Cause: Bacterial and nonbacterial etiologies

Epidem: Prostatitis affects up to 50% of men at some point in their lives. Affects men of all ages (Curr Opin Urol 1998; 8: 33). About 8% of all urology visits in United States related to prostatitis (National Ambulatory Medical Care Survey, 1992). Only about 6-8% of men with prostatitis have bacterial prostatitis (Urology 1990; 36[5 suppl]:13).

Pathophys: NIH classification and definitions of prostatitis:

I. Acute bacterial prostatitis

II. Chronic bacterial prostatitis: recurrent infection

III. Chronic abacterial prostatitis/chronic pelvic pain syndrome: no demonstrable infection

IIIA. Inflammatory chronic pelvic pain syndrome: wbc present in semen/expressed prostatic secretions or voided bladder urine (VB3)

IIIB. Noninflammatory chronic pelvic pain syndrome: no wbc noted in semen/expressed prostatic secretions or VB3

IV. Asymptomatic inflammatory prostatitis: detected by prostate bx or presence of wbc in prostatic secretions during evaluation for other disorders (JAMA 1999; 282: 236)

Organisms isolated in acute and chronic bacterial prostatitis are same as those causing UTIs (Tech Urol 1995; 1: 162). Escherichia
coli accounts for 80% of prostatic infections; other gram-neg organisms (Pseudomonas aeruginosa, Serratia, Klebsiella proteus) account for 10-15% of infections. Enterococci identified in 5-10% cases of prostatitis (Urology 1997; 49: 809). Role of Chlamydia trachomatis in prostatitis is controversial. Etiology of acute bacterial prostatitis is often due to reflux of infected urine into prostatic ducts that drain into posterior urethra (BJU 1974; 46: 537; 1982; 54: 729). Inflammation and edema may lead to occlusion of these ducts, trapping bacteria within, leading to chronic bacterial prostatitis (Urology 1997; 49: 809). Intraprostatic urinary reflux, causing a “chemical” prostatitis, may play a role in etiology of nonbacterial prostatitis (Urology 1987; 30: 183).

Sx: Urinary frequency and urgency, dysuria, malaise, pain in perineum, groin, testes, back, suprapubic area

Si: Fever/chills if acute bacterial, decreased urine flow rate, nocturia; tender, boggy, or firm prostate on digital rectal exam (DRE)

Diff Dx: Distal ureteral calculus, müllerian remnant, urethral stricture, BPH, seminal vesicle cyst, prostatic cyst, interstitial cystitis (IC), bladder Ca, urachal remnant, hernia, ejaculatory duct cyst, depression/stress, spinal stenosis, mesenteric cyst, fibromyalgia

Lab: Meares-Stamey test is gold standard for dx of bacterial prostatitis. After cleansing and retraction of foreskin, pt voids first 10 mL into sterile container (VB1), then collects midstream 5-10 mL (VB2), then prostatic massage performed, collect expressed prostatic secretions and review under microscope and collect first 10 mL of urine after massage (VB3). Modification of Nickels allows for simple testing with 91% sens and specif compared with Meares-Stamey technique. Modified Nickels technique: collect midstream urine and perform prostatic massage, then collect postmassage urine and perform UA, c + s on both. Future studies include immunologic techniques to allow for ab screening of the expressed prostatic secretions or VB3 specimen for common prostatic pathogens and molecular
biologic techniques using PCR to identify bacterial gene products (Urology 1998; 51: 362).

Xray: Bladder scanner postvoid residual (PVR) to ensure complete bladder emptying. Uroflow helpful in pts with voiding complaints. Cystoscopy not indicated in most pts. Videourodynamics in pts with nonbacterial chronic prostatitis may demonstrate spastic dysfunction of bladder neck and prostatic urethra.

Rx: Rx acute bacterial prostatitis with antibiotics; typically fluoroquinolones for 6-12 wk. Tm/S may be used. Chronic bacterial prostatitis rx with antibiotics for extended periods; in pts with frequent recurrent infections, long-term prophylactic antibiotics may be employed. Pts with chronic nonbacterial prostatitis may be treated as follows:

Category IIIA: Trial of broad-spectrum antibiotics, alpha-blocker therapy, anti-inflammatory agents, finasteride, or other 5-alpha reductase inhibitor if enlarged prostate; prostatic massage (2-3/wk); supportive therapy (counseling); transurethral microwave therapy or phytotherapy.

