Prostatitis – Causes, Symptoms, Diagnosis, Treatment

Prostatitis is inflammation or swelling of the prostate gland. When symptoms start gradually and linger for more than a couple of weeks, the condition is called chronic prostatitis. The prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a man’s fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis

Types of Prostatitis

Scientists have identified four types of prostatitis

  • Chronic prostatitis or chronic pelvic pain syndrome
  • Acute bacterial prostatitis
  • Chronic bacterial prostatitis
  • Asymptomatic inflammatory prostatitis

Prostatitis can be an acute illness or a chronic condition, The NIH consensus definition and classification of prostatitis is

Prostatitis is classified into four categories, each with its own treatment approach

  • Acute infection of the prostate – This sudden-onset infection is caused by bacteria that travel from the urethra, and perhaps from the rectum to the prostate. It’s the least common but most dramatic form of prostatitis, beginning abruptly with high fever, chills, joint and muscle aches, and profound fatigue. In addition, you may have pain around the base of the penis and behind the scrotum, pain in the lower back, and the feeling of a full rectum. As the prostate becomes more swollen, you may find it more difficult to urinate, and the urine stream may become weak. (If you can’t urinate at all, it’s a medical emergency; this usually means the prostate is so swollen that it’s completely blocking urine flow. Depending on the severity of symptoms, hospitalization may be necessary.)
  • Chronic bacterial prostatitis – This type of prostatitis is also caused by bacteria. It’s more common in older men who have BPH. It sometimes follows a bout of acute bacterial prostatitis. Unlike the acute form, however, chronic bacterial prostatitis is a subtle, low-grade infection that can begin insidiously and persist for weeks or even months. A man with chronic bacterial prostatitis usually doesn’t have a fever but is troubled by intermittent symptoms such as a sudden urge to urinate, frequent urination, painful urination, or the need to get up at night to urinate. Some men have low back pain, pain in the rectum, or a feeling of heaviness behind the scrotum. Others have pain after ejaculation, and the semen may be tinged with blood. These symptoms wax and wane and they are sometimes so understated that they aren’t noticeable.
  • Chronic nonbacterial prostatitis – Chronic nonbacterial prostatitis, also known as chronic pelvic pain syndrome is the most common form of prostatitis. Its symptoms resemble those of chronic bacterial prostatitis. Yet no bacteria are evident, and pinpointing a cause or causes has been difficult. Research suggests that chronic nonbacterial prostatitis may result from a cascade of interconnected events. The initiating event may be stress, an undetectable infectious agent, or physical trauma that causes inflammation or nerve damage in the genitourinary area. Over time, this may lead to heightened sensitivity of the nervous system. In other words, CP/CPPS may be an overactive pain syndrome. What’s more, some physicians and researchers are beginning to think that the condition may affect the entire pelvic floor—all of the muscles involved with bowel, bladder, and sexual function—not just the prostate gland.
  • Asymptomatic inflammatory prostatitis – This is usually discovered during tests for another medical condition, such as infertility or other prostate disorders. White blood cells are present in the urine or prostate secretions, but there are no symptoms. With no symptoms and no known cause, it isn’t treated.

Prostatitis describes a combination of infectious diseases (acute and chronic bacterial prostatitis), CPPS or asymptomatic prostatitis. The NIH classification of prostatitis syndromes includes:

  • Category I Acute bacterial prostatitis (ABP) which is associated with severe prostatitis symptoms, systemic infection, and acute bacterial UTI.
  • Category II  Chronic bacterial prostatitis (CBP) which is caused by chronic bacterial infection of the prostate with or without prostatitis symptoms and usually with recurrent UTIs caused by the same bacterial strain.
  • Category III  Chronic prostatitis/chronic pelvic pain syndrome which is characterized by chronic pelvic pain symptoms and possibly voiding symptoms in the absence of UTI.
  • Category IV  Asymptomatic inflammatory prostatitis (AIP) which is characterized by prostate inflammation in the absence of genitourinary tract symptoms.

Causes of Prostatitis

Most cases of urinary tract infections and burning sensations or dysuria, prostatitis, urethritis, vaginitis, of the urinary tract are due to the colonization of the urogenital tract with rectal and perineal flora. The most common organisms include Escherichia coli, Enterococcus, Klebsiella, Pseudomonas, and other Enterococcus or Staphylococcus species. Residential care patients, diabetics, and those with indwelling catheters or any form of immunocompromise can also colonize with Candida Albicans.

In these scenarios, one can always find protective factors that failed to prevent infection or risk factors that lead to poor resolution of sepsis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, higher morbidity, treatment failures, and reinfection.

