Clinical Notes : Urology

101. Chronic Bacterial Prostatitis 

 

NIH consensus definition and classification of prostatitis (1)

Prevalence :

International studies show approximately

  • Bacterial prostatitis (acute and chronic) : 10%

  • Nonbacterial prostatitis (Chronic Pelvic Pain Syndrome)  : 90%

 

Etiology of Chronic Bacterial Prostatitis:

  • Gram-negative Enterobacteriaceae family of bacteria are the most common causative organisms (2)

    • 80% Escherichia coli

    • 10-15% Pseudomonas aeruginosa, Serratia species, Klebsiella species, Proteus species, and Enterobacter aerogenes

  • Gram-positive organisms (3)

    • 5-10% Enterococci

 

Biofilm formation by bacteria allows the bacteria to persist despite antibiotic treatment (4)

Biofilms are protective aggregates of bacteria that form in response to host defenses or antibiotic therapy.

In prostatitis, they develop deep in the ducts of the prostate.

Patients with organisms persisting in biofilms or within obstructed ducts may have persistent symptoms despite sterile cultures.

Risk factors 

  • Intraprostatic ductal reflux and prostatic calculi

    • Reflux :

      • The peripheral zone of the prostate is composed of a system of ducts with a poor drainage system, which prevents the dependent drainage of secretions and makes that zone the most susceptible to reflux. As the prostate enlarges with age, the poorly draining ducts can become obstructed and reflux (5)

    • Calculi :

      • Prostatic calculi are generally evidence of intraprostatic reflux because they are composed of substances only found in urine and not in secretions from the prostate. They serve as a source of bacterial colonization allowing bacterial to aggregate or form biofilms leading to recurrent UTIs despite adequate antimicrobial therapy. (6)

  • Other infections (eg, acute epididymitis, urinary tract infections)

  • Phimosis 

  • Unprotected penetrative anal intercourse

  • Manipulation of the lower urinary tract

    • Indwelling urethral catheters or condom catheters

    • Transurethral surgery, especially in men with infected urine who have not been treated. 

    • Prostate biopsy can irritate the prostate or cause an infection. Infections following prostate biopsy often involve organisms with different virulence and resistance than those from spontaneous acute infections of the prostate. Extended-spectrum β-lactamase (ESBL)  E coli infection after prostate biopsy is a risk factor for chronic prostatitis. (7)

  • Secretory dysfunction of prostate gland

    • It is unclear whether the changes in prostatic fluid are a cause or consequence of inflammation, but they correlate with inflammation and are blamed for reducing the antibacterial nature of prostatic secretions.

Presentation

Chronic bacterial prostatitis (CBP) often present with history of recurrent urinary tract infections (UTIs).

 

Presenting complaints may vary from patient to patient, and may include any of the following (8) :

  • Genitourinary pain

  • LUTS

    • Urinary frequency

    • Urgency or urge incontinence

    • Hesitancy

    • Dysuria

    • Nocturia

    • Postvoid dribbling

  • Voiding symptoms

    • Weak stream

    • Straining

    • Urinary hesitancy

  • Hematuria

  • Malodorous urine

  • Urethral discharge

  • Psychological issues

    • Depression

    • Anxiety or stress

    • Overall decreased quality of life

    • Cognitive or behavioral deficits

  • Sexual dysfunction

    • Ejaculatory pain

    • Hematospermia

    • Erectile dysfunction

    • Decreased libido

    • Premature or delayed ejaculation

 

Between episodes of acute infections, some patients are asymptomatic, while others may describe a long history of persistent symptoms similar to chronic prostatitis/pelvic pain syndrome (CPPS).

Fevers and chills are uncommon, as they are typically seen only with acute bacterial prostatitis. 

Diagnosis 

In the OOH setting, Chronic Bacterial Prostatitis can be diagnosed by :

  • Primarily, history and presentation

  • ​Digital rectal examination (DRE)

    • In Chronic Bacterial Prostatitis, the prostate may be normal in size and consistency or may seem slightly boggy.

