Prostatitis AUA 2017

Created: September 11, 2017
AUA Core Curriculum

Prostatitis
Introduction
• Very common in clinical practice
• Can be life threatening
• Acute vs. Chronic
• Bacterial vs. Abacterial
• Other syndromes and symptoms
Epidemiology
• Most common urologic diagnosis in men <50
• 3rd most common urologic diagnosis in men >50
• 5% of men aged 20-50 have a history of prostatitis
• Prevalence can vary by world region
• 12.2% in Nigeria
• 8% in Malaysia
• 6.6% in Canada
• 2.7% in Singapore
Definitions/Classification
• Traditional = Meares and Stamey in 1968
– four-glass test
• Acute bacterial prostatitis
• Chronic bacterial prostatitis
• Non-bacterial prostatitis
• Prostatodynia (prostatic pain)
4 Glass Test
Acute vs. Chronic bacterial prostatitis
• Acute
– Fevers, Chills, Sepsis
– Luekocytes in the prostatic fluid
• Chronic
– Luekocytes in the prostatic fluid only
– Positive cultures for bacteria
Abacterial vs. Prostodynia
• Abacterial
– Luekocytes in the prostatic fluid
– Negative culture
• Prostodynia
– No leukocytes
– No bacteria
NIH Classification
• Category I – Identical to acute bacterial prostatitis
• Category II – Identical to chronic bacterial prostatitis
• Category III Chronic Pelvic Pain Syndrome (CPPS) –GU pain, no bacteria
• Category IIIA (Inflammatory CPPS) – Excessive WBC in EPS
• Category IIIB (Non-inflammatory CPPS) – No significant WBC
• Category IV (Asymptomatic Inflammatory) –WBC or bacteria, no symptoms
Clinical Presentation: History
• Pain = Location, Frequency, Quality
– Pain with urination or ejaculation
• Urination = Incomplete emptying/Frequency
• Impact: changes behavior, occupies thoughts
• Quality of Life
NIH-Chronic Prostatitis Symptom Index
(NIH-CPSI)
Clinical Presentation: History
• Sexually transmitted infection history
• Recent new contacts
• Recent hospitalization (i.e. catheterization)
• Recent urologic procedures
• BCG, Exposure to Tuberculosis
UPOINT
• Phenotypic classification
– Urinary
– Psychosocial
– Organ specific
– Infection
– Neurologic/systemic
– Tenderness of skeletal muscles
Clinical Presentation: Exam
• Dominated by pain
– suprapubic pain – difficulty urinating
– testicular pain – dysuria
– penile pain – painful ejaculation
– urethral pain – perineal pain
• Digital rectal exam
• tender and boggy
• warm prostate in acute prostatitis
• tender prostate in chronic prostatitis.
• no need for expression of prostatic fluid in ACUTE phase
• risk that an aggressive prostate exam may cause sepsis
• Urinalysis and urine culture
• PSA is not necessary
4 Glass
Prostate Message
VB= voided bladder urine

2 Glass
Prostate Message
Nickel et al.
demonstrated 2
Glass Test had a
91% sensitivity
and specificity
compared with
the traditional
Meares-Stamey
test
Etiology
• Microbial
Etiology
• E. coli 65-80%
• Host Defense –
• Intraprostatic ductal reflux of urine
• Phimosis
• Indwelling Foley catheter
• Transurethral Surgery
• Dysfunctional Voiding
• high pressure voiding
• Bladder neck hypertrophy
Treatment
• Antibiotics
• Alpha-blockers
• Anti-inflammatories
• 5-alpha-reductase inhibitors
• Physical therapy
• Prostate massage
• Frequent ejaculation
• Surgery
Antibiotics
• Bactrim (TMP-SMX)
– most commonly used antibiotic in the 70’s to 90’s
– efficacy rates of 30-50%
– treatment courses reaching up to 90 days
• Fluoroquinolones
– more efficacious and require shorter durations of therapy
– 57-77% cure rates
– Treat 4-6 weeks if pretreatment cultures are positive
Alpha Blockers
• Bladder neck and prostate are rich in alpha-adrenergic receptors
• Relaxation via alpha-adrenergic blockade may improve outflow
• improving urinary flow and decreasing intra-prostatic ductal reflux
• Clinical Trial (Nickel et al. 2008)
– Men with chronic prostatitis and alpha blocker naive
– Treated with alfuzosin vs. placebo x 12 weeks
– No significant difference in resolution rates
Anti-Inflammatory
• Non-steroidal anti-inflammatories
• Corticosteroids
• Immunosuppressive drugs
• Clinical Trial
– Dimitrakov in 2004
– high dose methylprednisolone followed by rapid tapering
– Vs. Placebo
– May have more efficacy than placebo even after 12 months
– side effect profile was deemed to be moderately severe
Hormonal
• 5 alpha-reductase inhibitors
• Multiple studies have shown reductions in
prostatitis and BPH symptom scores.
– long-term dutasteride therapy
• improvement in prostatitis related symptoms
• older men with an increased PSA and BPH
Physical Therapy, Prostate Massage, and
Alternative Medicine
• Physical therapy
– Reduce Stress and overall pain symptoms
• Prostate Message
– 10-minute prostate exam 3 times per week
• Alternative Medicine
– Acupuncture (Lee et al in 2008) = small improvement
– Myofacial Trigger point message
References

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Created: September 11, 2017

AUA Core Curriculum

VB= voided bladder urine

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