  • Neisseria gonorrhea – It is the leading cause of urethritis and dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Neisseria gonorrhea is a gram-negative bacteria transmitted through sexual intercourse. The incubation period is 2-5 days. Patients are commonly co-infected with Chlamydia trachomatis.
  • Chlamydia trachomatis – It is the most common nongonococcal cause of urethritis, dysuria, urinary tract infection, prostatitis, vaginitis, and is also transmittable through sexual intercourse. Chlamydia trachomatis is one of the smallest gram-negative obligate intracellular parasitic bacteria. The incubation period is usually 7-14 days even it becomes more. It is commonly associate or co-infected with Mycoplasma genitalium and Neisseria gonorrhea.
  • Complicated – Anatomical or systemic factors that increase the chance of infection like male gender, diabetes, immunosuppression, polycystic kidney, hospital-acquired, bladder outflow obstruction, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, (prostate hypertrophy, urethral stricture), neuropathic bladder (multiple sclerosis, diabetes mellitus), catheterization or ureter stent, ureterolithiasis, genitourinary surgery or malignancy, vesicoureteral reflux
  • Mycoplasma genitalium a –  Its cause of recurrent or persistent urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and is commonly a causative agent in men with nongonococcal urethritis. This organism is small self-replicating bacteria lacking a cell wall synthesis. This organism can be difficult to detect to identifying or given its slow-growing nature.
  • Trichomonas vaginitis – It is a flagellated parasitic protozoal STI, is a common infection affecting the urogenital tract of both men and women in most commonly. 
  • Herpes Simplex virus – It is a double-stranded DNA virus, can cause genital dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, infection involving the urethra.
  • Adenovirus – is an uncommon cause of urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in men. However, it should be considered in all males presenting with dysuria, mastitis, and associated conjunctivitis or constitutional symptoms.
  • Treponema pallidum – It may cause urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, from an endourethral syphilitic chancre; uncommon.
  • Haemophilus influenza – It is an uncommon cause of dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, transmitted through oral sex from respiratory secretions.
  • Neisseria meningitides – It is a gram-negative diplococcus that colonizes the nasopharynx. Transmission of this organism is through oral sex is most common and is a less common cause of urethritis.
  • Ureaplasma urealyticum and ureaplasma parvum – In some scientific studies show uncommon links to urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.  In patients that have tested positive, it is usually in younger men and men with fewer sexual partners.  This causative agent should be of suspicion when other identifiable nongonococcal urethritis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, is absent.
  • Candida – species are a common fungal yeast that can cause infections and irritation to the urogenital tract, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.

Non-infectious etiologies associated with urethritis include

  • Trauma – It is less commonly the cause of dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. However, inflammation and irritation may occur with intermittent catheterization and surgical problems, after urethral instrumentation, or from a foreign body or any particle insertion.
  • Irritation – of the genital area may also result in urethritis from
    • Rubbing or pressure resulting from tight clothing or sex and associate system.
    • Physical activity including activities such as bicycle riding, cricket playing, running, stairs climbing.
    • Irritants including various soaps, body powders, fungal infection, protozoa, and spermicides.
    • Menopausal females with insufficient estrogen levels in the body may develop dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, due to the tissues of the urethra and bladder becoming thinner and dryer, causing irritation. This is a very common cause of urethritis with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in older women.
  • Vaginitis – It is one of the presence of vaginal discharge, odor, pruritus, dyspareunia. No frequency/urgency.
  • Urethritis – Urinalysis shows dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, but no bacteria. Common in sexually active women.
  • Painful bladder syndrome – It is also found in the diagnosis of exclusion. Dysuria, frequency, urgency, but no evidence of infection in some cases.
  • Pelvic inflammatory disorder – It causes lower abdominal/ pelvic pain, fever, cervical discharge, cervical motion tenderness.
  • Prostatitis – It is considered in men. May present with pain during ejaculation and tender prostate on digital and manual rectal examination.
  • Anatomical defects – It leads to stasis, obstruction, urinary reflux all result in an increased predisposition to recurrent urinary tract infections, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis. Vesicoureteric reflux (VUR) is identified in up to 40% of women being investigated for a first UTI. Cystocele is also an important risk factor for recurrent dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in women.
  • Functional defects – like overactive bladder and urinary incontinence also lead to recurrent infections with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.
  • Recurrent urinary tract infections – It may be commonly seen in sexually active women without any identifiable structural abnormality or another associated condition. Older men can often develop urinary tract infections due to obstruction or neurogenic bladder in urinary stasis dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and an increased risk of recurrent infection.
  • Several other lesions – It may indicate to recurrent dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, including intraluminal (bladder stones, neoplasms, indwelling catheter), intramural (ureteral stenosis/strictures), and extramural lesions (inflammatory mass, fibrosis, or neoplasm).