Category IIIB: Alpha-blocker therapy, muscle relaxant, analgesics, biofeedback, relaxation exercises, supportive therapy (counseling).

Other therapies: Sitz baths; avoidance of spices, caffeine, and alcohol. Biofeedback has encouraging results in pts with noninflammatory chronic pelvic pain syndrome (Curr Opin Urol 1996; 6: 53).

Cause: Bacterial infection

Epidem: Most cases occur in men in their 50s to 60s but also have been reported in infants (Rev Inf Dis 1988; 10: 239). Since the 1940s the incidence has decreased and the causative organism has changed. Before the 1940s, Neisseria gonorrhoeae accounted
for 40% of cases; currently E. coli accounts for 70% of cases (Rev Inf Dis 1988; 10: 239; Am J Surg 1931; 11: 334). Rarely, may occur secondary to Staphylococcus aureus infection (J Urol 1986; 136: 1281). Increased risk in males with DM, chronic renal failure on dialysis, immunocompromised and recent urethral instrumentation, or requiring chronic indwelling catheters (Rev Infect Dis 1988; 10: 239; J Urol 1986; 136: 1281).

Pathophys: Secondary to ascending urethral infection and intraprostatic reflux of infected urine, which leads to acute bacterial prostatitis, which, in predisposed individuals, may develop into a prostatic abscess

Sx: Dysuria, frequency, perineal pain, low back pain

Si: Urinary retention, fever/chills, hematuria, urethral discharge. Prostate may be fluctuant (16%), tender to palpation (35%), or enlarged (75%) on DRE (Rev Infect Dis 1988; 10: 239).

Cmplc: Mortality rate of about 5% (Rev Infect Dis 1988; 10: 239)

Diff Dx: Prostatitis, seminal vesiculitis

Lab: UA, c + s, CBC

Xray: CT scan or transrectal US helps dx and serves as a guide for percutaneous aspiration for culture, drainage, and to evaluate response to rx.

Rx: Antibiotics specific for the organism and drainage. Drainage may be achieved percutaneously or via transurethral incision/resection.

AUA Guidelines (www.auanet.org)

Cause: Benign neoplasm of the prostate. Development requires a combination of testicular androgens and aging (J Androl 1991; 12: 356). Appears to be a progressive condition (J Urol 2002; 168: 1446), with PSA and prostate volume as common predictors of clinical progression (Curr Opin Urol 2005; 15: 35).

Epidem: Most common neoplastic condition affecting males. There is a 30% prevalence by physical exam; at age 40-50, 40% of all men eventually have sx requiring meds or surgery (Curr Opin Urol 2005; 15: 35) and 50% over age 70.

Pathophys: Hyperplastic tissue located centrally in periurethral portion of the prostate. All glandular and stromal elements of the nl prostate are involved to a variable degree in BPH. Sx do not necessarily correlate with the prostatic size (J Urol 1984; 132: 474; BJU 1981; 53: 613).

Sx: Urinary frequency, urinary urgency, feeling of incomplete emptying, nocturia, hesitancy, intermittent stream. AUA scoring system (N Engl J Med 1995; 332: 99): 5 points = always, 4+ > 1/2 the time, 3 = 1/2 the time, 2+ < 1/2 the time, 1 = < 1/5 the time, 0 = never, for each of the following sx:

Classification: mild = 0-7 total points, moderate = 8-18, severe = 19-35. Scoring system is helpful in assessing the severity of sx but is not specific for BPH.

Si: Enlarged prostate, distended bladder, hematuria, incontinence, UTI, urinary retention. Prostate size: no standardized nomenclature for describing prostate size; commonly used: nl gland is size of horse chestnut, 20 g.

DRE tends to underestimate prostate size up to 40 g (J Urol 1986; 135: 190).

Crs: Up to 50% men will have si requiring medical or surgical treatment.

Cmplc: Urinary retention; risk may increase with age (J Urol 1997; 158: 481), renal insufficiency, chronic/recurrent UTI, gross hematuria, bladder stones, bladder calculi: no increased risk of prostate Ca except that incurred by age (Ann Intern Med 1997; 126: 480). Significant impact on quality of life.

