Prostatitis is defined as painful inflammation jogging per prostatite the prostate gland although this collective clinical term is used for several complex diseases that may or may not be associated with the presence of polymorphonuclear cells PMNs in the prostatic fluid secretions. This chapter focused on acute and chronic bacterial prostatitis with an emphasis on the microbiology, diagnosis and antimicrobial therapy jogging per prostatite these challenging conditions in the face of increasing antibiotic resistance.
Prostatitis syndromes may be divided into four broad categories including: 1 Type I or acute bacterial prostatitis is an acute infection of the prostate. Although acute bacterial infection of the prostate is rare and diagnosed in less than 0. Two subgroups are designated within CPPS, those men who have evidence of inflammation [i. PMNs are found in the semen, expressed prostatic secretion EPS or urine obtained after prostatic massage voided bladder urine or VB-3 ] and those that have non-inflammatory disease where no evidence of leukocytes are found in any of these samples, and 4 Type IV is asymptomatic inflammatory prostatitis where there are no clinical symptoms but PMNs jogging per prostatite found in prostatic secretions at the time of surgery, biopsy or autopsy.
Reports from international studies show comparable estimated prevalence rates of prostatitis in men in Europe and Asia. Despite the enormous burden prostatitis places on the healthcare system, it has been difficult to determine the precise epidemiology of the various prostatitis syndromes because of the differing definitions used to describe these conditions, and the heterogeneity of various diagnostic criteria including the lack of specificity of genitourinary tract inflammatory localization.
Acute bacterial and chronic bacterial prostatitis only account for a small proportion of all cases. Acute bacterial prostatitis accounts for less than 0. Prostatitis is the most common urologic condition in men younger than 50 years of age. The age incidence rates for men with a diagnosis of acute prostatitis and prostatitis jogging per prostatite otherwise specified by type or chronic prostatitis show jogging per prostatite different pattern.
For men with acute prostatitis, rates are highest between the 3rd and 5th decades from 3. In contrast, the incidence of chronic jogging per prostatite remains low until after age 50 when the rates begin to steadily rise in elderly men. Aside from acute bacterial prostatitis, the precise etiology and pathogenesis of the other types of prostatitis outlined jogging per prostatite the NIH classification remain to be fully elucidated.
Acute bacterial prostatitis is most likely caused by reflux of urine from the urethra into the intraprostatic ducts, which promotes ascending infection of the urinary tract jogging per prostatite prostate. Animal models of bacterial prostatitis in the rat have demonstrated that the infection is mainly located along the base of the prostatic glands. Once infected, bacteria may chronically colonize the prostate gland in an asymptomatic manner after acute infection, but persist and cause recurrent episodes of chronic infection.
Prostatic calculi may also play a role in inducing chronic infection, but obstruction of the intraprostatic ducts jogging per prostatite promote and potentially maintains low grade glandular infection. Certain Gram-positive bacteria that are part of the skin microbiota in the genital tract i. Atypical bacterial pathogens that may be sexually acquired and transmitted have also recently been recognized as having a critical role in bacterial prostatitis.
Atypical sexually transmitted pathogens have all been isolated from the male genitourinary tract of men suffering from acute and chronic prostatitis but their role in causing infection needs to be further elucidated. Once bacterial infection of the prostate is established, it is likely maintained due to the formation of a micro-organism biofilm.
Bacterial biofilm formation may therefore promote the persistence of infection and lead to chronic bacterial infection and inflammation. Granulomatous prostatitis is also a rare complication of military tuberculosis in otherwise healthy jogging per prostatite. Immunocompromised patients including those with diabetes and human immunodeficiency virus jogging per prostatite are at increased risk.
Spinal cord injury or the presence of a neurological disorder that jogging per prostatite the detrusor or pelvic floor musculature may also be at higher risk. Clinical studies have not shown a role for other factors such as urogenital trauma, dehydration or sexual abstinence.
Prostatitis jogging per prostatite to bacterial infection is often associated with lower urinary tract symptoms such as dysuria, and urinary frequency. However, unlike urinary tract infection alone, men with prostatitis typically have suprapubic, rectal, testicular, scrotal and penile pain, and sexual dysfunction or discomfort, including erectile dysfunction, painful ejaculation and postcoital pelvic discomfort. Digital rectal examination should be performed in all men with symptoms of prostatitis, but prostatic massage should not be done during acute prostatic infection.
