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2002 guideline for the management of prostatitis(USA)

2002 national guideline for the management of prostatitis

RECOMMENDATIONS

 

MAJOR RECOMMENDATIONS

Levels of evidence (I-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

Diagnosis of Acute Prostatitis

  • Mid-stream urine sample for dipstick testing, culture for bacteria, and antibiotic sensitivity
  • Blood cultures for bacteria and antibiotic sensitivity
  • Prostatic massage should not be performed on patients with acute bacterial prostatitis. This would be extremely painful, could precipitate bacteraemia, and is likely to be of little benefit as pathogens are almost always isolated from urine

Management of Acute Prostatitis

General advice

Adequate hydration should be maintained, rest encouraged, and analgesics such as non-steroidal anti-inflammatory drugs used.

Treatment

  • As acute prostatitis is a serious and severe illness, empirical therapy should be started immediately.
  • Parenteral or oral treatment should be selected according to the clinical condition of the patient. If there is deterioration or failure to respond to oral therapy, urgent admission and parenteral therapy should be arranged.
  • Good antibiotic penetration into all areas of the prostate gland is achieved because of the intense inflammation.
  • Antibiotics should be continued or changed according to sensitivity results.
  • If acute retention occurs, suprapubic catheterisation should be performed to avoid damage to the prostate (Luzzi, 1996; Meares, 1987).

Recommended regimens

For patients requiring parenteral therapy, antibiotics covering the likely organisms should be used (Katoh et al., 1992):

  • A high dose broad spectrum cephalosporin--for example, cefuroxime, cefotaxime, or ceftriaxone plus gentamicin (Level of Evidence IV, Grade of Recommendation C)
  • When clinically improved, the therapy can be switched to oral treatment according to sensitivities.

For patients suitable for oral therapy, quinolones can be used: (Arakawda et al., 1994; Andriole, 1991)

  • Ciprofloxacin 500 mg twice daily for 28 days (Level of Evidence IV, Grade of Recommendation C) (Andriole, 1991; Naber, 1991)

    OR

  • Ofloxacin 200 mg twice daily for 28 days (Level of Evidence IV, Grade of Recommendation C) (Suzuki et al., 1984; Remy et al., 1988)

Allergy

For patients intolerant of, or allergic to, quinolones, an alternative is:

  • Co-trimoxazole (TMP-SMX) 960 mg twice daily for 28 days (Meares, 1987)
    OR
  • Trimethoprim 200 mg twice daily for 28 days (Level of Evidence IV, Grade of Recommendation C)

Sexual partners

Treatment of sexual partners is not required as the condition is caused by uropathogens.

Follow-up

  • If the patient fails to respond fully to therapy the diagnosis of a prostatic abscess should be considered (Meares, 1986). This can be confirmed by transrectal ultrasound scan or computed tomography scan of the prostate gland. If present, perineal or transurethral drainage will be necessary (Meares, 1987).
  • If acute prostatitis is managed correctly, the prognosis is good and cure likely. At least 4 weeks of antibiotic therapy is recommended in all patients to try to prevent chronic bacterial prostatitis (Meares, 1987).
  • When the patient has recovered, his urinary tract should be investigated to exclude a structural cause for urinary tract infection (Luzzi, 1996).

Diagnosis of Chronic Prostatitis

Strictly, symptoms should have been present for at least 6 months to diagnose chronic prostatitis although in practice the diagnosis is made after a shorter duration of symptoms.

Non-specific genital infection can cause many of the same symptoms and this diagnosis should be considered and excluded.

The investigation of chronic prostatitis which has been the standard for evidence based research is the lower urinary tract localisation procedure (Meares & Stamey, 1968). Although time consuming, this is the most accurate method for differentiating chronic bacterial prostatitis, chronic abacterial prostatitis/chronic pelvic pain syndrome-inflammatory, and chronic abacterial prostatitis/chronic pelvic pain syndrome-non-inflammatory (Nickel, 1998; Drach et al., 1978).

Some authors argue that the lower urinary tract localisation procedure should be confined to research (Berger et al., 1989). It is useful in diagnosing chronic bacterial prostatitis but it is often not used in clinical practice and may not alter patient management (McNaughton Collins et al., 2000).

When the patient attends for prostatic massage:

  • No antibiotics should have been taken for 1 month (Bergman, Wedren, & Holm, 1989)
  • The patient should not have ejaculated for 2 days
  • The patient should have a full but not distended bladder (Luzzi, 1996; Jameson, 1967)

Prostatic massage should not be performed if there is evidence of urethritis or urinary tract infection. If either of these is present they should first be treated to prevent prostatic secretion contamination (Thin, 1997; Simmons & Thin, 1983; Nickel, 1996).

Prostatic massage

  • The foreskin should be fully retracted and the penis well cleaned to prevent contamination.
  • A 5 to 10 mL sample of first void urethral urine should be collected.
  • The patient should urinate a further 100 to 200 mL urine and then a further 5 to 10 mL sample of mid-stream bladder urine should be collected.
  • By digital rectal examination a vigorous massage of the prostate gland should be performed for 1 minute, from periphery towards the midline with a sterile container held over the glans to collect any expressed prostatic secretions.
  • A wet preparation microscopic examination of a sample of expressed prostatic secretions should be made to determine the number of polymorphonuclear leucocytes per high power field (x 400) (Bergman, Wedren, & Holm, 1989; Simmons & Thin, 1983).
  • Immediately after the massage another 5 to 10 mL post-massage urine should be collected.
  • All three urine samples should have microscopy and quantitative culture.

A dry prostatic massage is reasonably common.