Examples of a complicated UTI include

  • Infections occurring despite the presence of anatomical protective measures (dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, in males are by definition considered complicated UTI)
  • Infections occurring due to anatomical abnormalities, for example, an obstruction, hydronephrosis, renal tract calculi, or colovesical fistula  with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Infections occurring due to an immune-compromised state, for example, steroid use, post-chemotherapy, tumor, neoplasm, diabetes, elderly population, HIV)
  • Atypical organisms causing dysuria, urinary tract infection, prostatitis, urethritis, vaginitis.
  • Recurrent infections adequate treatment (multi-drug resistant organisms)
  • Infections are occurring in pregnancy or non-pregnant women (including asymptomatic bacteriuria)
  • Infections are occurring after instrumentation, nephrostomy tubes, ureteric stents, suprapubic tubes, or Foley catheters, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Infections in renal transplant patients with dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Infections are occurring with impaired renal function
  • Infections following dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,or radiotherapy

Inflammation and irritation

A range of problems may lead to inflammation or irritation dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, of the urinary tract or genital area, leading to the symptom of a painful urination. Besides infections, other reasons that area may be irritated or inflamed that are included

  • Stones in the urinary tract, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis,
  • Irritation of the urethra from sexual activity or after
  • Interstitial cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, a condition caused by bladder inflammation
  • Vaginal changes or vaginal discharge related to menopause
  • Activities such as horseback riding or bicycling, bike riding.
  • Vaginal sensitivity or irritation related to the use of scented unqualified soaps or bubble baths, toilet paper, or other products such as douches or spermicides.
  • Side effects from certain medications, supplements, and treatments, cosmetic use.
  • Tumor, neoplasm in the urinary tract

Symptoms of Prostatitis

Each type of prostatitis has a range of symptoms that vary depending on the cause and may not be the same for every man. Many symptoms are similar to those of other conditions.

Chronic prostatitis/chronic pelvic pain syndrome – The main symptoms of chronic prostatitis/chronic pelvic pain syndrome can include pain or discomfort lasting 3 or more months in one or more of the following areas:

  • between the scrotum and anus
  • the central lower abdomen
  • the penis
  • the scrotum
  • the lower back

Pain during or after ejaculation is another common symptom. A man with chronic prostatitis/chronic pelvic pain syndrome may have pain spread out around the pelvic area or may have pain in one or more areas at the same time. The pain may come and go and appear suddenly or gradually. Other symptoms may include

  • pain in the urethra during or after urination.
  • pain in the penis during or after urination.
  • urinary frequency—urination eight or more times a day. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination.
  • urinary urgency—the inability to delay urination.
  • a weak or an interrupted urine stream.

Acute bacterial prostatitis – The symptoms of acute bacterial prostatitis come on suddenly and are severe. Men should seek immediate medical care. Symptoms of acute bacterial prostatitis may include

  • urinary frequency
  • urinary urgency
  • fever
  • chills
  • a burning feeling or pain during urination
  • pain in the genital area, groin, lower abdomen, or lower back
  • nocturia—frequent urination during periods of sleep
  • nausea and vomiting
  • body aches
  • urinary retention—the inability to empty the bladder completely
  • trouble starting a urine stream
  • a weak or an interrupted urine stream
  • urinary blockage—the complete inability to urinate
  • a UTI—as shown by bacteria and infection-fighting cells in the urine

Chronic bacterial prostatitis – The symptoms of chronic bacterial prostatitis are similar to those of acute bacterial prostatitis, though not as severe. This type of prostatitis often develops slowly and can last 3 or more months. The symptoms may come and go, or they may be mild all the time. Chronic bacterial prostatitis may occur after previous treatment of acute bacterial prostatitis or a UTI. The symptoms of chronic bacterial prostatitis may include

  • urinary frequency
  • urinary urgency
  • a burning feeling or pain during urination
  • pain in the genital area, groin, lower abdomen, or lower back
  • nocturia
  • painful ejaculation
  • urinary retention
  • trouble starting a urine stream
  • a weak or an interrupted urine stream
  • urinary blockage
  • a UTI

Patient with cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis may present with the following symptoms

