Prostatitis
What are potential complications of acute bacterial prostatitis?
-prostatic abscess -urinary retention -septicemia -vertebral osteomyelitis (Rare) -chronic bacterial prostatitis (rare if tx with appropriate abx regimen for appropriate timeframe - dont undertx)
What labs for acute bacterial prostatitis?
UA -may see pyuria, bacteriuria, variable degree of hematuria Urine C/S -isolates offending bacteria CBC -leukocytosis w left shift blood cultures if clinical evidence of impending or severe sepsis PSA - if drawn, will be elevated
What imaging for acute bacterial prostatitis?
acute prostatitis can progress to a prostatic abscess if pts do not respond to treatment within 1-2 days, need a pelvic CT or transrectal US to r/o abscess
What is acute bacterial prostatitis? What are RFs?
acute urogenital symptoms with evidence of bacterial infection of the prostate RF -other urinary tract infections (cystitis, urethritis) -underlying fx or anatomic anomalies -urogenital instrumentation (catheter, prostate bx) -many pts have no clear RFs
What is the 4 glass test?
collect first 5-10 mL of voided urine (VB1) collect midstream sample and then stop voiding before bladder empty (VB2) prostate is digitally massaged for 1 minute followed by collection of any expressed prostatic secretions then collect first 5-10 mL of subsequently voided urine (VB3) finding pathogens on prostatic samples exclusively or at levels 10x higher than in the urethral or bladder samples is diagnostic for chronic bacterial prostatitis
What is the 2 glass test?
compares post-prostatic massage urine with pre-massage bladder urine sample (mid-stream clean catch) slightly lower sensitivity than 4 glass test cultures of post-prostatic massage urine or expressed prostate secretions are almost always positive in chronic bacterial prostatitis
What us asymptomatic inflammatory prostatitis?
incidential findings of prostatic inflammation on testing for a different reason (bx, signs of inflammation on semen analysis) no further testing or treatment is needed
What is the prognosis of chronic bacterial prostatitis?
chronic bacterial prostatitis can be difficult to treat and often recurs even if treated appropriately repeat courses of abx are often necessary
What is chronic bacterial prostatitis? RFs?
chronic or recurrent urogenital sx with evidence of bacterial infection of the prostate RFs - similar to acute bacterial prostatitis -previous acute bacterial prostatitis -prior manipulation of urinary tract -voiding sx -diabetes -smoking -prostate stones
What is chronic pelvic pain syndrome d/t chronic prostatitis?
chronic pelvic pain for at least 3 of the preceding 6 months in the absence of other identifiable causes, often with urinary symptoms and/or sexual dysfx has also been called prostatodynia and abacterial prostatitis
How does chronic bacterial prostatitis present?
classic presentation is sx of recurrent UTI -frequency, dysuria, urgency, perineal discomfort, possibly low grade fever with repeated isolation of same organism on urine cx most pts have only one or a few sx, and some will be asx with incidentally noted persistent/recurrent bacteriuria other symptoms include -pain - perineum, lower abd, testicles, penis, and/or w ejaculation -bladder irriation -bladder outlet obstruction -blood in semen
What are proposed causes of chronic pelvic pain syndrome d/t chronic prostatitis?
etiology is unknown, but theories include -inflamm d/t trauma or normal prostate flora -AI response -neurogenic -interplay of somatic and psychological factors -psychological stress/anxiety
What is the prognosis of acute bacterial prostatitis? F/U?
fever and dysuria should abate within 2-6 days of abx urine cx should be negative after 7 days, so repeat urine cx at 7 days and if still positive, alternative abx reigmen should be started if acute retention develops, suprapubic cath is recommended over urethral as urethral cath increases risk of sepsis or abscess rupture if pt has an abscess that persists after 1 week, refer to urology
What is involved in the PE for acute bacterial prostatitis?
gentle DRE -avoid vigorous prostate massage as this will be extremely painful and increases risk of bacteremia prostate will be firm, edematous, and extremely tender PE should also include genital exam to check for signs of epididymitis or STI as well as an abdominal exam
How is chronic pelvic pain syndrome d/t chronic prostatitis managed?
