INFECTIONS OF UTI
PROSTATITIS AND CHRONIC PELVIC PAIN
SYNDROME
• Prostatitis is the most common urologic diagnosis in
men younger than 50 years and the third most
common urologic diagnosis is men older than 50
years after BPH and prostate cancer.
• Prevalence rate -7% for chronic prostatitis
Histopathology:
• Most common pattern of inflammation is a
lymphocyte infiltrate in the stroma immediately
adjacent to prostatic acini.
• Granulomatous prostatitis presents a variable
histologic pattern typified by heavy lobular, mixed
inflammatory infiltrates that include abundant
histiocytes, lymphocytes and plasma cells
Etiology:
1) Microbiology [Link] (60-80%)
• Others Pseudomonas, Serratia, Klebsiella, ESBL [Link]
• Gram positive bacteria Enterococci (5 to 10%),
Staphylococcus saprophyticus, hemolytic streptococci
• Anaerobic bacteria
• Corynebacterium, Chlamydia trachomatis, Ureaplasma,
Candida
• Nanobacteria difficult to isolate and culture
2) Altered prostate host Defense:
• Intraprostatic ductal reflux
• Phimosis
• Unprotected penetrative anal rectal intercourse
• UTI
• Acute epididymitis
• Indwelling urethral catheters
• Transurethral surgery
3) Dysfunctional voiding
4) Immunologic alterations Increased IgA + IgG levels
5) Autoimmune process
6) Pelvic floor muscle abnormalities
7) Neural sensitization
8) Psychosocial association
9) Association with interstitial cystitis
• Symptoms of CPPS appear to result from an interplay
between psychological factors and dysfunction in the
immune, neurological and endocrine systems
Secretory dysfunction
• Decreased fructose, citric acid,
Acid phosphatase, zinc, magnesium, and calcium,
zinc-containing prostatic antibacterial factor
• Increased -pH, the ratio of lactate dehydrogenase-
5 to lactate dehydrogenase-1, ceruloplasmin,
complement C3 .
- Alkaline pH -hampers diffusion of basic antimicrobial
drugs into the prostatic tissue and fluid .
National Institutes of Health (NIH) classification
system
•Category I (Acute bacterial prostatitis) Acute
infection of prostate gland. Presents with storage and
voiding symptoms
•Category II (chronic bacterial prostatitis) chronic
infection of prostate gland
•Category III (CPPS) chronic genitourinary pain in the
absence of uropathogenic bacteria localized to prostate
gland
Category IIIA (Inflammatory CPPS) significant
number of WBCs seen in EPS, post prostatic massage
urine
Category IIIB (Non inflammatory CPPS/
prostatodynia)- insignificant number of WBCS in EPS,
VB3
• Category IV (Asymptomatic inflammatory prostatitis
/ Histologic prostatitis) WBCs seen in EPS,
VB3/semen/Histologic specimen of prostate gland)
Evaluation
Mandatory:
• History
• Physical examination including DRE and pelvic floor
• Urinalysis and culture
Recommended :
• Two glass lower urinary tract evaluation
• NIH-CPSI
• Sexual functioning assessment
• Flow rate
• Residual urine
• Urine cytology
Not recommended for routine initial evaluation
• Four glass lower urinary tract evaluation
• Semen analysis and culture
• STI evaluation / urethral culture
• Pressure flow studies
• Video urodynamics
• TRUS of prostate
• Pelvic imaging CT/MRI/USG
• Serum PSA
UPOINT Phenotypic Classification System
(Snowflake Hypothesis)
• Urinary Voiding / storage alphablockers
,Anticholinergics ,Diet modification
• Psychosocial Depression, Anxiety
Antidepressants, Anxiolytics ,CBT ,Appropriate
referral
• Organ specific Prostate tenderness Cernilton 1
