SUNA 2013 - Acute and chronic prostatitis - Session Highlights

SAVANNAH, GA USA (UroToday.com) - Kaye Gaines presented a basic review of the different types of prostatitis. She began by providing the literal definition of prostatitis, "an inflammation of the prostate gland," noting that this does not really provide the entire picture. Prostatitis is a complex, multifactorial condition that can be difficult to accurately assess. It is seen more frequently in young & middle-aged men, affecting up to 25% of men in their lifetime. It is often misdiagnosed, as < 10% of cases are proven to be caused by a bacterial infection.

[ref: Lipsky BA, Byren I, Hoey CT. Clin Infect Dis. 2010 Jun 15;50(12):1641-52. doi: 10.1086/652861. Review]

She reviewed the NIH classification system and discussed each type in more detail:

• Category I: Acute prostatitis
• Category II: Chronic bacterial prostatitis
• Category III: Chronic prostatitis/chronic pelvic pain syndrome
  1. Inflammatory
  2. Non-inflammatory
• Category IV: Asymptomatic inflammatory prostatitis

Ms Gaines noted that prostatitis symptoms depend on the NIH category and include hesitancy, dribbling, dysuria, urgency, abdominal, groin, back pain, testicular, perineal pain, erectile dysfunction, painful ejaculation, blood in semen/urine, malaise, flu-like symptoms, fever, and chills.

• Acute bacterial prostatitis, NIH Category I, is an acute infection of the prostate gland (see Category 1 Table) manifested by signs and symptoms similar to an acute urinary tract infection. Most patients have urinary frequency and urgency; most also have fever/chills, malaise, and myalgias that suggest systemic infection. Patients may also exhibit dysuria, pelvic/perineal pain, and cloudy urine/pyruia. Bacteriuria and pyuria are caused by standard uropathogens, especially Escherichia coli. Acute bacterial prostatitis is easily recognized, readily treated, and essentially unrelated to the other categories of prostatitis.
  
  

  Category I Table: Acute Prostatitis
  Clinical Presentation	Risk Factors	Diagnosis	Treatment
  Affects all age groups—acute onset Least common -- most easily recognized Same organisms as UTI/urethritis	trauma, dehydration, sexual abstinence (??) intermittent catheterization/indwelling catheter urethral stricture prostate hypertrophy	Early diagnosis and treatment is recommended to prevent secondary problems Acutely tender prostate Possibly elevated PSA  Obtain UA--gram stain--culture If septic, obtain blood cultures	Oral Antibiotics-sulfonamides, quinolones best (usually need to treat for at least 4-6 weeks) IV antibiotics-aminoglycosides, quinolones NSAIDS for pain and inflammation

  
  
  
• Chronic bacterial prostatitis, NIH Category II, a well-defined infectious disease of the prostate (see Category II Table), most common in young/middle-aged men, and is associated with recurrent episodes of UTI caused by the same organism. Chronic bacterial prostatitis is associated with ejaculate infection and epididymitis.
  
  

  Category II Table: Chronic Bacterial Prostatitis
  Clinical Presentation	Diagnosis	Treatment
  Same symptoms as acute prostatitis but gradual onset and often less severe Recurrent UTI STDs, HIV                           Pathogen usually gram-negative rods (75-80% E.coli but occasionally other gram-negative organisms or enterococci) Less common: chlamydia, enterococci, ureaplasma urealyticum, fungi, mycobacterium TB	“Four-glass test” or “Two-glass test” that requires 3 different voided urines and expressed prostate secretions (described in literature but not widely used clinical). May consider testing for chlamydia if urine/prostate secretion negative	Fluoroquinolones effective in 2/3 of patients (caution risk of tendinitis/rupture),  duration 4-6 weeks—up to 3 months Recurrence common requiring a longer 2nd course of different class of antibiotic Treat chlamydia with doxycycline, minocycline or azithromycin

  
  
  
• Chronic prostatitis associated with chronic pelvic pain syndrome, Category III, is the term applied to patients with symptomatic prostatitis of nonbacterial origin and reflects the fact that other organs may be contributing to symptoms (see Category III Table), These patients, who represent 90 - 95% of men with nonbacterial prostatitis, do not have active urethritis, urogenital cancer, urinary tract disease, functionally significant urethral stricture, or neurologic disease involving the bladder. This category of prostatitis is associated with other pain syndromes— IBS, chronic fatigue, fibromyalgia, or depression.
  
  

  Category III Table:  Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)  Inflammatory/Non-inflammatory
  Clinical Presentation	Symptoms	Diagnosis	Treatment
  Persistent infection Inflammation due to trauma Pelvic muscle spasms                           Neurogenic pain Increased prostate tissue pressure Autoimmune factors Somatic, psychological factors trigger symptoms—stress, anxiety, fear	Pelvic pain:  perineum, abdomen, penis, scrotum, rectum, low back Painful intercourse, pain with ejaculation Blood in semen, urine Mild prostate tenderness                           Dysuria, voiding problems Usually w/o fever/chills	Exclude other possible etiology of pelvic pain (urethritis/UTI, cancer, stricture, neurological bladder dysfunction) NIH Chronic Prostatitis Symptom Index (NIH-CPSI)	Conservative treatments (physical therapy—myofascial trigger point release, prostate massage, biofeedback,  phytotherapy, herbal medications, homeopathy, psychological, emotional support, prostate healthy diet,     acupuncture, sitz baths, meditation Transurethral microwave thermotherapy/Prostatectomy Medications (antibiotics, alpha blockers, 5-alpha-reductase inhibitors, NSAIDs, glucocorticoids, gabapetin, amitriptyline)

  
  
  
• Asymptomatic inflammatory prostatitis, NIH Category IV, is diagnosed when there is evidence of infection or inflammation in the absence of a history of genitourinary pain. This pertains to 95% of men with BPH, 90% of men with prostate cancer, and 40% of men with infertility. This type of prostatitis is usually discovered incidentally during investigation of the genitourinary tract for other reasons (e.g. elevated PSA level, prostate biopsy, or infertility workup). There may be elevated white blood cells in ejaculate, which may contribute to male infertility. This type is usually not treated.

Presented by Kaye K. Gaines, FNP-BC, CUNP at the Society of Urologic Nurses and Associates (SUNA) 2013 Annual Symposium - March 7 - 9, 2013 - Hyatt Regency - Savannah, GA USA

Medicine Service, Department of Veterans Affairs, Bay Pines VA Healthcare System, Bay Pines, FL USA

Reported by Diane K. Newman, DNP, FAAN, BCB-PMD

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