PROSTATITIS: DEFINITION: Prostatitis is an infection in the prostate gland. This gland lies just below the bladder. Bacteria enter the prostate gland from the urine. Symptoms of prostatitis may include pelvic aching and groin pain, fever, pain on urination, and discharge from the penis. THERAPY: Prostatitis is treated with antibiotics. A follow-up exam is usually required to insure that the infection has resolved. Some cases of prostatitis become chronic. It's important that you take the medication as prescribed. Drink plenty of fluids. Sexual intercourse is not recommended until after taking antibiotics for at least 48 ours. IF PROBLEMS: Call the doctor or return for re-examination at once if you feel more ill, develop high fever and shaking chills, have increasing pain, or if you are unable to pass your urine. Prostatitis INTRODUCTION Background: Prostatitis is an infection and/or inflammation of the prostate gland which presents as several syndromes with varying clinical features. The 4 most common syndromes of prostatitis are acute bacterial prostatitis, chronic bacterial prostatitis, non-bacterial prostatitis and prostatodynia. Those with Acute and Chronic bacterial prostatitis have documented bacterial infections of the prostate. Patients with nonbacterial prostatitis have signs of prostatic inflammation but no signs of bacterial infection. Prostatodynia is characterized by complaints consistent with prostatitis but no signs of protatic inflammation. While overall the majority of cases are non-bacterial in origin, in the ED setting acute bacterial prostatitis is most common. Pathophysiology: In bacterial prostatitis, sexual transmission of bacteria is common, but hematogenous, lymphatic and contiguous spread of infection from surrounding anatomy must also be considered. Prostatitis is characterized by the presence of acute inflammatory cells in the glandular epithelium and lumens of the prostate, with chronic inflammatory cells in the periglandular tissue. However, the presence and quantity of inflammatory cells in the urine or prostatic secretions does not correlate with the severity of physical symptoms. Non-bacterial prostatitis is a diagnosis based on negative cultures of the urine and prostatic secretions. Neuromuscular dysfunction or congenital reflux of urine into the ejaculatory and prostatic ducts may be a precipitating factor. Viral prostatitis may be associated with HIV transmission and is another cause of culture negative disease. Those with HIV may also develop CMV prostatitis infection. Frequency: In the U.S.: Prostatitis is one of the most common diseases seen in urology practices in the U.S., accounting for over one million visits a year with chronic and non-bacterial prostatitis being most frequently diagnosed. The diagnosis of prostatitis is made in approximately 25% of male patients presenting with genitourinary symptoms and 5 - 10 % have positive cultures. Autopsy studies have revealed a histologic prevalence of prostatitis of 64-86%. Internationally: There is an increased incidence of mycobacterial prostatitis, concomitant with disseminated disease, in underdeveloped countries. Areas with widespread sexually transmitted disease rates and prostitution have more patients with acute bacterial prostatitis. Mortality/Morbidity: Particularly susceptible patients include those with diabetes mellitus, patients on dialysis for chronic renal failure, the immunocompromised and post surgical patients who have had urethral instrumentation. In these patients, prostatitis can lead to urosepsis with significant associated mortality. The prostate gland should not be overlooked when searching for a source of sepsis in these patients. In the U.S., long term prognosis of the first occurrence of acute bacterial prostatitis is good with antibiotic therapy in compliant patients. Sex: Male Age: Average age varies for the different syndromes. In patients under the age of 35, the most common syndrome is acute bacterial prostatitis. HIV related disease is also seen predominantely in the younger patient. Rare causes: Case reports of Wegener granulomatosis in 4th and 5th decades; prostatitis can be a presenting feature of Wegener granulomatosis and a clinical manifestation of relapse. CLINICAL History: Due to the variety of different prostatic