Prostatitis

01.07.2020

Painful, frequent, and urgent urination (Lower Urinary Tract Symptoms or LUTS) with malaise or fever, distressing but poorly localized pain, are typical symptoms of acute prostatitis. Chronic prostatitis, on the other hand, means that the symptoms are less evident and LUTS are accompanied by pain that can occur at various locations including the perineum, scrotum, penis, and inner part of the leg. Natural or home treatment is not recommended in prostatitis and the main medication is an antibiotic course for at least 2-3 weeks.

In young people, prostatitis is mostly a complication of urethritis caused by STI (Sexually Transmitted Infections). In fact, the infection of the urethra after sexual intercourse can spread up to the prostate. Usually, isolated LUTS if not correctly recognized as urethritis and treated, after a few days or weeks, urinary symptoms may worsen to fever and malaise caused by prostatitis. If this acute infection is not well recognized or treated only partially, chronic prostatitis may occur. In this case, the treatment and bacterial eradication are not always successful. Chronic prostatitis can be so annoying that it makes life difficult for years. This is also called Chronic Prostatitis and Pelvic Pain Syndrome and often it has not a definite treatment.

In older patients, the prostate enlargement and the obstructed micturition is the reason for recurrent acute and chronic prostatitis. In these cases, the bacteria involved are different from the ones causing STI.

Diagnosis

Digital rectal examination (DRE) is an important diagnostic step for supporting the diagnosis of acute or chronic prostatitis. However, in acute prostatitis, excessive prostate massage can result in worsening symptoms and high fever.

The most important investigation for acute prostatitis is mid-stream urine culture. In chronic prostatitis, the Meares and Stamey test is an important investigations to categorize clinical prostatitis. Accurate microbiological analysis of samples from the Meares and Stamey test may also provide useful information on the presence of atypical pathogens causing STD or STI. 

Prostate Ultra Sound scan (supra-pubic or trans-rectal) is useful to detect prostate calcifications that are very commonly associated with chronic prostatitis.

Prostate-specific antigen is increased in about 60% and 20% of men with acute and chronic prostatitis, respectively. The PSA level decreases after antibiotic therapy (which occurs in approximately 40% of patients) and correlates with clinical and microbiological improvement.

Performing an ejaculated semen culture improves the diagnostic utility of the Meares and Stamey test.

Bladder outflow and urethral obstruction should always be considered and ruled out by uroflowmetry, retrograde urethrography, or endoscopy. 

Treatment

Prompt antibiotic treatment is mandatory in acute prostatitis since its trend is unpredictable. Antimicrobials, in fact, are life-saving in acute prostatitis and recommended in chronic prostatitis. A combination of antibiotics with various herbal extracts may attenuate clinical symptoms.

In asymptomatic post-treatment patients, routine urinalysis and/or urine culture is not mandatory as there are no validated tests of the cure for bacterial prostatitis except for cessation of symptoms. In patients with persistent symptoms and repeated positive microbiological results for sexually transmitted infections (STI), microbiological screening of the patient's partner is recommended. Antibiotic treatments may be repeated with a more prolonged course, higher dosage, and/or different compounds.