Diff Dx: (1) Other causes of bladder outlet obstruction (BOO): bladder neck obstruction, prostate Ca, müllerian duct cysts, urethral stricture, urethral valves; (2) impaired detrusor contractility; (3) overactive bladder; (4) inflammatory and infectious conditions, including cystitis, CIS of the bladder; (5) prostatitis syndromes, including acute bacterial prostatitis, chronic prostatitis, nonbacterial prostatitis, prostatodynia, pelvic floor dysfunction

Lab: UA, c + s to r/o hematuria and infection; urine cytology if microhematuria and predominance of irritative voiding sx, especially if h/o smoking; PSA should be offered to those with at least a 10-yr life expectancy and in whom the presence of prostate Ca would alter their management and for those in whom the PSA measurement may change the management of their voiding sx. Noninvasive: peak urine flow rate (voided volume must be at least 150 cm³ to be reliable): > 20 cm³/s nl, 15-20 cm³/s = mild, 10-15 cm³/s = moderate, < 10 cm³/s = severe, not specific for BPH (N Engl J Med 1995; 332: 99). Invasive: pressure-flow study.

Xray: Bladder scan PVR determination

Rx: (N Engl J Med 1995; 332: 99). Rx primarily for quality of life. Criteria for intervention: urinary retention, bilateral hydronephrosis with altered renal function, recurrent or chronic UTI, recurrent gross hematuria of prostatic origin, bladder calculi, pt desire. AUA guidelines advocate watchful waiting for men with mild sx of BOO (AUA/IPSS ≤ 7) as well as moderate sx severity (AUA/ IPSS ≥ 8) if sx are not bothersome

Medical: Avoid caffeine and alcohol. Alpha-blockers: tone of bladder neck and prostate is thought to be autonomically controlled via alpha₁-adrenoreceptors (J Urol 1989; 141: 1283; 1983; 130: 275). Terazosin (N Engl J Med 1996; 335: 533): start with 1 mg and increase sequentially to max of 5-10 mg po qd; improves flow within 2 wk (Med Lett 1994; 36: 15). Doxazosin: Start with 2 mg po qd, and increase to max of 8 mg po qd as tolerated. Both doxazosin and terazosin may cause postural hypotension, and BP should be checked with each incremental dose. Tamsulosin (Med Lett 1997; 39: 96): daily dose of 0.4 or 0.8 mg a half hour after same meal each day; no titration necessary. Alfuzosin selective alpha₁-adrenergic receptor blocker, 10 mg po qd immediately after same meal each day. Rapaflo 8 mg is a oncedaily alpha-blocker that should be taken with a meal. All alpha-blockers have potential side effects of dizziness, nasal stuffiness, and ejaculatory dysfunction. See prescribing recommendations for use of alpha-blockers with oral PDE-5 inhibitors (sildenafil, vardenafil, and Cialis for treatment of erectile dysfunction). A 5-alpha-reductase inhibitor decreases plasma and intraprostatic dihydrotestosterone levels (Arch Androl 1982; 9: 56). Finasteride 5 mg po qd (N Engl J Med 1998; 338: 612; 1994; 330: 120; 1992; 327: 1185). Works best on large prostate glands. May take 6 mo to 1 yr for maximal improvement in sx. If effective, may remain so for at least 5 yr. Lowers PSA by 50% (Prostate 1993; 22: 31). Long-term finasteride use does not appear to affect histologic features of BPH (Urology 1999; 32: 696). With long-term
(5-yr) rx, prevalence of ejaculatory disorder, impotence, and decreased libido was 1.0%, 5.1%, and 2.6%, respectively (N Engl J Med 1998; 338: 557). Dutasteride, a dual 5-alpha reductase inhibitor, appears to have similar treatment responses as finasteride but a more rapid biochemical action, with changes in flow rate significantly better than placebo in clinical trials at 3 mo (Curr Opin Urol 2003; 13: 31). The Medical Therapy of Prostatic Symptoms (MTOPS) trial demonstrated that combination therapy (alpha-blocker plus 5-alphareductase inhibitor) was superior to either drug alone for preventing disease progression. Jalyn, a single capsule combination of dutasteride (0.5 mg) and tamsulosin (0.4 mg) recently approved for BPH. All therapies improved maximum flow rate and si over placebo, but combination therapy was significantly better than finasteride or doxazosin alone (J Urol 2002; 167[4 suppl]:265).