostate ducts, direct invasion from the rectum or metastatic spread through the lymphatics. Approximately 80% of these infections are caused by gram negative bacilli including Escherichia coli, Enterobacter, Serratia, Pseudomonas, Enterococcus and Proteus species. It is important to note that mixed bacterial infections are quite uncommon. Aeromonas hydrophila and A. caviae are known to cause prostatitis and there is a reported case where they were from cave diving in Florida. Urinary complaints in male patients less than 35 years should make one consider Neisseria gonorrhoeae and Chlamydia trachomatis infections.

Chronic Bacterial Prostatitis:

This is most often associated with primary voiding dysfunction, either physical or functional. Escherichia coli alone was found to cause 75-80% of these cases whereas the remaining 20-25% included Enterococci and other gram-negative aerobes such as Pseudomonas. Other possible bacteria are Chlamydia trachomatis, colonizing Ureaplasma species, and parastic Trichomonas vaginalis. Some of the rare causes are tubercular etiology and fungal etiology including candida, histoplasma and coccidioides.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS):

Despite the existence of a name for this disease, the pathogenesis of CP/CPPS remains unknown and the disease could be an infection or inflammation with subsequent nervous system disorders and pathophysiological changes in the pelvic floor. It is predominantly localized to the perineal region and less frequently testicular, pubic, and penile. It is important to note that urogenital pain is more worrying to the patients than urogenital symptoms. Irritable bowel syndrome is reported in 25% of men with CP/CPPS. In 5 to 8% of cases, a bacterial pathogen is isolated from urine or prostatic fluid at some stage of the disease.

Acute bacterial prostatitis is usually well managed especially if the diagnosis is made early and treated using the recommended drugs. The prognosis for chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients is more difficult to establish. Some of the factors that are used in the determination of prognosis include the age, general health of the patient and even the initial response to treatment. Patients with previous histories of recurrent urinary tract infections and diabetes or other immunosuppressive conditions may have a poor prognosis. Other factors that may affect the outcome include presence of bladder outlet obstruction greater than 30 percent and presence of prostatic calculi. Stress and anxiety have been found to be associated with severity and duration of the symptoms in the condition known as CP/CPPS.

Acute Bacterial Prostatitis   

Age group: 20-40 and >50

Associated Comorbidity: UTIs, recent catheterization, BPH, immunocompromised states

Acuity of Presentation: Acute onset, high fever, severe symptoms

Chronic Bacterial Prostatitis

Age group: 30 to 50

Associated Comorbidity: Recurrent UTIs, prostatic calculi, previous acute prostatitis

Acuity of Presentation: Gradual onset, recurrent or persistent symptoms

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)  

Age group: 36 to 50

Associated Comorbidity: Psychological stress, pelvic trauma, STIs, overactive bladder

Acuity of Presentation: Chronic, persistent pelvic pain and urinary symptoms

Asymptomatic Inflammatory Prostatitis Older men Infertility evaluations, elevated PSA, BPH      Asymptomatic, incidental finding

Abdominal Examination:

Check for suprapubic sensitivity, which may suggest bladder involvement or an enlarged bladder because of urinary retention.

Genitourinary Examination:

Penile and Scrotal Examination: Look for symptoms of infection like white or clear urethral discharge or swollen/tender scrotum which may be due to associated epididymitis.

Digital Rectal Examination (DRE): The DRE is very important in examination of the prostate gland. In performing the digital rectal exam, a lubricated gloved finger is introduced into the rectum to feel the prostate.

Size and Consistency: Determine the size and shape of the prostate gland also check whether the gland is hard, soft, smooth or nodular. The normal prostate gland is hard and spongy to feel.

Tenderness: Inflamed and enlarged prostate is painful, and its gripping presence may be due to acute bacterial prostatitis. In chronic prostatitis the prostate may not be palpated, may feel like a small nodularity, or may be palpated firm.

Nodules or Indurations: Especially look for nodules or areas of induration or other pathology that may be suggested by the occurrence of prostate cancer.