if voiding sx -alpha blocker and NSAID -5 alpha reductase inhibitors may be used also for pain, NSAIDs or neuropathic pain meds may be used alone PDE5 inhibitors if sexual dysfx Abx may be used as a one time trial -4 week course of fluoroquinolone or tetracycline pelvic floor PT if pelvic floor muscle spasms or painful ejaculation CBT acupuncture
Describe the patho of acute bacterial prostatitis. What organisms are most commonly implicated?
in most cases, bacteria migrate from the urethra or bladder through the prostatic ducts can also be caused by direct inoculation after transrectal bx and/or transurethral manipulations - catheter or cystoscopy Gram negative infections are the most common -E coli - MC -Proteus -KES species -pseudomonas STIs such as gonorrhea and chlamydia may also acutely involve the prostate
How is chronic pelvic pain syndrome d/t chronic prostatitis diagnosed?
it is a diagnosis of exclusion Step 1 - determine if bacterial infection -Step 2 - eval for other conditions -Step 3 - confirm findings consistent with chronic pelvic pain syndrome d/t chronic prostatitis any abnormal findings on hx, PE, labs/imaging that are not consistent with chronic pelvic pain syndrome d/t chronic prostatitis must be worked up completely
What may seen on PE in a pt with chronic pelvic pain syndrome d/t chronic prostatitis?
may have a mildly tender prostate, but in many cases prostate is normal may have muscle spasm or myofascial tenderness on palpation of the pernium, pelvic floor, or pelvic sidewalls
How does acute bacterial prostatitis present?
patients are often acutely ill -spiking fever, chills, malaise, myalgias -irritative voiding sx of dysuria, increased frequency, urgency, urge incontinence -pelvic, perineal, sacral, or suprapubic pain -pain at tip of penis -obstructive urinary sx of hesitancy, dribbling, retention -cloudy urine
What can be felt on exam in a pt with chronic bacterial prostatitis?
prostate exam is frequently normal, but may be -hypertrophic -tender -edematous -nodular -boggy -indurated
How is acute bacterial prostatitis managed?
pts with no major comorbs, no S/Sx of severe sepsis, and who can reliably take PO Abx can be treated outpt outpt regimen is empiric pending cx results for 4-6 weeks -bactrim -cipro -levofloxacin if hospitalized -IV levofloxacin or cipro w/wo gentamicin or tobromycin -switch to PO regimen after afebrile for 1-2 days -total tx duration again is 4-6 weeks
What labs for chronic bacterial prostatitis?
routine labs are non-diagnostic UA may have bacteriuria elevated WBCs often absent and elevated PSA in only 25% of pts
Describe the patho of chronic bacterial prostatitis. What organisms are involved?
same as acute bacterial prostatitis may be a complication of inadequate and/or too short of tx of acute bacterial prostatitis Gram negative rods are the culprit, with E coli being MC fungi or TB are rare causative agents seen in the immunocompromised
What is involved in F/U for chronic pelvic pain syndrome d/t chronic prostatitis? Prognosis?
should be seen every 3-4 months until they have improved and stabalized if initial tx fails, refer to urology annoying, recurrent symptoms are common, but serious sequelae have not been found
How is chronic bacterial prostatitis managed?
symptomatic relief -NSAIDs -sitz baths -alpha blockers (tamsulosin, alfuzosin) Abx therapy - at least 6 weeks with an agent with good penetration into prostatic tissue for initial and recurrent infection - fluoroquinolones are first line unless contraindicated or resistance is shown -cipro, levo -bactrim is the alternate)
How is chronic bacterial prostatitis diagnosed?
the diagnostic standard is finding bacteria at higher levels in prostatic fluid compared to urethral/bladder specimens referral to urology for prostatic fluid testing is an alternative to presumptive diagnosis (since expressing prostatic fluid is rarely performed in clinic) -4 or 2 glass test
How does chronic pelvic pain syndrome d/t chronic prostatitis present?
the primary presenting sx is pain, may be sharp/dull and is variable in duration, lasting from minutes to hours to days or even constant pain -perineum - MC -testes -suprapubic -penile -dysuria -pain with ejaculation urinary sx suc has frequency and urgency or a painful bladder filling sensation premature ejaculation (64%) and ED
What labs/imaging for chronic pelvic pain syndrome d/t chronic prostatitis?
there are no abnormal lab/imaging findings assoc with this UA and urine culture are non-diagnostic but can r/o other things PSA not indicated testicular pain should be evaluated using scrotal US bladder US or cath to check for post-void residual if there is sensation of incomplete emptying