  • Frequency, dysuria, urgency, suprapubic pain, abdominal pain, cloudy urine, hematuria, nausea, vomiting, and fever
  • Similar symptoms of  cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis but usually will have flank pain, fever, and other systemic symptoms
  • Apart from a typical presentation, they tend to have altered mental status, lethargy, and, mental, emotional weakness.
  • Recurrent or resistant with urinary tract infection
  • Irritative urinary symptoms like frequency, dysuria, cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis, and urgency
  • Flank pain, the renal mass, tumors may be present in the case of renal TB.
  • Testicular mass, perineal pain, abdominal or lower abdominal, and urethral discharge may be seen in genital TB.
  • Menstrual irregularity, abdominal pain, infertility, or pelvic inflammatory cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis disease in case of female genital involvement
  • Unexplained infertility in both sexes man and women.
  • Non-specific symptoms in some cases like fever, weight loss, and backache

Associated symptoms include

  • Flank pain is more common in cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis
  • Lower abdominal pain
  • Painful urination and burning sensation.
  • Urinary urgency or frequency with cystitis, dysuria, urinary tract infection, prostatitis, urethritis, vaginitis
  • Fever
  • Active menstruation
  • Passing stone or grits
  • Recent throat or skin infection, skin rash
  • Joint pains, oral ulcers in the mouth and another organ, rash
  • Hemoptysis
  • Leg swelling
  • Hearing loss
  • Flank mass
  • Constitutional associate symptoms like weight loss, anorexia, cachexia
  • Back pain and chronic lower back pain, sciatica.

Diagnosis of Prostatitis

Medical History

  • Taking a personal and family medical history is one of the first things a health care provider may do to help diagnose prostatitis.
  • A mandatory history is required for all patients at the time of evaluation (4:C). The following presenting symptoms should be elicited: pain location (severity, frequency, and duration), lower urinary tract symptoms (obstructive/voiding and irritative/storage), associated symptoms (fever, other pain syndromes), and impact on activities/quality of life. A comprehensive systems review should document past medical and surgical (particularly urologic) history, history of trauma, medications, and allergies.

Physical Exam

A physical exam may help diagnose prostatitis. During a physical exam, a health care provider usually

  • Examines a patient’s body, which can include checking for discharge from the urethra enlarged or tender lymph nodes in the groin a swollen or tender scrotum performs a digital rectal exam;
  • A digital rectal exam, or rectal exam, is a physical exam of the prostate. To perform the exam, the health care provider asks the man to bend over a table or lie on his side while holding his knees close to his chest.
  • The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to the rectum. The man may feel slight, brief discomfort during the rectal exam. A health care provider usually performs a rectal exam during an office visit, and the man does not need anesthesia.
  • The exam helps the health care provider see if the prostate is enlarged or tender or has any abnormalities that require more testing.

1. Acute bacterial prostatitis (NIH category I)

  • Physical examination – Mandatory (4:C): The abdomen, external genitalia, perineum, and prostate must be examined. Prostate massage during a digital rectal examination (DRE) is not recommended.
  • Imaging – Optional (2:A) –  A transrectal prostatic ultrasonography (TRUS) or computed tomography scan is indicated in ABP patients refractory to initial therapy to rule out prostate abscess/pathology. Pelvic ultrasound (or bladder scan) is indicated in ABP patients with severe obstructive symptoms, poor bladder emptying, or physical examination findings of possible urinary retention. Initial imaging of the prostate is not recommended (3:B).
  • Serum PSA – Not recommended (3:C): Elevated prostate-specific antigen (PSA) associated with ABP usually leads to confusion and worry.

2. Chronic bacterial prostatitis (NIH category II)

  • Physical examination Mandatory (4:C) – This must include examination of the abdomen, external genitalia, perineum, prostate, and pelvic floor.
  • Microbiological localization cultures of the lower urinary tract (4-Glass Test or 2-Glass Pre- and Post-Massage Test [PPMT]) – Recommended (3:A): The 4-glass test is the criterion standard for the diagnosis of CBP. The 2- glass pre- and post-massage test (PPMT) is a simple and reasonably accurate screen for bacteria. Microscopy is optional. Rationale and description can be found in reference.
  • Semen cultures – Not recommended (3:D): Based on limited evidence, semen cultures have not been shown to be significantly helpful in identifying men with CBP, unless the same organism causing recurrent UTIs is cultured.
  • Transrectal prostatic ultrasonography – Not recommended (3:B): A TRUS cannot be relied upon for differential diagnosis of categories of prostatitis. A TRUS can be considered optional (4:D) if there is a specific indication.
  • Urodynamics – Optional (4:D) – Uroflow may be helpful to confirm obstruction. Urodynamics cannot be relied upon for differential diagnosis of categories of prostatitis but may help document obstruction and/or bladder problems.

