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Bacterial prostatitis

Acute prostatitis (I)

• Histologic dx: presence of inflammation on prostate samples
• Clinical dx: UTI (frequency + dysuria) +/- systemic symptoms (fever, malaise, myalgias) +/- pain (lower abdominal or perineal)
• Exam: DRE ok, but prostate massage can cause sepsis, check PVR to rule out retention (consider placing SPT)
• Labs: UCx and CBC, consider blood cultures if systemic symptoms
• Treatment: 4-6wks lipid-soluble antibiotics, includes quinolones, trimethoprim, macrolides, tetracyclines

Chronic prostatitis (II)

• 2 glass test: urine culture obtained before and after prostatic massage, > 95% accurate for diagnosis
• 4 glass (Mears-Stamey) test: historic gold standard, collect initial 5-10mL voided urine, midstream urine, prostate massage expressed secretions, and post-massage urine
• Further workup: assess for retention (PVR), cancer (DRE), scrotal/abdominal exam, hematuria, consider sending for other cultures if history HIV or immunosuppressions, if < 45yo and first UTI, rule out urethral stricture with RUG
• CT imaging: obtain if UTI and hx DM, CKD, stones, LUTS, neurologic disease, hematuria, or urea-splitting bacteria
• Antibiotics: need to have good lipid solubility, includes quinolones, trimethoprim, macrolides, tetracyclines, may require treating for up to 6mo
• TURP: has been shown to improve symptoms in 52-67%

Chronic Prostatitis + Pelvic Pain Syndrome (IIIa+IIIb)

Potential causes

• Infection: may have history recurrent UTI
• Inflammation: histologic confirmation does not correspond with symptom severity
• Neurologic: patients demonstrate central sensitization (neural stimulation in absence of stimulus)
• Pelvic floor dysfunction: spastic pelvic muscles, difficulty relaxing, confirm on exam
• Psychosocial: association between pain and perceived stress
• Endocrine: higher levels cortisol may be present
• Genetic: association between CPPS and other pain conditions

Evaluation/Diagnosis

• Diagnosis of exclusion: pain in the absence of urethritis, GU cancer, UTI, strictures, or NGB
• Assess for nonurologic associated symptoms: GI, neuro, rheum (chronic pain syndromes)
• DRE: rule out acute prostatitis or prostate cancer, assess pelvic floor tenderness
• Other testing: obtain UA, UCx, PVR, consider cytology, PSA, imaging, cystoscopy

Treatment via "UPOINT" system (honestly outdated)

• THE KEY: most of the below management plans indicate that "chronic prostatitis" is actually a mis-diagnosis and there is another underlying condition, most patients can likely be managed with "UPT" alone
• Urinary: alpha-blockers and 5ARi for voiding symptoms, pentosan polysulfate for bladder pain with filling (IC/BPS)
• Psychosocial: diet (food sensitivity), exercise, stress management
• Organ-specific: prostate massage, frequent ejaculation, circumcision, botox, TUIP
• Infectious: questionable benefit to antibiotic treatment, consider 6 weeks (quinolones/tetracyclines) if no prior antibiotic treatment and symptom duration < 1yr
• Neurologic: TCAs, gabapentin/pregabalin, SSRI/SNRIs, SNS/PTNS
• Tenderness (MSK): pelvic floor physical therapy (since the diagnosis is likely pelvic floor dysfunction)
• Other potential treatments: NSAIDs, quercetin 500mg BID (bioflavonoid)

Types of Prostatitis (in table form)

NIH Classification	Symptoms	Pyuria?	Bacteruria?	Treatment	Key findings
Acute bacterial (I)	UTI symptoms Systemic (fever/chills) Pelvic pain	Yes	Yes	PO/IV antibiotics x2-4 weeks 6mo if TB related	Acute infectious + systemic symptoms
Chronic bacterial (II)	Recurrent UTIs	Yes	Yes, 10x increase after prostate massage	Antibiotics x4-6 weeks	Recurrent UTI with same organism
Chronic prostatitis/pelvic pain Inflammatory (IIIa)	Pelvic pain without positive urine cultures	Yes (especially after prostate massage)	No	UPOINT	Pelvic pain in absence of infectious symptoms
Chronic prostatitis/pelvic pain non-Inflammatory (IIIb)		No (even after prostate massage)
Asymptomatic inflammatory (IV)	None	Yes	No	None	Discovered incidentally on biopsy/semenalysis

Other prostatic infection

Prostate abscess

• Evaluation: suspect if prostatitis diagnosis and persistent fevers despite 48hrs abx
• Risk factors: catheter/GU instrumentation, DM, HIV, cirrhosis, ESRD/HD, BOO, prostate biopsy
• Imaging: confirm diagnosis with CT pelvis with contrast
• Management: if < 1-2cm, okay for antibiotics only, otherwise consider percutaneous drainage (recurrence rates 15-33%), if "very large" or abscess recurs, perform TUR unroofing

Post-prostate biopsy sepsis

• Initial treatment, carbapenems, amikacin, or 2nd/3rd gen cephalosporins, do not treat with bactrim or quinolones (high rates of ESBL resistance)
• Further treatment: can transition to quinolones if culture is sensitive, recheck culture in 1 week to confirm resolution

Granulomatous prostatitis

• Cause: commonly seen with TB infection or after BCG administration
• Histology: epithelioid granulomas
• Workup: check Tb cultures and acid fast staining of prostatic secretions or semen
• Treatment: only treat if symptomatic, isoniazid 300mg QD + rifampin 600mg QD x3-6mo, also give pyridoxine 50mg QD

IgG4 prostatitis

• Cause: may be seen with retroperitoneal fibrosis (Ormond disease)
• Histology: fibroinflammatory cells with IgG4+ plasma cells
• Treatment: responds well to steroids, consider in patient with LUTS and autoimmune pancreatitis/cholangitis, or histologic confirmation