The prostate gland is tender and enlarged jogging per prostatite an episode of acute infection. Patients with acute bacterial prostatitis may present with bacteremia and septic shock i. Urinary outflow obstruction must be urgently identified and rectified jogging per prostatite placement of a suprapubic catheter. Prostatic abscess may also be present or develop during the course of the infection. Patients with severe pain or fluctuance on digital prostate exam should have an urgent transrectal ultrasound or computerized tomography scan of the prostate gland.
Chronic bacterial prostatitis is a relapsing subacute illness that presents with persistent symptoms that mimic a urinary tract infection but wax and wane. Patients usually have dysuria and urinary frequency and urgency jogging per prostatite with lower back pain, perineal or scrotal pain, and painful ejaculation that have been present for more than 3 months. Men with chronic bacterial prostatitis do not present with systemic symptoms of infection fever, chills and rigors. The physician exam including the digital rectal exam of the prostate do not reveal any abnormalities.
Chronic pain and jogging per prostatite dysfunction occur as complications of chronic prostatic infection and inflammation. Since simple cystitis is a localized urinary infection of the bladder, men with this infection will not have systemic symptoms of infection including fever, chills and rigors.
Although patients with pyelonephritis manifest systemic symptoms of infection, they typically also have costovertebral angle tenderness flank painand a digital rectal exam will reveal a normal prostate gland. BPH is defined as prostate gland enlargement secondary to hyperproliferation of stromal and glandular cells, with predominance of mesenchymal cells BPH presents with progressive lower urinary tract symptoms including voiding dysfunction urinary frequency and retention.
Progressive prostatic jogging per prostatite appears to be an important factor in the pathogenesis and progression of BPH. Intraprostatic inflammation in men with BPH who required a TURP has recently been jogging per prostatite to be a significant indicator of progressive disease compared to men with BPH who had lesser or absent inflammation.
A prior episode of prostatitis is also more common in ageing men who develop BPH although both conditions may co-exist. Further research is needed to delineate an association between the earlier presence of different types of prostatitis, chronic glandular inflammation and the development of BPH jogging per prostatite ageing men. Prostate cancer must also be ruled out in men with chronic prostatitis and persistently elevated prostate specific antigen PSA levels i. Urinalysis should be done on all patients suspected jogging per prostatite having prostatitis to pyuria and bacturiuria as indicators of urinary tract infection.
The ratios from jogging per prostatite specific urinary proteins have also recently been shown to assist in diagnosing renal and urological disorders. A recent study of men with renal or urological disorders demonstrated that presence of two specific urinary proteins A2M and urinary albumin was diagnostic of acute prostatitis The mid-stream portion of the urine stream should be collected after retracting the foreskin and cleansing the head of the penis and voiding the sample into a sterile container.
The jogging per prostatite specimen is then aseptically transferred in a sterile tube containing a preservative such as Boric acid or inoculated onto jogging per prostatite Dipslide for transportation to the microbiology laboratory. EPS need not be cultured during acute infection episodes since the microorganisms can be recovered from an MSU culture and a prostatic massage should not be done. Blood cultures should also be done on all patients with acute bacterial prostatitis to detect bacteremia.
A minimum of two sets should be ordered to ensure an adequate volume of blood is cultured to achieve an optimal sensitivity. The Meares-Stamey 4-Glass test is performed by sequentially collecting four separate segmented urine samples into separate sterile containers as follows: 1 VB1 mls of first-void urine sample is initially collected after retracting the foreskin and cleansing the head of the penis with a soapy solution, 2 VB2 mls of the mid-stream portion of voided urine is next collected, 3 VB3 EPS fluid is collected after the physician performs prostatic massageand 4 VB4 mls of post-massage urine is collected.
However, many clinicians including urologists infrequently perform this procedure because it is difficult to perform, particularly collection of the EPS sample and the results are difficult to interpret.
A total of vs. Few studies have evaluated available methods for detecting expressed prostatic secretion inflammation, although many clinical laboratories continue to rely on the traditional coverglass wet mount slide method. When inflammation was defined at 1, PMNs per mm3 or greater the hemocytometer still identified significantly more EPS specimens and patients with inflammation. Further evaluation and standardization of clinical laboratories methods for EPS inflammation detection need to be done.
Anaerobic bacteria are also not routinely isolated from urinary tract specimens and required inoculation of special pre-reduced media and incubation under anaerobic environmental conditions.