tab tds ,Quercetin 500mg bd, Saw palmetto 150 mg
od
• Bladder improvement with voiding Pentosan
polysulfate, Quercetin, Intravesical therapy
• Infection Positive culture antibiotics
• Neuropathic Gabapentinoids , Amitriptyline,
Neuromodulation , Acupuncture, Pain clinic
• Tenderness Pelvic floor muscle pain / spasm
Biofeedback, ESWT, Exercise, heat therapy
• Sexual dysfunction / pain PDE inhibitors
Suggested Therapies In CPPS And Chronic
Prostatitis
Recommended
1) Alpha blockers
2) Antimicrobials
3) Phytotherapy
4) Multimodal therapy directed by clinical phenotype
5) Directed physiotherapy
Not Recommended
1) Alpha blocker monotherapy particularly in patients
treated with alpha blockers previously
2) Antiinflammatory monotherapy
Antimicrobial therapy failed antimicrobial therapy
4) 5 alpha reductase monotherapy
5) TUNA, laser therapies
6) URP, Radical prostatectomy
Requiring further evaluation:
1) Low intensity shock wave treatment
2) Acupuncture
3) Biofeedback
4) Invasive neuromodulation
5) Electromagnetic stimulation
6) Botox A injection
7) Medical therapies including mepartricin, muscle
relaxants, neuromodulators, immunomodulators
Orchitis
Definition:
• Acute orchitis sudden occurrence of pain and
swelling of testis associated with acute inflammation
of the testis.
• Chronic orchitis inflammation and pain in the testis
usually without swelling for more than 6 weeks
Classification
Acute bacterial orchitis
–Secondary to UTIs E. coli, Pseudomonas,
Staphylococcus
–Secondary to STDs [Link], Chlamydia,
Treponema pallidum
Non bacterial orchitis
–Viral Mumps, infectious mononucleosis
–Fungal Candidiasis, Aspergillosis, Histoplasmosis,
Coccidiodomycosis, Actinomycosis, Blastomycosis
–Parasites Filariasis, Trypanosomiasis
–Rickettsial
Noninfectious orchitis
• Idiopathic
• Traumatic
• Autoimmune polyarteritis nodosa, Behcet
disease,antisperm antibodies
Chronic orchitis
Chronic orchialgia
Diagnosis
• Urine analysis
• Urine culture
• Urethral swab culture
• Colour Doppler USG
• MRI second line investigation
• D/D: testicular torsion
Treatment
• Bed rest
• Scrotal support
• Antipyretics
• Analgesics
• Antibiotic therapy
• ATT-if due to [Link] infection
• Spermatic cord blocks
• Glucocorticoids and immunosuppressive drugs
Treatment
For chronic orchitis
• Antiinflammatory agents
• Heat therapies
• Nerve blocks
• Neuromodulation
• Orchiectomy is indicated only in cases in which pain
control is refractory to all other measures
Epididymitis
Definition:
• Acute epididymitis sudden occurrence of pain and
swelling of the epididymis associated with acute
inflammation
• Chronic epididymitis inflammation and pain in the
epididymis usually without swelling but with
induration persisting for over 6 weeks
Classification
Acute bacterial epididymitis
• Secondary to UTIs E-coli
• Secondary to STDs [Link], C. trachomatis
Nonbacterial infectious epididymitis
• Viral
• Fungal
• Parasitic
Noninfectious epididymitis
• Idiopathic
• Traumatic
• Autoimmune
• Amiodarone induced
Chronic epididymitis
Chronic epididymalgia
Diagnosis
• Urine analysis
• Urine culture
• Urethral swab culture
• USG
• MRI
Treatment
• Ceftriaxone / Doxycycline for men younger than 35
years age
• Levofloxacin / ofloxacin for men older than 35 years
age
• For chronic epididymitis 4 to 6 week course of
antibiotics
• Bed rest
• Scrotal support
• Antiinflammatory drugs
• Analgesics
-Spermatic cord block
-Epididymectomy as a last resort