    • In Chronic non-bacterial Prostatitis (Chronic Pelvic Pain Syndrome),the prostate is moderately to severely tender, and slightly congested or boggy.

    • In Acute Bacterial Prostatitis, the prostate is very tender, warm, swollen, and boggy.

  • Urine dipstick  to evaluate for signs of infection and hematuria. 

 

A urine sample should be collected for urine culture.

Prostatic calculi are rarely palpable on prostate examination because they are typically located deep within the prostate gland​​

 
 
 
 

Further testing to exclude differential diagnoses, is best left for the GP follow-up or Urology referral, and includes :

  • Expressed prostatic specimen after prostatic massage

  • four-glass urine test

  • semen culture

  • PSA testing

  • imaging studies

Differential diagnoses to consider include :

  • Anorectal Abscess

  • Benign Prostatic Hyperplasia (BPH)

  • Nonbacterial Prostatitis

  • Prostate Cancer 

  • Ureteral Stricture

  • Urethritis

  • Urinary Tract Infection (UTI) in Males

  • Urinary Tract Obstruction

Treatment

Chronic Bacterial Prostatitis can impair the patient's quality of life to the same degree as coronary artery disease or Crohn disease. Studies show that CBP has the same effect on a patient's mental health as do diabetes mellitus and chronic heart failure (9)

Although bacteria are cultured in only 5%-10% of prostatitis cases, bacteria may still be the cause of the chronic prostatitis in many patients with the syndrome.

Thus, if clinical evidence strongly suggests chronic prostatitis in a patient with negative cultures, a 2-week trial of antibiotics is still worthwhile.

If the symptoms improve, prescribe a complete 4-6 week course of antibiotics. 

If the symptoms do not improve, repeated use of antibiotics should be avoided (10)

  • Fluoroquinolones are the mainstay in the treatment of CBP (eg, ciprofloxacin, levofloxacin, ofloxacin, moxifloxacin)

    • microbiological eradication rates are 40%-70% for ciprofloxacin and 75% for levofloxacin (11)

    • levofloxacin produces lower rates of microbiological recurrence than ciprofloxacin (12)

  • Azithromycin (13)

    • should not be used as a first-line antibiotic but can be used when microbiological studies identify susceptible pathogens

    • has reported eradication rates of around 80%

    • has good penetration into the prostate and is active against gram-positive bacteria and Chlamydia.

  • NSAIDs and corticosteroids​ (14)

    • in combination are 80% more likely to achieve a favorable response, compared with placebo

  • Suppressive antibiotics

    • Patients with persistent or recurrent infections, especially those who have symptom improvement while on antibiotics but who quickly have a recurrence after finishing a course of antibiotics, may benefit from suppressive therapy with low-dose daily prophylactic antibiotics.

    • Good choices are tetracycline, nitrofurantoin, nalidixic acid, cephalexin, and trimethoprim

  • Alpha Blockers

    • relax smooth muscle in the bladder neck, can help to decrease recurrences of CBP by diminishing urinary obstruction due to prostate enlargement or congestion secondary to inflammation.

    • include tamsulosin, alfuzosin, doxazosin, terazosin, and silodosin

 
 
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journals.png

1. Krieger JN, Nyberg L Jr, Nickel JC.

NIH consensus definition and classification of prostatitis. 

JAMA. 1999. 282:236-7. 

View/Access

2. Weidner W, Schiefer HG, Krauss H, Jantos C, Friedrich HJ, Altmannsberger M

Chronic prostatitis: a thorough search for etiologically involved microorganisms in 1,461 patients.

Infection. 1991. 19 Suppl 3:S119-25.

View/Access

3. Krieger JN, Ross SO, Limaye AP, Riley DE

Inconsistent localization of gram-positive bacteria to prostate-specific specimens from patients with chronic prostatitis.

Urology. 2005 Oct. 66 (4):721-5.

View/Access

4. Nickel JC, Costerton JW, McLean RJ, Olson M

Bacterial biofilms: influence on the pathogenesis, diagnosis and treatment of urinary tract infections.

