Prostatitis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Prostatitis is inflammation of the prostate gland, which can be due to infection, autoimmune reactions, or chronic pelvic pain syndrome. It is classified into four main types:

  • Acute bacterial prostatitis (ABP): sudden bacterial infection of the prostate.
  • Chronic bacterial prostatitis (CBP): recurrent or persistent bacterial infection.
  • Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): most common type, often non-infectious.
  • Asymptomatic inflammatory prostatitis: inflammation found incidentally without symptoms.

Aetiology

1. Infectious Causes:

  • Bacterial:
    • Escherichia coli (most common cause).
    • Klebsiella pneumoniae and Pseudomonas (seen in catheterised patients).
    • Proteus mirabilis (common in recurrent UTIs).
  • Sexually Transmitted Infections (STIs):
    • Chlamydia trachomatis
    • Neisseria gonorrhoeae
    • Trichomonas vaginalis

2. Non-Infectious Causes (CP/CPPS):

  • Autoimmune response.
  • Neuromuscular dysfunction.
  • Pelvic floor muscle dysfunction.
  • Chronic stress or psychological factors.

Pathophysiology

  • Bacterial prostatitis results from ascending infection via the urethra.
  • Inflammatory cytokines lead to swelling, pain, and urinary symptoms.
  • In CP/CPPS, inflammation may be due to immune-mediated reactions without bacterial involvement.
  • Recurrent infections may lead to fibrosis and chronic pain.

Risk Factors

  • Urinary tract infections (UTIs).
  • Indwelling urinary catheter.
  • Benign prostatic hyperplasia (BPH).
  • Sexually transmitted infections.
  • Pelvic trauma or surgery.
  • Immunosuppression (e.g., diabetes, HIV).

Signs and Symptoms

Acute Bacterial Prostatitis (ABP):

  • Fever >38°C and chills.
  • Severe perineal, rectal, or lower back pain.
  • Dysuria: painful urination.
  • Urinary urgency and frequency.
  • Haematuria: blood in the urine.
  • Suprapubic tenderness.

Chronic Bacterial Prostatitis (CBP):

  • Recurrent UTIs with similar bacterial strains.
  • Perineal discomfort.
  • Ejaculatory pain.
  • Dysuria and urinary hesitancy.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS):

  • Pelvic pain >3 months.
  • Sexual dysfunction or pain during ejaculation.
  • Variable urinary symptoms.

Investigations

  • Urinalysis:
    • Leukocytes and nitrites suggest infection.
    • Blood in urine may be present.
  • Urine Culture:
    • Essential in bacterial prostatitis to identify causative organism.
    • Repeated cultures in chronic prostatitis.
  • Prostate Specific Antigen (PSA):
    • May be elevated due to inflammation.
    • Not reliable for prostate cancer diagnosis during infection.
  • Transrectal Ultrasound (TRUS):
    • Assesses prostatic abscess or structural abnormalities.
  • Four Glass Test (Rarely Used):
    • Sequential urine and prostatic secretion samples for bacterial localisation.

Management

1. Acute Bacterial Prostatitis (ABP):

  • First line: ciprofloxacin 500mg BD or Trimethoprim 200mg BD for 14 days.
  • Severe cases: IV antibiotics (Gentamicin + Co-amoxiclav).
  • Supportive care: hydration, analgesia (paracetamol, NSAIDs).

2. Chronic Bacterial Prostatitis (CBP):

  • First line: ciprofloxacin 500mg BD for 4–6 weeks.
  • Alternative: trimethoprim 200mg BD if fluoroquinolone resistance.
  • Consider alpha-blockers (Tamsulosin) to improve urinary symptoms.

3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS):

  • Multimodal approach: pain relief, physiotherapy, and lifestyle changes.
  • NSAIDs: for pain control.
  • Alpha-blockers (Tamsulosin): may relieve urinary symptoms.
  • Amitriptyline/Gabapentin: neuropathic pain relief.
  • Pelvic floor physiotherapy: beneficial in muscular dysfunction.

4. Refractory Cases:

  • Refer to urology for further evaluation.
  • Consider transurethral resection of the prostate (TURP) in severe cases.
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