An anaerobic culture of urine, semen or EPS should only be requested in patients suspected of having a vesiculo-enteric fistula. Jogging per prostatite antigen PSA is an important inflammatory marker for detecting and monitoring prostate cancer. However, the specificity jogging per prostatite the prostate-specific antigen level is not high when the level is intermediate i.
The association between chronic prostate inflammation due to prostatitis and elevated prostate-specific antigen levels has however been controversial. Serum prostate-specific antigen and percent free prostate-specific antigen values changes were recently studied before and after antibiotic treatment in a study of 65 asymptomatic men with persistently elevated intermediate prostate-specific antigen levels 9.
In addition, the rage of variations of prostate-specific antigen and percent free prostate-specific antigen values also decreased significantly. Subclinical prostatic inflammation may contribute to an elevated prostate-specific antigen level and its variation amongst men with prostate cancer.
Other inflammatory markers may be increased during acute or chronic bacterial prostatitis episodes but both an erythrocyte sedimentation rate ESR or C-reactive protein elevation are non-specific markers of inflammation. No studies have been done evaluating the use of these inflammatory markers for therapeutic monitoring of prostatic inflammation.
These tests only have the potential to be useful in monitoring resolution of prostatic inflammation in patients with no other foci of ongoing inflammation. Patients with difficulty voiding of incomplete voiding should have further studies to diagnose urinary obstruction.
Evaluation of bladder emptying by flow jogging per prostatite analysis measured by ultrasonography may be used voiding efficiency. A voiding cystourethrogram may also reliably detect urodynamic changes including reflux. Urethrocystoscopy may detect inflammation in the posterior urethra during prostatitis.
Transrectal ultrasound TRUS of the prostate should be used to jogging per prostatite prostatic calculi and the presence of a prostatic abscess. Sonographic changes of acute prostatitis are jogging per prostatite of tissue jogging per prostatite, venous engorgement and increased blood flow to jogging per prostatite gland.
Acute inflammation causes a generalized enlargement and change in shape of the gland jogging per prostatite triangular or ovoid shape to a more rounded symmetrical shape. There is also a generalized decrease in parenchymal echogenicity due to edema and inflammatory infiltrate. Prostatic abscess has a variable sonographic appearance depending on the stage of the infection. Early on TRUS will only show multifocal hypoechoic areas in the peripheral and transition zones of the gland representing edema and inflammatory infiltrates which is non-diagnostic Later on TRUS will demonstrate progression to the distinctive appearance of a 1.
Longitudinal imaging may therefore be necessary to obtain the most accurate picture of the evolution of complex jogging per prostatite in the prostate including extracapsular extension and involvement of the seminal vesicles. Since TRUS may underestimate the extraglandular extent of an abscess, patients with sonography showing extension to the prostatic capsule, apex or base should have a CT scan to better delineate the extent of the infection, which dictates the approach to medical and surgical management.
The findings include hypoechoic peripheral changes, calcification, and periprostatic venous engorgement and seminal vesicle abnormalities Acute or chronic jogging per prostatite prostatitis is by definition a complicated urinary tract infection due to the sequestered nature of the prostate gland due to the poor penetration of many drugs into this site.
Selection of an appropriate antimicrobial agent that has optimal pharmacokinetics for prostatic tissue is important to prevent treatment failure. Antibacterial diffusion into prostate tissue depends upon the lipid solubility, molecular size and pKa of the agent.
Prostatic fluid is typically jogging per prostatite alkaline with a pH of 7. Fluoroquinolones have the best penetration into prostatic tissue of all currently available antibiotic classes of drugs.
Since these drugs exist in their zwitterion form with a pKa in both acidic jogging per prostatite alkaline environments, these drugs penetrate and achieve prostatic fluid levels that are similar to those in plasma with ratios ranging from 0. The concentration of ciprofloxacin in alkaline seminal fluid has been shown to exceed that in plasma. Selection of an effective empiric antibiotic treatment regimen for acute or chronic bacterial prostatitis is further complicated by the increasing antimicrobial resistance of uropathogens to conventional antibiotic regimens.
Recent research demonstrates that in vitro resistance patterns predict the therapeutic efficacy of antimicrobials jogging per prostatite urinary tract infections including bacterial prostatitis. Physicians therefore need to jogging per prostatite the local resistance jogging per prostatite of specific uropathogens to aid in initially choosing the most effective regimen prior to urine, EPS and blood culture results being available.