syndromes, a multitude of symptoms may be present: Fever Chills Malaise Arthralgia and Myalgia Obstructive Urinary Tract Symptoms Frequency, urgency, dysuria, nocturia, hesitancy, incomplete voiding Low back pain Described as a sacral ache, may radiate to one side if a seminal vesicle is involved Perineal and rectal pain Oftened worsened by defecation Orchalgia Urethralgia Suprapubic pain Spontaneous urethral discharge Physical: Fever Acute Bacterial Prostatitis Nodular, boggy or normal feeling gland May be tender to palpation / "Hot" to the touch Chronic Bacterial Protatitis Normal feeling gland / +/- calcifications Nonbacterial Prostatitis Normal feeling gland Prostatodynia Normal feeling gland Causes: Nisseria gonorrhea and chlamydia trachomatis should be considered in any male less than 35 years of age presenting with urinary tract symptoms. However, patients presenting with true signs and symptoms of acute prostatitis should be treated for the predominant organisms involved in this disease as well as possible STD. Most common organisms of Acute Bacterial Prostatits : 80 % gram negative organisms - Mainly E. Coli, Enterobacter, Serratia, Pseudomonas, Enterococcus. Chronic Bacterial Prostatitis As in acute disease. Nonbacterial Prostatitis Clamydia Trachomatis, Ureaplasma and gram + organisms have all be implicated. Uncommon organisms such as Mycobacterium tuberculosis, Coccidioides, Histoplasma and Candida must also be considered. Prostatodynia Not a true inflammation. May be due to a primary voiding dysfunction. May also have a psychological component. HIV alone may cause prostatic changes and Cytomegalovirus prostatitis may also be found. DIFFERENTIALS Rectal Fistulas and Fissures WORKUP Lab Studies: While not applicable to the ED, fractionated urine specimens remain the hallmark of the diagnosis of prostatitis. Serial collection of the urine occurs (V1, V2, EPS, V3). These are used to define and identify the organisms involved. CBC with differential and blood cultures in cases of acutely ill patient or suspected septicemia Urinalysis: Quantitative values for WBC and bacterial count, presence of oval fat bodies and lipid laden macrophages. Culture of urine will identify causative organism, if any. Prostate specific antigen if neoplasm is suspected as an underlying cause. Imaging Studies: Trans-rectal ultrasound Characteristic features are capsular thickening and prostatic calculi. Hypoechoic halo in the periurethral region, heterogenous echo pattern, enlargement and thickening of the septa of the seminal vesicles may be seen. Interpretation is highly subjective and therefore not very reliable, needs clinical correlation and digital rectal examination. Color Doppler ultrasound In acute prostatitis, a marked increase in color in the prostatic urethral site, around the ejaculatory ducts and close to the seminal vesicles will be visualized. Computed tomography Studies of the pelvis may be useful in evaluation of prostatic abscess or suspected neoplasm. Cystoscopy Useful in follow up of refractile cases to rule out neoplasm of the bladder or interstitial cystitis. Intravenous urography or voiding cystourethrogram Appropriate in patients with full renal function, for evaluation of the outlet system Procedures: The patient may undergo the following procedures under the care of the urologist: In cases of prostatic abscess, the fluctuant site may be drained under local anesthesia through the perineal route, followed by insertion of a pigtail cather. When urinary tract obstruction has occurred, a suprapubic catheter may be placed. In those cases where infected prostatic calculi serve as a nidus, transuretheral resection or total prostatectomy may result in a cure. TREATMENT Emergency Department Care: Individuals presenting with acute bacterial prostatitis will appear acutely ill and need admission. In cases of obstruction, a suprapubic tube should be inserted. Serial examinations of the prostate should be avoided to avoid seeding of the blood and subsequent bacteremia. Parenteral antibiotics consisting of an aminoglycoside and ampicillin should be administered. Chronic bacterial prostatitis, nonbacterial prostatitis and prostatodynia are probably best treated by/or in consultation with an urologist. Consultations: Urology Health department