Treatment of Prostatitis

Prostatitis is inflammation of the prostate gland. In clinical practice, the term prostatitis encompasses multiple diverse disorders that cause symptoms related to the prostate gland. One author has described prostatitis as “a wastebasket of clinical ignorance”1 because so many poorly characterized syndromes are diagnosed as prostatitis. The spectrum of prostatitis ranges from straightforward acute bacterial prostatitis to complex conditions that may not even involve prostatic inflammation. These conditions can often be frustrating for the patient and the clinician.To get more news about Chronic prostatitis treatment, you can visit our official website.

Prostatitis is a common condition. In a survey of National Guard members (20 to 49 years of age) using a self-reported diagnosis of prostatitis, a 5 percent lifetime prevalence was noted.2 A population-based study of men (40 to 79 years of age) in Olmstead County, Minn., suggests a lifetime prevalence close to 9 percent. The latter study used a medical record review to confirm physician diagnosis of prostatitis. Patients with a previous episode of prostatitis were at significantly increased risk for subsequent episodes.3 In a nationwide review of data from outpatient physician visits, it was noted that 15 percent of men who saw a physician for genitourinary complaints were diagnosed with prostatitis.4 Every year, approximately 2 million physician visits include the diagnosis of prostatitis. Despite its widespread prevalence, prostatitis remains a poorly studied and little understood condition.
Prostatitis is not easily diagnosed or classified. Patients with prostatitis often present with varied, nonspecific symptoms, and the physical examination is frequently not helpful. The traditional diagnostic test for differentiating types of prostatitis is the Stamey-Meares four-glass localization method.5 It includes bacterial cultures of the initial voided urine (VB1), midstream urine (VB2), expressed prostatic secretions (EPS), and a postprostatic massage urine specimen (VB3). The VB1 is tested for urethral infection or inflammation, and the VB2 is tested for urinary bladder infection. The prostatic secretions are cultured and examined for white blood cells (more than 10 to 20 per high-power field is considered abnormal). The postmassage urine specimen is believed to flush out bacteria from the prostate that remain in the urethra.

Although widely described as the gold standard for evaluation for prostatitis, this diagnostic technique has never been appropriately tested to assess its usefulness in the diagnosis or treatment of prostatic disease. The expression of prostatic secretions can be difficult and uncomfortable. In addition, the test is somewhat cumbersome and expensive, which may explain its infrequent use by primary care physicians and urologists.3,6

An alternative diagnostic test, called the pre- and postmassage test (PPMT) has been proposed. Although easier to carry out, this test has also not been validated; in retrospective studies, it performed about as well as the four-glass method. 7

The technique is straightforward. The patient retracts the foreskin, cleanses the penis and then obtains a midstream urine sample. The examiner performs a digital rectal examination and vigorously massages the prostate from the periphery toward the midline. The patient collects a second urine sample, and both specimens are sent for microscopy and culture. See Table 1 for interpretation of results of the four-glass test and the PPMT.
Traditionally, prostatitis has been divided into four subtypes based on the chronicity of symptoms, the presence of white blood cells in the prostatic fluid and culture results. These subtypes are acute bacterial prostatitis, chronic bacterial prostatitis, chronic nonbacterial prostatitis and prostadynia.5 Although this classification system has been widely used, it has never been validated for diagnostic or therapeutic utility.

At a recent National Institutes of Health (NIH) conference, a new classification system was proposed that could account for patients who do not clearly fit into the old system.3,8 The subgroups of acute and chronic bacterial prostatitis remain essentially unchanged. Chronic nonbacterial prostatitis and prostadynia have been merged into a new category called chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CNP/CPPS). This category can be subdivided further based on the presence or absence of white blood cells in prostatic secretions. A fourth and final category of asymptomatic prostatitis was added to the classification system. A large-scale study is in progress in an attempt to validate the new classification system. Table 2 compares the two classification systems.
Acute bacterial prostatitis (ABP) may be considered a subtype of urinary tract infection. Two main etiologies have been proposed. The first is reflux of infected urine into the glandular prostatic tissue via the ejaculatory and prostatic ducts. The second is ascending urethral infection from the meatus, particularly during sexual intercourse.1 The causative organisms are primarily gram-negative, coliform bacteria. The most commonly found organism is Escherichia coli. Other species frequently found include Klebsiella, Proteus, Enterococci and Pseudomonas. On occasion, cultures grow Staphylococcus aureus, Streptococcus faecalis, Chlamydia or anaerobes such as Bacteriodes species.9–13

Because acute infection of the prostate is often associated with infection in other parts of the urinary tract, patients may have findings consistent with cystitis or pyelonephritis. Patients with ABP may present with fever, chills, low back pain, perineal or ejaculatory pain, dysuria, urinary frequency, urgency, myalgias and varying degrees of obstruction.9,13

Typically, the prostate gland is tender and may be warm, swollen, firm and irregular. A standard recommendation is to avoid vigorous digital examination of the prostate, because, theoretically, that may induce or worsen bacteremia.

Although no test is diagnostic for acute bacterial prostatitis, the infecting organism can often be identified by culturing the urine.13 Initially, antibiotic selection is empiric, but the regimen can be modified once pathogen susceptibilities are available. Patients respond well to most antibiotics, although many cross the blood-prostate barrier poorly. The inflammation caused by ABP may actually allow better penetration of antibiotics into the organ.