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PROSTATITIS
Background
Prostatitis is an infection or inflammation of the prostate gland that presents
as several syndromes with varying clinical features. The term prostatitis is
defined as microscopic inflammation of the tissue of the prostate gland and is
a diagnosis that spans a broad range of clinical conditions.
The National Institutes of Health (NIH) has recognized and defined a
classification system for prostatitis in 1999. [1] The 4 syndromes of prostatitis
are as follows:
I - Acute bacterial prostatitis
II - Chronic bacterial prostatitis
III - Chronic prostatitis and chronic pelvic pain syndrome (CPPS; further
classified as inflammatory or noninflammatory)
IV - Asymptomatic inflammatory prostatitis
Acute prostatitis and chronic bacterial prostatitis are defined by documented
bacterial infections of the prostate and are treated with antibiotic therapy and
supportive care (see Treatment).
CPPS is characterized primarily by urological pain complaints in the absence
of urinary tract infection. This syndrome excludes the presence of active
urethritis, urogenital cancer, urinary tract disease, significant urethral stricture,
or neurological disease affecting the bladder. It is subdivided into
inflammatory and noninflammatory subtypes. Inflammatory CPPS is defined
by the presence of white blood cells in the semen, expressed prostatic
secretions, or voided bladder urine after prostatic massage (see Workup).
Noninflammatory CPPS is defined by the absence of white blood cells. [2]
Asymptomatic inflammatory prostatitis is characterized by the incidental
discovery of prostatic inflammation without genitourinary complaints. [3] This
condition is diagnosed during a workup for infertility or elevated prostate-
specific antigen (PSA) level. This disease entity can produce elevated white
blood cells in the ejaculate (leukocytospermia) and can cause male infertility
but is usually otherwise left untreated. See the following for more information:
Acute Bacterial Prostatitis
Chronic Bacterial Prostatitis
Chronic Pelvic Pain in Men
Granulomatous Prostatitis
Nonbacterial Prostatitis
Patient education
For patient education information, see the Prostate Health Center, as well
as Prostate Infections.
Pathophysiology
In bacterial prostatitis, sexual transmission of bacteria is common, but
hematogenous, lymphatic, and contiguous spread of infection from
surrounding organs must also be considered. Although various routes have
been postulated, none has been firmly substantiated.
A history of sexually transmitted diseases is associated with an increased risk
for prostatitis symptoms.
The presence of acute inflammatory cells in the glandular epithelium and
lumens of the prostate, with chronic inflammatory cells in the periglandular
tissue, characterizes prostatitis (see the image below). However, the presence
and quantity of inflammatory cells in the urine or prostatic secretions does not
correlate with the severity of the clinical symptoms.
A nonspecific mixed inflammatory infiltrate that consists of lymphocytes,
plasma cells, and histiocytes is typical in chronic bacterial prostatitis.
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Chronic pelvic pain syndrome is diagnosed based on pain in the setting of
negative cultures of urine and prostatic secretions. Neuromuscular
dysfunction or congenital reflux of urine into the ejaculatory and prostatic
ducts may be a precipitating factor.
Viral and granulomatous prostatitis may be associated with HIV infection and
is another cause of culture-negative disease. A common viral pathogen of
prostatitis in HIV-infected patients is cytomegalovirus (CMV). [4] Mycobacteria,
such as Mycobacterium tuberculosis, and fungi, such as Candida
albicans, have also been associated with culture-negative disease in this
population. [5]
Etiology
Acute bacterial prostatitis may be caused by ascending infection through the
urethra, refluxing urine into prostate ducts, or direct extension or lymphatic
spread from the rectum. Approximately 80% of the pathogens are gram-
negative organisms (eg, Escherichia coli, Enterobacter, Serratia,
Pseudomonas, Enterococcus, and Proteus species). [6, 7] Mixed bacterial
infections are uncommon. One case report of prostatitis caused by methicillin-
resistant Staphylococcus aureuswas documented in a diabetic patient.