Antibiotics: Initial empirical antibiotic administration is mandatory; the first-choice drugs may be ciprofloxacin or levofloxacin in many cases. Culturally relevant modifications are made according to the culture results and sensitivity.

Supportive Care: This includes water, having paracetamol or any another pain relievers, as well as antipyretics for fever.

Hospitalization: Sometimes needed in seriously ill patients, or if there is an acute problem such as sepsis or urinary incontinence.

Medications:

Alpha-Blockers: To relieve the symptoms of urinary incontinence such as urgency, frequency, and nocturia.

Anti-inflammatory Drugs: It is advisable that the patient should take non-steroidal anti-inflammatory drugs (NSAIDs) or other anti-inflammatory drugs to minimize the pain.

5-Alpha-Reductase Inhibitors: Sometimes, especially if there is some development of benign prostatic hyperplasia.

Physical Therapy: Pelvic PT can help resolve some issues related to muscle tone as well as pain that primarily affects the pelvic region.

Emergency Medicine

Pelvic Floor Physical Therapy: Physical therapy activities like Kegels may also help to improve the tone of the pelvic floor muscles which can be helpful in reducing the pain or discomfort felt. It assists patients in passive and active ways to manage the muscles in the pelvic floor and pain.

Dietary Modifications: Pregnant women should avoid spicy foods, coffee, alcohol and foods that are acidic for the problem to be solved. Drinking more fluids has been found to dilute the contents of the urinary tract and may possibly cause a reduction in the symptoms.

Lifestyle Changes: It is also recommended to avoid stressful situations, as well as practice some relaxation techniques like meditation, deep breathing exercises, and yoga. Physical activity, including walking and other moderate-intensity exercises, may benefit your overall health and possibly alleviate pelvic pain.

Heat Therapy: Taking a warm water bath or placing a heating pad on the certain region of the pelvis area also gives relief from the aching sensations.

Behavioral Therapy: Cognitive behavioral therapy is effective in the treatment of chronic pain together with anxiety or depression since treatment can enhance general symptoms and quality of life.

Emergency Medicine

Terazosin: It is a quinazoline derivative that inhibits alpha-1 adrenergic receptors and reduces the spasm of the bladder neck due to inflammation of the prostate gland. This action helps in enhancing the rate of urinary flow.

Tamsulosin (Flomax): It is an alpha-adrenergic blocker that selectively acts on the alpha-1 subcategory of adrenergic receptors referred to as alpha-1 receptors. This is known for resulting in fewer cases of orthostatic hypotension than other medicines in its category and does not call for gradual titration of the dose. However, it is linked with a higher rate of ejaculatory dysfunction where 8 percent of patients being treated experienced the condition.

Emergency Medicine

Levofloxacin (Levaquin): It is an antibiotic from the fluoroquinolone group and is used in bacterial prostatitis of both acute and chronic forms by pathogens like Escherichia coli, Enterococcus faecalis, and Staphylococcus epidermidis. They attain high concentrations in the prostate gland. It is the L-isomer of the racemic compound of the drug ofloxacin with the D-isomer being pharmacologically inactive. Levofloxacin is well established as a monotherapy and has good coverage against Pseudomonas species and pneumococcus. It works through blocking DNA gyrase.

Ofloxacin: It is a fluoroquinolone antibacterial drug of pyridine carboxylic acid derivative which acts bactericidal on various types of bacteria.

Ciprofloxacin (Cipro, Cipro XR, Proquin XR): It is within the fluoroquinolone class which is active against a wide range of bacteria by inhibiting the bacterial DNA synthesis by preventing the action of DNA gyrase and topoisomerases which are vital enzymes for bacterial replication, transcription and translation. It is active against a broad spectrum of gram-positive and gram-negative aerobic bacteria but does not inhibit anaerobic organisms. It should last at least 48 hours from the time the symptoms disappear, generally for from 7 to 14 days.