J Antimicrob Chemother. 1994 May. 33 Suppl A:31-41.

View/Access

5. Pontari MA.

Etiology of chronic prostatitis/chronic pelvic pain syndrome: psychoimmunoneurendocrine dysfunction (PINE syndrome) or just a really bad infection?.

World J Urol. 2013 Apr 12.

View/Access

6. Ludwig M, Weidner W, Schroeder-Printzen I, Zimmermann O, Ringert RH

Transrectal prostatic sonography as a useful diagnostic means for patients with chronic prostatitis or prostatodynia.

Br J Urol. 1994 Jun. 73 (6):664-8.

View/Access

7. Oh MM, Chae JY, Kim JW, Kim JW, Yoon CY, Park MG, et al.

Positive culture for extended-spectrum β-lactamase during acute prostatitis after prostate biopsy is a risk factor for progression to chronic prostatitis.

Urology. 2013 Jun. 81 (6):1209-12.

View/Access

8. Vicari LO, Castiglione R, Salemi M, Vicari BO, Mazzarino MC, Vicari E

Effect of levofloxacin treatment on semen hyperviscosity in chronic bacterial prostatitis patients.

Andrologia. 2015 Aug 10.

View/Access

9. McNaughton Collins M, Pontari MA, O'Leary MP, Calhoun EA, Santanna J, Landis JR, et al.

Quality of life is impaired in men with chronic prostatitis: the Chronic Prostatitis Collaborative Research Network.

J Gen Intern Med. Oct/2001. 16(10):656-62

View/Access

10. Rees J, Abrahams M, Doble A, et al.

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline.

BJU International. 2015. 116:509-525.

View/Access

11. Bundrick W, Heron SP, Ray P, Schiff WM, Tennenberg AM, Wiesinger BA, et al.

Levofloxacin versus ciprofloxacin in the treatment of chronic bacterial prostatitis: a randomized double-blind multicenter study.

Urology. 2003 Sep. 62 (3):537-41

View/Access

12. Zhang ZC, Jin FS, Liu DM, Shen ZJ, Sun YH, Guo YL.

Safety and efficacy of levofloxacin versus ciprofloxacin for the treatment of chronic bacterial prostatitis in Chinese patients.

Asian J Androl. 2012 Nov. 14 (6):870-4.

View/Access

13. Perletti G, Marras E, Wagenlehner FM, Magri V.

Antimicrobial therapy for chronic bacterial prostatitis.

Cochrane Database Syst Rev. 2013 Aug 12. CD009071.

View/Access

14. Anothaisintawee T, Attia J, Nickel JC, et al.

Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis.

JAMA. 2011 Jan 5. 305(1):78-86.

View/Access

Urological Infections

European Association of Urology

EAU Guidelines. Edn. presented at the EAU Annual Congress Barcelona 2019. 

G. Bonkat (Chair), R.R. Bartoletti, F. Bruyère, T. Cai, S.E. Geerlings, B. Köves, S. Schubert, F. Wagenlehner

View/Access

Ireland notes.png

The following are available in Ireland :

ciprofloxacin (Cifloxager, Cifox, Ciplox, Ciprofloxacin Teva, Ciproxin, Profloxin, Truoxin)

levofloxacin (Tavanic)

ofloxacin (Biravid,Tarivid)

moxifloxacin (Avelox)

azithromycin (Azithromycin clonmel, Azyter, Zithromax)

tetracycline (Lycimor, Tetralysal)

nitrofurantoin (Macrobid, Macrodantin)

cephalexin (Keflex)

trimethoprim-sulfamethoxazole (Septrin)

tamsulosin (Omnelex, Tamnaxyl XL, Tamnic, Tamsu)

alfuzosin (Alfu, Tevax, Xatger, Xatral)

doxazosin (Cardura, Carsem XL, Doxacar, Doxane XL, Doxatan, Raporsin)

terazosin (Hytrin)

silodosin (Urorec)

The following are N/A available Ireland :

nalidixic acid 

 

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