3. Chronic prostatitis/chronic pelvic pain syndrome (NIH category IIIA, IIIB)

  • Symptom scoring questionnaire – Recommended (3:A)- the NIH-CPSI has become the established international standard for symptom evaluation (not for diagnosis) of prostatitis. The index has been shown to be reliable and can evaluate the severity of current symptoms and be used as an outcome measure to evaluate the longitudinal course of symptoms with time or treatment. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) captures the three most important domains of the prostatitis experience: pain (location, frequency, and severity), voiding (irritative and obstructive symptoms), and quality of life (including impact). This index is useful in research studies and clinical practice. Adapted from Litwin et al. Reprinted with permission.
  • Physical examinations Mandatory (4:C) – Examination of the abdomen, external genitalia, perineum, and prostate is mandatory. Exacerbation of typical pelvic pain with normal DRE pressure is helpful in determining prostate centricity while evaluating myofascial trigger points and/or possible musculoskeletal dysfunction of the pelvis and pelvic floor during DRE is believed to be helpful in treatment decisions.
  • 4-Glass test and 2-glass pre- and post-massage test (PPMT) – Recommended (3:A): Culture of the lower urinary tract urine specimens is recommended. The 4-glass test is the criterion standard to rule out CBP. The 2-glass PMT is a simple and reasonably accurate screen for bacteria. A rationale and description for this recommendation are available. At this time, there is no evidence that suggests that microscopy of the EPS or urine sediment adds any clinical value (microscopy optional).
  • Cystoscopy – Not recommended (4:D) for routine evaluation. Optional (4:D): For selected patients. Endoscopy may be indicated in selected patients with obstructive voiding symptoms (refractory to medical therapy), patients with hematuria, or other suspected lower urinary tract pathology.
  • Transrectal ultrasound – Not recommended (3:B) in routine practice, unless there is a specific indication.
  • CT scan and/or magnetic resonance imaging (MRI) – Not recommended (3:B): At present, the value is unknown.
  • Urodynamics – Optional (3:C): In selected men with obstructive voiding symptoms, it is reasonable to consider urodynamic evaluation (e.g., flow rates, post-void residual, pressure flow studies).
  • Serum PSA Levels – Not recommended (3:B) – There is no evidence that serum PSA levels in patients with CP/CPPS will help diagnosis and direct therapy. Indications for serum PSA determinations should be the same as for men without CP/CPPS.
  • Psychological Assessment Optional (3:B) –There is accumulating evidence that psychosocial parameters, such as depression, maladaptive coping mechanisms (catastrophizing, resting as a coping mechanism), and poor social support impact symptoms and results of therapy. The physician should screen for these psychological problems. There is a practical algorithm to assess a man presenting with presumed CP/CPPS.

Lab  Tests

A health care provider may refer men to a urologist—a doctor who specializes in the urinary tract and male reproductive system. A urologist uses medical tests to help diagnose lower urinary tract problems related to prostatitis and recommend treatment. Medical tests may include

  • Urinalysis – Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container in a health care provider’s office or a commercial facility. A health care provider tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in the urine.
  • Blood tests – Blood tests involve a health care provider drawing blood during an office visit or in a commercial facility and sending the sample to a lab for analysis. Blood tests can show signs of infection and other prostate problems, such as prostate cancer.
  • Urodynamic tests – Urodynamic tests include a variety of procedures that look at how well the bladder and urethra store and release urine. A health care provider performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely and may include the following uroflowmetry, which measures how rapidly the bladder releases urine postvoid residual measurement, which evaluates how much urine remains in the bladder after urination.
  • Cystoscopy – Cystoscopy is a procedure that uses a tubelike instrument, called a cystoscope, to look inside the urethra and bladder. A urologist inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. He or she performs cystoscopy during an office visit or in an outpatient center or a hospital. He or she will give the patient local anesthesia. In some cases, the patient may require sedation and regional or general anesthesia. A urologist may use cystoscopy to look for narrowing, blockage, or stones in the urinary tract.
  • Transrectal ultrasound – Transrectal ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The health care provider can move the transducer to different angles to make it possible to examine different organs. A specially trained technician performs the procedure in a health care provider’s office, an outpatient center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images; the patient does not require anesthesia. Urologists most often use transrectal ultrasound to examine the prostate. In a transrectal ultrasound, the technician inserts a transducer slightly larger than a pen into the man’s rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormalities, such as tumors. Transrectal ultrasound cannot reliably diagnose prostate cancer.
  • Biopsy – A biopsy is a procedure that involves taking a small piece of prostate tissue for examination with a microscope. A urologist performs the biopsy in an outpatient center or a hospital. He or she will give the patient light sedation and local anesthetic; however, in some cases, the patient will require general anesthesia. The urologist uses imaging techniques such as ultrasound, a computerized tomography scan, or magnetic resonance imaging to guide the biopsy needle into the prostate. A pathologist—a doctor who specializes in examining tissues to diagnose diseases—examines the prostate tissue in a lab. The test can show whether prostate cancer is present.
  • Semen analysis – Semen analysis is a test to measure the amount and quality of a man’s semen and sperm. The man collects a semen sample in a special container at home, a health care provider’s office, or a commercial facility. A health care provider analyzes the sample during an office visit or sends it to a lab for analysis. A semen sample can show blood and signs of infection.