Trimethoprim and Sulfamethoxazole (Bactrim, Bactrim DS, Septra DS):
Trimethoprim is metabolized into its active form which prevents the synthesis of dihydrofolic acid to slow down bacterial development. Trimethoprim and sulfamethoxazole have antibacterial synergism against many bacteria typical of acute UTI; however, it does not effective against Pseudomonas aeruginosa.

Ceftriaxone (Rocephin): It belongs to third generation cephalosporines and it has the activity mainly directed towards gram-negative bacteria. Despite that it is less active against gram-positive bacteria, the activity against resistant strains has been enhanced. It has bactericidal action because it acts on the synthesis of the bacterial cell wall by binding to the PBPs. Ceftriaxone is slightly sensitive to beta-lactamases and its major route of elimination is through the kidneys in urine and through biliary tract. It goes with plasma proteins and has affinity for plasma proteins and the more the concentration of the drug, the lesser is the binding.

Doxycycline (Adoxa, Monodox, Doryx, Vibramycin): It is a tetracycline class of antibiotics which has marked bacteriostatic action and gets incorporated into the bacterial cell and especially in the parts of the 30S and probably the 50S subunit of the microbial ribosome which stops RNA directed synthesis of proteins. It is used to cure nonbacterial prostatitis due to chlamydia species, Macrolide antibiotic and derives from erythromycin. As both Chlamydia and Ureaplasma are often hard to culture, an empirical course of doxycycline is often administered.

Emergency Medicine

Transurethral Resection of the Prostate (TURP): Sometimes employed when symptoms of chronic prostatitis or chronic pelvic pain syndrome (CPPS) have been persistent and cannot be controlled using drugs. This involves the excision of the portion of the prostate gland through a process called resection, which is performed using a resectoscope that is inserted through the urethra.

Prostate Massage: May be employed in the management of chronic prostatitis concerning the extrusion of prostatic secretion and subjective complaint. Concerns tender rubbing of the prostate gland with fingers via the rectum. It may be useful in situations where bacterial infection is not the main issue.

Prostate Biopsy: In cases of abnormal digital rectal exam, hematuria or elevated PSA level that does not respond to initial management, prostate cancer can be suspected. A biopsy incorporates a thin hollow puncture device into the prostate via rectum; sometimes might use the perineum to gain a sample in the prostate tissue.

Transrectal Ultrasound (TRUS)-Guided Prostate Biopsy: When there is an indication of prostate abnormalities, meaning when it must be excluded that there could be prostate cancer or even when the prostate related symptoms do not subside. The needle biopsy is done with the help of an ultrasound probe that is inserted in the rectum to locate areas in the prostate.

Endoscopic Procedures: Applied to specific kinds of prostatitis when structural irregularities provoking the manifestations are present. Involve a multiplicity of ways of visualizing and managing pathological processes in the prostatic or urethral zone with the help of instruments, which are inserted into the organism.

Emergency Medicine

Acute Phase: The primary objective is aversive due to the necessity to eliminate symptoms and halt their progression. This may require giving the patient antibiotic medications for bacterial infections or anti-inflammatory drugs for inflammation and pain control, with support from sufficient fluids and recommendations on how to manage pain. Overall, if the patient has significant symptoms like fever, chills, or inability to urinate, he or she may need to be hospitalized for intravenous antibiotics and observe the progress.

Subacute Phase: When the worst of the symptoms has passed the next step is aimed at avoiding relapse and at least a minimum intervention for the persistent symptoms. This may require oral antibiotics to be continued for a longer period just in case the infection is not completely cleared out. Further management of the pain can be made using other medications which include non-steroidal anti-inflammatory drugs (NSAIDS) or analgesics.

Chronic Phase: Due to the nature of chronic prostatitis and since some of the treatments may not eliminate the problem, there is the need to develop a more holistic approach to the management of the disorder. This phase also consists of a continued administration of antibiotics in case a person has an infection that requires it, along with other interventions directed to manage chronic pain and discomfort.