notification if reportable sexually transmitted disease is cultured. Psychiatry consultation if psychosomatic disorder suspected. MEDICATION The different prostatitic syndromes are treated with different medical therapy. Antibiotics that are familiar choices for gram negative enterobacter or sexually transmitted diseases often do not penetrate the prostate well. Antibiotic therapy will be ineffective in the treatment of prostatodynia as no infection is present. Drug Category: Antibiotics - For treatment of acute prostatitis in patients under 35 years of age where N. gonorrhea and C. trachomatis are the primary suspected pathogens. Drug Name Ofloxacin (floxin) - Ofloxacin penetrates the prostate well and is effective against N. gonorrhea and C. trachomatis. Adult Dose 400 mg P.O. X 1 dose Contraindications Allergy to fluoroquinolones Interactions Cimetidine, sucralfate, antacids, multivitamins, NSAIDS Pregnancy C - Safety for use during pregnancy has not been established Precautions Adjust dose in patients with impaired renal or liver function, monitor patients Drug Name Azithromycin - Alternative choice, effective against N. gonorrhoeae, Chlamydia, Bacteriodes, Enterobacteriaceae, Streptococci and H. ducreyi. May be used I.V. in severe cases requiring hospitalization. Adult Dose 1 gram P.O. - one dose Pregnancy B - Usually safe but benefits must outweigh the risks Precautions 5% incidence of diarrhea with treatment - Acute Bacterial Prostatitis - Parenteral antibiotics while in hospital followed by 4 weeks of oral medications to avoid development of chronic disease. Drug Name Ampicillin Adult Dose 1 - 2 grams IM/IV q 4-6 hours Pregnancy B - Usually safe but benefits must outweigh the risks Drug Name Gentamicin Adult Dose 1 mg / kg IV/IM q 8 hours Pregnancy D - Unsafe in pregnancy Drug Name Bactrim Adult Dose 5 mg / kg IV q 6 hours Pregnancy C - Safety for use during pregnancy has not been established - For Chronic Bacterial Prostatitis Bactrim, Carbnicillin, Flouroquinolones for 30 -40 days or IV Gentamicin Drug Name Carbenicillin Adult Dose 382 - 764 mg P.O. qid Pregnancy B - Usually safe but benefits must outweigh the risks Drug Name Ofloxacin Adult Dose 200 - 400 mg P.O. q 12 hours Interactions Antacids, iton, sucralfate, cimetidine, caffeine, cyclosporine, hydantoins, anti Pregnancy C - Safety for use during pregnancy has not been established - Nonbacterial prostatitis - as chlamydia and ureaplasma are difficult to culture, an empiric trial of doxycycline or erythromycin should be instituted. Drug Name Doxycycline Adult Dose 100 mg P.O. BIB X 2 - 3 weeks Pregnancy D - Unsafe in pregnancy Drug Name Erythromycin Adult Dose 500 mg P.O. qid X 2 - 3 weeks Pregnancy B - Usually safe but benefits must outweigh the risks - Prostadynia may be treated with one of the two drugs below with the addition of sitz baths. Drug Name Prazosin Adult Dose 1 mg P.O. tid Pregnancy C - Safety for use during pregnancy has not been established Drug Name Valium Adult Dose 5 mg P.O. qid Pregnancy D - Unsafe in pregnancy FOLLOW-UP Further Inpatient Care: Careful treatment of associated septicemia in acutely ill patients Careful monitoring for bladder outlet obstruction and renal failure Further Outpatient Care: After primary management and stabilization, the care of the patient is appropriately transferred to urology, as aggressive treatment of acute prostatitis can lessen the chance of developing chronic prostatitis. Deterrence: Protection against sexually transmitted disease will avoid many of the organisms associated with acute bacterial prostatitis, development of chronic prostatitis and suspected causes of non-bacterial prostatitis. Recognition of the frequency of underlying psychosomatic disease in chronic cases, and appropriate psychiatric referral and treatment will lessen the recurrence rate. Complications: Chronic prostatitis Bladder outlet obstruction Infertility due to scarring of the urethra Recurrent cystitis Pyelonephritis Renal damage Prognosis: Prognosis of the first occurrence of acute bacterial prostatitis is good with aggressive antibiotic therapy and good patient compliance. In cases of recurrent chronic prostatitis that may present with acute exacerbations, causative underlying factors from common to rare must be determined to affect outcome.