Treatment

amitriptyline, gabapentin, biofeedback, massage therapy, acupuncture, neurostimulation

1. Acute bacterial prostatitis (NIH Category I)

  • Antimicrobials: Patients with severe symptomatic febrile acute bacterial prostatitis: Aminoglycosides in combination with ampicillin, broad-spectrum penicillin in combination with a beta-lactamase inhibitor, a 3rd generation cephalosporin, or a fluoroquinolone is required until defervescence and normalization of associated urosepsis. (Recommended 2:A). Following the resolution of severe infection and for less severely ill patients, outpatient oral fluoroquinolones for 2-4 weeks are appropriate. (Recommendation 4:B)
  • Alpha-blocker medications, such as tamsulosin (Flomax) or terazosin (Hytrin), may be prescribed to relax the muscles that control the bladder. These may relieve symptoms of urgency, hesitancy, or dribbling. Similar effects may be seen with drugs that shrink the size of the prostate, including finasteride (Proscar).
  • Pain relievers, anti-inflammatory drugs, and muscle relaxants may help with pain and muscle spasms. Some men find relief with warm baths or with biofeedback programs designed to reduce tension in the pelvic muscles.
  • Hospitalization if indicated (Recommended 3:B)
  • Urinary drainage if indicated (Recommended 3:B)
  • Imagine if indicated (Recommended 4:A)
  • Drainage of prostatic abscess if indicated (Recommended 4:A)

2. Chronic Bacterial Prostatitis (NIH Category II)

  • Oral fluoroquinolone therapy for susceptible bacteria for 4-6 weeks. (Recommended 2:A)
  • Trimethoprim-sulfamethoxazole (or other antimicrobials) for fluoroquinolone-resistant bacteria. (Recommended 3:B)
  • Alpha-blocker medications, such as tamsulosin (Flomax) or terazosin (Hytrin), may be prescribed to relax the muscles that control the bladder. These may relieve symptoms of urgency, hesitancy or dribbling. Similar effects may be seen with drugs that shrink the size of the prostate, including finasteride (Proscar).
  • Pain relievers, anti-inflammatory drugs and muscle relaxants may help with pain and muscle spasms. Some men find relief with warm baths or with biofeedback programs designed to reduce tension in the pelvic muscles.
  • intermittent antimicrobial treatment of acute symptomatic cystitis; (Recommended 3:A)
  • radical TURP or simple prostatectomy (as a last resort if all other options have failed). (Recommended 4:C)
  •  low-dose antimicrobial suppression; (Recommended 3:A)
  • Alpha-blocker medications, such as tamsulosin (Flomax) or terazosin (Hytrin), may be prescribed to relax the muscles that control the bladder. These may relieve symptoms of urgency, hesitancy or dribbling. Similar effects may be seen with drugs that shrink the size of the prostate, including finasteride (Proscar).
  • Pain relievers, anti-inflammatory drugs and muscle relaxants may help with pain and muscle spasms. Some men find relief with warm baths or with biofeedback programs designed to reduce tension in the pelvic muscles.

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (NIH Category IIIb)