Consider Neisseria gonorrhoeae and Chlamydia trachomatis infection in any
male younger than 35 years presenting with urinary tract symptoms.
Nursing home patients with indwelling urethral catheters may also be at
increased risk of acute bacterial prostatitis. Sclerotherapy for rectal prolapse
may also increase risk. [8]
Chronic bacterial prostatitis may be due to the following:
A primary voiding dysfunction problem, either structural or functional
E coli is responsible for 75-80% of chronic bacterial prostatitis cases.
Enterococci and gram-negative aerobes such as Pseudomonas are
usually isolated in the remainder of cases.
C trachomatis, Ureaplasma species, Trichomonas vaginalis
Uncommon organisms, such as M tuberculosis and Coccidioides,
Histoplasma,and Candida species , must also be
considered. Tuberculous prostatitis may be found in patients with renal
tuberculosis
Human immunodeficiency virus
Cytomegalovirus
Inflammatory conditions (eg, sarcoidosis)
The etiology of chronic prostatitis and chronic pelvic pain syndrome is poorly
understood but may involve an infectious or inflammatory initiator that results
in neurologic injury and eventually in pelvic floor dysfunction in the form of
increased pelvic tone. [2] About 5-8% of men with this syndrome eventually
have a bacterial pathogen isolated from urine or prostatic fluid.
Causes of chronic prostatitis and chronic pelvic pain syndrome may include
the following:
Functional or structural bladder pathology, such as primary vesical neck
obstruction, pseudodyssynergia (failure of the external sphincter to relax
during voiding), impaired detrusor contractility, or acontractile detrusor
muscle
Ejaculatory duct obstruction
Increased pelvic side wall tension
Nonspecific prostatic inflammation
Causes of asymptomatic inflammatory prostatitis are similar to those of
chronic inflammatory prostatitis without symptoms.
Epidemiology
United States statistics
Prostatitis is one of the most common diseases seen in urology practices in
the United States, accounting for nearly 2 million outpatient visits per
year. [9, 10, 11] The diagnosis is made in approximately 25% of male patients
presenting with genitourinary symptoms. Autopsy studies have revealed a
histologic prevalence of prostatitis of 64-86%.
Approximately 8.2% of men have prostatitis at some point in their
lives. [2] Among the 4 categories of prostatitis, the most common is chronic
prostatitis/chronic pelvic pain syndrome, accounting for 90-95% of prostatitis
cases. Acute bacterial prostatitis and chronic bacterial prostatitis each make
up another 2-5% of cases.
International statistics
The incidence of mycobacterial prostatitis, concomitant with disseminated
disease, is increasing in underdeveloped countries. Areas with widespread
sexually transmitted disease (STD) rates and prostitution have a higher
incidence of acute bacterial prostatitis.
Age-related demographics
In patients younger than 35 years, the most common variant of the syndrome
is acute bacterial prostatitis. HIV-related disease is also predominantly seen in
younger patients.
Among older patients, nonbacterial prostatitis (National Institutes of Health
[NIH] types II and IV) are the most common. Of importance, rare causes of
prostatitis should be sought during evaluation. According to case reports of
Wegener granulomatosis in the fourth and fifth decades of life, prostatitis can
be a presenting feature of Wegener granulomatosis and a clinical
manifestation of relapse. [12, 13, 14]Fungal infection with C
albicans and Coccidioides immitis and mycobacterial infection with M
tuberculosis have also been reported.
Prognosis
The prognosis in patients with the first occurrence of acute bacterial prostatitis
is good, with aggressive antibiotic therapy and good patient compliance. In
patients with recurrent chronic prostatitis who may present with acute
exacerbations, causative underlying factors affect outcome.
Prostatitis may lead to urosepsis with significant associated mortality in
patients with diabetes mellitus, patients on dialysis for chronic renal failure,
patients who are immunocompromised, and postsurgical patients who have
had urethral instrumentation.
Chronic prostatitis and asymptomatic inflammatory prostatitis have not been
definitively linked to the development of prostate cancer.