B20. Prostatitis and lower urinary tract infections in men: Diagnosis and treatment

From greek.doctor

For lower urinary tract infection in general, see topic B19.

Acute bacterial prostatitis

Acute bacterial prostatitis is a severe infection of the prostate. It typically affects young and middle-aged men and is usually associated with a lower UTI. Untreated it can progress to chronic bacterial prostatitis, sepsis, prostatic abscess, and endocarditis.

  • Etiology
    • UTIs
    • Genitourinary tract interventions
  • Clinical features
    • High fever
    • Pain
      • Perineal or pelvic area
      • On defecation
    • Dysuria
    • Frequency
  • Diagnosis
    • Urinalysis
    • Urine culture
    • DRE
      • Usually not needed
      • Very carefully, to prevent bacteriaemia
      • Painful, firm, oedematous prostate
  • Treatment
    • Inpatient treatment in most cases
    • Long duration antibiotic treatment (6 weeks)
      • Fluoroquinolones and sulphametoxazole/trimethoprim penetrate the prostate
    • Suprapubic catheter in case of urinary retention

Chronic bacterial prostatitis

Chronic bacterial prostatitis refers to chronic or recurrent urogenital symptoms with evidence of bacterial infection of the prostate, usually defined as symptoms > 3 of the last 6 months. It's relatively rare.

  • Etiology
  • Clinical features
    • Same as acute, but intermittent and less severe
    • No systemic symptoms
  • Diagnosis
    • Meares-Stamey four-glass test
      • Used to determine the location of the bacterial infection within the urinary tract
      • Only performed in men
      • Four glasses are taken
        • 1st glass – the first 10 mL of urine
        • The patient then voids another approx. 100 mL of urine
        • 2nd glass – another 10 mL of urine
        • 3rd glass – the patient’s prostate is massaged, and the fluid ejected from the urethra is collected
        • 4th glass – another 10 mL of urine after the prostate massage
      • The first glass represents the urethral specimen
      • The second glass represents the bladder specimen
      • The third and fourth glasses represent the prostate specimen
      • Each glass is cultured for bacteria and examined for WBCs -> which glass has bacteria will give information on the location of the infection
      • In chronic bacterial prostatitis, the third or fourth glasses will have evidence of bacteria
    • Enlarged, soft or boggy, moderately tender prostate on DRE
  • Treatment
    • Long duration antibiotic treatment (6 – 12 weeks)
      • Fluoroquinolones and sulphamethoxazole/trimethoprim penetrate the prostate
    • NSAIDs

Chronic pelvic pain syndrome

Chronic pelvic pain syndrome (CPPS), also called chronic non-bacterial prostatitis, is a condition with chronic or recurrent urogenital symptoms (like chronic bacterial prostatitis) but without evidence of bacterial infection.

  • Types
    • Inflammatory type (WBCs in four-glass test)
    • Non-inflammatory type (no WBCs)
  • Clinical features
    • Pain or discomfort
      • Perineal, suprapubic, rectal, etc.
    • Pain upon ejaculation
    • Bloody ejaculate
  • Diagnosis
    • CPPS is a diagnosis of exclusion
    • No bacteria on four-glass test
  • Treatment
    • Antibiotics
      • No bacteria can be detected but it’s worth to try
    • Alpha blockers
    • Biofeedback
    • Physiotherapy
    • NSAIDs
    • Phytotherapy

Acute epididymitis

Acute epididymitis is the acute inflammation of the epididymis. It's one of the most common cause of acute scrotum. Symptoms include unilateral scrotal pain and swelling, usually of gradual onset.

50% of acute epididymis cases also include inflammation of the testicles, called epididymo-orchitis.

Etiology

Acute epididymitis is most commonly due to a sexually transmitted infection like Neisseria gonorrhoeae and Chlamydia trachomatis. It may also be secondary to a lower urinary tract infection.

Diagnosis and evaluation

The diagnosis is clinical, when other causes of acute scrotum (like torsion and Fournier gangrene) are ruled out. The Prehn sign is positive, meaning that the pain is reduced when the scrotum is elevated. There may be concurrent symptoms of UTI or STI. The cremaster reflex is intact (as opposed to testicular torsion). Inflammatory markers may be elevated.

Urine dipstick test may show evidence of UTI, and PCR may be positive for STI pathogens.

Management

The choice of empiric antibiotics depends on whether the epididymitis is presumed to be secondary to UTI or STI. If presumed due to UTI, sulfamethoxazole and trimethoprim can be a first choice, and if presumed due to STI, doxycycline can be a first choice.

Elevation of the painful testicle and analgesics are indicated for supportive therapy.