  • Antibiotic therapy for newly diagnosed, antimicrobial naĂŻve patients (Recommended 4:D); Antibiotic therapy for patients who have failed previous antibiotic therapy (Not recommended 1:A)
  • Alpha-blocker as first-line monotherapy (not recommended 1:A); Alpha-blocker therapy for newly diagnosed, alpha-blocker naĂŻve patients with voiding symptoms as part of a multi-modal treatment strategy (Optional 1:A)
  • Anti-inflammatory monotherapy (Not-recommended 1:B); Anti-inflammatory therapy as part of a multimodal treatment strategy (Optional 2:C)
  • Pain relievers, anti-inflammatory drugs, and muscle relaxants may help with pain and muscle spasms. Some men find relief with warm baths or with biofeedback programs designed to reduce tension in the pelvic muscles.
  • The phytotherapy quercetin and pollen extract (recommended 2:B) but are likely most effective as a part of a multimodal treatment strategy (3:C)
  • Five alpha-reductase inhibitor monotherapy. (Not recommended 1:A); Five alpha-reductase inhibitor therapy in older men with lower urinary tract symptoms and/or as part of a multimodal treatment strategy (Optional 2:C)
  • Individualized multimodal therapy directed towards defined clinical phenotype. (Recommended 3:C)
  • Minimally invasive therapies such as TUNA, laser therapies, etc. (Not recommended 2:A)
  • Invasive surgical therapies such as TURP and radical prostatectomy. (Not recommended 4:D)
  • The following potentially effective therapies can be considered in selected patients (Optional 4:D)
  • Heat therapy in the form of microwave
  • Pudendal nerve modulation
  • Neuromodulating agents (gabapentinoids, tricyclic antidepressants)
  • Muscle relaxants (diazepam, baclofen, cyclobenzaprine)
  • Electromagnetic stimulation
  • Acupuncture
  • Psychotherapy (Mandatory for severe depression and/or suicidal tendencies)
  • Physical therapy
  • Biofeedback

4. Asymptomatic Inflammatory Prostatitis (NIH Category IV)

  • Definitive therapy (Not recommended: 3:A)Antimicrobial therapy for selected patients with elevated PSA, infertility, or manipulation (biopsy) warrants consideration. (Optional 3:C)

1. Acute bacterial prostatitis (NIH category I)

ABP can be a serious infection with fever, intense local pain, and general symptoms. Septicemia and urosepsis are always potential risks. The following factors must be taken into account when treating ABP: potential urosepsis, choice of antimicrobial agent, urinary drainage, risk factors justifying hospitalization, and auxiliary measures intended to improve treatment outcomes.

  • Antimicrobial Therapy (2:A) – The choice and duration of antimicrobial therapy for ABP are based on experience and expert opinion and are supported by many uncontrolled clinical studies., For initial treatment of severely ill patients, the following regimens are recommended: intravenous administration of high doses of bactericidal antimicrobials, such as aminoglycosides in combination with ampicillin, broad-spectrum penicillin in combination with a beta-lactamase inhibitor, a third-generation cephalosporin or a fluoroquinolone is required until defervescence and normalization of associated urosepsis (this recommendation is based on the treatment of complicated UTIs and urosepsis). Patients who are not severely ill or vomiting may be treated with an oral fluoroquinolone., Trimethoprim-sulfamethoxazole (TMP/SMX) is no longer recommended as first-line empirical therapy in areas where TMP/SMX resistance for E. coli, the most frequent pathogen, is greater than 10% to 20%.– Treatment should continue for 2 to 4 weeks.,
  • Urinary drainage (3:B) – A single catheterization with the trial of voiding or short-term small-caliber urethral catheterization is recommended for patients with severe obstructive voiding symptoms or urinary retention. Suprapubic tube placement is optional for patients who cannot tolerate a urethral catheter.
  • Hospitalization (3:B) – Hospitalization is mandatory in cases of hyperpyrexia, prolonged vomiting, severe dehydration, tachycardia, tachypnea, hypotension, and other symptoms related to urosepsis. Hospitalization is recommended in high-risk patients (diabetes, immunosuppressed patient, old age or prostatic abscess) and those with severe voiding disorders.
  • Drainage of a prostate abscess (4:A) – Incision and drainage of prostate abscesses are required in selected treatment-refractory patients. The transurethral route appears to be the modality of choice but abscess may be drained via perineum, rectum, or transperineal route.
  • Auxiliary measures – Nonsteroidal anti-inflammatory agents have been suggested for reducing symptoms including fever.– Alpha-blockers may be considered, particularly in men with moderately severe obstructive voiding symptoms to reduce the risk of urinary retention and facilitate micturition.–

2. Chronic bacterial prostatitis (NIH category II)

  • Antimicrobial therapy (2:A) – Because of their unique and favorable pharmacokinetic properties, their broad antibacterial spectra, and comparative clinical trial evidence, fluoroquinolones are the recommended agents of choice for the antimicrobial treatment of CBP., Data from CBP fluoroquinolone treatment trials with a follow-up of at least 6 months support the use of fluoroquinolones as first-line therapy.– The recommended 4- to 6-week duration of antimicrobial treatment is based on experience and expert opinion and is supported by many clinical studies., In general, therapeutic results (defined as bacterial eradication) are good in CBP due to E. coli and other members of the family Enterobacteriaceae. CBP due to P. aeruginosa and Enterococci shows a poorer response to antimicrobial therapy.CBP associated with a confirmed uropathogenic that is resistant to the fluoroquinolones can be considered for treatment with trimethoprim-sulfamethoxazole (or other antimicrobials), but the treatment duration should be 8 to12 weeks.
  • Alpha-Blockers (3:C) – The combination of antimicrobials and alpha-blockers has been suggested to reduce the high recurrence rate and this combination of two therapeutic regimens is considered optional for in-patients with obstructive voiding symptoms.
  • Treatment refractory cases – For treatment-refractory patients with confirmed uropathogenic localized to the prostate, the following are optional treatment strategies are the intermittent antimicrobial treatment of acute symptomatic episodes (cystitis) (3:A); low-dose antimicrobial suppression (3:A); or radical TURP or open prostatectomy if all other options have failed (4:C).

3. Chronic prostatitis/chronic pelvic pain syndrome (NIH category III)

The introduction of an internationally accepted classification system, a validated outcome index, the NIH-CPSI, and the significant number of randomized placebo-controlled clinical trials published over the last decade and a half has permitted best-evidence-based guideline recommendations. Twenty-three clinical trials– were available at time of this guideline development. These English-language trials evaluated medical therapies using a prospective, randomized controlled design; these trials were used to support these recommendations. These have been recently reviewed and analyzed. We also used a literature search strategy. In addition, a best-evidence-based treatment algorithm was used

  • Antimicrobials – Antimicrobials cannot be recommended for men with longstanding, previously treated CP/CPPS (1:A). However, uncontrolled clinical studies suggest that some clinical benefits can be obtained with antimicrobial therapy in antimicrobial naĂŻve early-onset prostatitis patients (4:D).
  • Alpha-blockers – Alpha-blockers cannot be recommended as a first-line monotherapy (1:A). However, there is some evidence that alpha-blocker naĂŻve men with moderately severe symptoms who have relatively recent onset of symptoms may experience benefit (1:A). Alpha-blocker therapy appears to provide benefit in a multimodal therapeutic algorithm for men with voiding symptoms (2:C)). Alpha-blockers must be continued for over 6 weeks (likely over 12 weeks).
  • Anti-inflammatory – Anti-inflammatory therapy is helpful for some patients, but is not recommended as a primary treatment (1:B); however, it may be useful in an adjunctive role in a multimodal therapeutic regimen (2:C).
  • Phytotherapies – Phytotherapies (specifically quercetin and the pollen extract, cernilton) are optional recommendations for first-line (2:B) and combination multimodal therapy (3:C).
  • Other medical therapies – Other medical therapies, such as 5-alpha-reductase inhibitor therapy, pentosan polysulfate, and pregabalin, while not recommended as primary monotherapy (1:A), may provide benefit in selected patients (older men with LUTS for 5-ARI therapy, men with associated pain perceived bladder pain and irritative voiding symptoms for pentosan polysulfate and neuropathic type pain for pregabalin).
  • Other potential medical therapies – Muscle relaxants, saw palmetto, corticosteroids, and tricyclic antidepressants have all been suggested and used, but recommendations will have to wait for results from properly designed randomized placebo-controlled trials (4:D).
  • Physiotherapies – A number of physical therapies have been recommended, but they also suffer from a lack of perspective controlled data obtained from properly designed controlled studies. Prostatic massage, perineal or pelvic floor massage, and myofascial trigger point release have also been suggested as a beneficial treatment modality for patients, however, focused pelvic physiotherapy has yet to be shown to provide more benefit compared to SHAM physiotherapy. Biofeedback, acupuncture, and electromagnetic therapy also show promise, but like all the other physical therapeutic modalities, require sham-controlled trials before recommendations can be made (3:C).
  • Psychotherapies – Psychological support and therapy have been advocated based on new psycho-social modeling of this syndrome. This treatment ideally would include a cognitive behavioral therapy program. A referral to a psychologist or psychiatrist should be considered mandatory in patients with severe depression and/or suicidal tendencies.
  • Multimodal Therapy (POINT) – A number of uncontrolled clinical studies have strongly suggested that multimodal therapy is more effective than monotherapy in patients with long-term symptoms., Individualized personal therapy algorithms directed toward clinically defined presenting phenotypes (POINT) have been proposed and the early results of such a strategy look promising. Based on the fact that monotherapies provide (at best) modest efficacy, a multimodal approach using specific clinical phenotypes to choose therapies is considered an optional recommendation. An algorithm has been proposed.

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