Other possible investigations

  • The presence of clumps of polymorphonuclear leucocytes (5+) and oval fat bodies (macrophages containing fat droplets) can be noted on wet preparation examination (Oates, 1969; Thin, 1991).
  • The pH of expressed prostatic secretions increases with prostatitis and a pH greater than or equal to 8 indicates likely prostatitis, but this should only be used in conjunction with the other tests detailed above (Thin, 1991).
  • Transrectal ultrasound in chronic prostatitis may identify those who have cysts or abscesses suitable for aspiration and are likely to experience relief of symptoms (Thin, 1997). Transrectal ultrasound should not be used to differentiate the different forms of chronic prostatitis (Ludwig et al., 1994).
  • A serum prostate-specific antigen should be measured in men over 45 years (Luzzi, 1996), although it will probably be above normal in men with prostatic inflammation (Nadler et al., 1995).

Interpretation of results

  • To assign an organism to the prostate, the colony count in the expressed prostatic secretions and post-massage urine is required to be at least 10 times greater than in first void urethral urine and mid-stream bladder urine.
  • For prostatic inflammation >10 polymorphonuclear leucocytes/high power field (hpf) is considered diagnostic (Wright et al., 1994; Doble, 1994; Anderson & Weller, 1979; Weidner, 1992). In cases of a dry expressate a polymorphonuclear leucocyte count of 10/hpf greater in post-massage urine than first void urethral urine and mid-stream bladder urine is diagnostic of prostatitis.
  • If there is significant bacteriuria in both mid-stream bladder urine and post-massage urine 3 days of nitrofurantoin 50 mg four times daily, which is not prostate penetrating, should be given and the procedure then repeated.
  • An expressed prostatic secretion pH >8 suggests prostatitis although it is not diagnostic.
  • Clumping of polymorphonuclear leucocytes and presence of lipid laden macrophages suggests prostatitis, although this is not diagnostic.

Management and Treatment of Chronic Prostatitis

General advice

Patients should be given a detailed explanation of their condition with particular emphasis on the long-term implications for their health. This should be reinforced by giving them clear and accurate written information.

Treatment for chronic bacterial prostatitis

Many antimicrobials penetrate the prostate gland poorly. In chronic bacterial prostatitis the gland is either subacutely inflamed or non-inflamed.

Treatment should be chosen according to antimicrobial sensitivities.

Recommended regimens

For patients with chronic bacterial prostatitis, first line treatment is with a quinolone such as (Andriole, 1991; Naber, 1991):

  • Ciprofloxacin 500 mg twice daily for 28 days (Level of Evidence III, Grade of Recommendation B) (Weidner, Schiefer, & Dalhoff, 1987; Childs, 1987; Weidner, Schiefer, & Brahler, 1991)

    OR

  • Ofloxacin 200 mg twice daily for 28 days (Level of Evidence III, Grade of Recommendation B) (Remy et al., 1988; Koff, 1996)

    OR

  • Norfloxacin 400 mg twice daily for 28 days (Level of Evidence III, Grade of Recommendation B) (Sabbaj, Hoagland, & Cook, 1986; Schaeffer & Darras, 1990)

Allergy

For those allergic to quinolones, the following is recommended:

  • Minocycline 100 mg twice daily for 28 days (Paulson & White, 1978) (Level of Evidence III, Grade of Recommendation B) (In practice most experts would use doxycycline 100 mg twice daily for 28 days because of more toxicity with minocycline.)

    OR

  • Trimethoprim 200 mg twice daily for 28 days

    OR

  • Co-trimoxazole (TMP-SMX) 960 mg twice daily for 28 days (Level of Evidence III, Grade of Recommendation B) (Naber, 1991).

If minocycline is used, antibiotic sensitivity testing is essential as many urinary pathogens are tetracycline resistant. Many studies using trimethoprim or co-trimoxazole have used 90 days treatment (Naber, 1991).

Some studies have looked at longer treatment periods of 90 days or more (Andriole, 1991; Naber, 1991; Childs, 1987; Paulson & White, 1978; Milingos et al., 1983) but there is no evidence that this is superior to 28 days.

It is difficult to make evidence based recommendations about treatment because most studies have small patient numbers, are non-comparative, define chronic bacterial prostatitis in different ways, have no placebo group, use different doses of the drug studied for different lengths of time, use different treatment outcomes and have different periods of follow-up. These recommendations are based on the studies available plus expert opinion.

Prostatic calculi have been suggested as a source for recurrent infection (Meares, 1987). They are extremely common radiographically (Ludwig et al., 1994; Peeling & Griffiths, 1984). Radical transurethral prostatectomy or total prostatectomy is effective in some patients if they are selected carefully (Barnes, Hadley, & O'Donoghue, 1982; Smart, Jenkins, & Lloyd, 1975).

Treatment for chronic abacterial prostatitis/chronic pelvic pain syndrome

There are no universally effective treatments for chronic abacterial prostatitis/chronic pelvic pain syndrome. The lack of knowledge of the etiology of these conditions means that no specific recommendations can be made and treatment choice is usually trial and error. There is currently a systematic review of therapies for chronic abacterial prostatitis/chronic pelvic pain syndrome taking place (McNaughton Collins, MacDonald, & Wilt, 2000).

Despite negative cultures most clinicians try antibiotics initially to cover occult infection. This may be effective in a number of patients (Brunner, Weidner, & Schiefer, 1993; Colleen & Mardh, 1975; Bergman, Wedren, & Holm, 1989; Thin & Simmons, 1983; Pavone-Macaluso, Di Trapani, & Pavone, 1991; Simmons & Thin, 1985) although this does not mean that the problem was genuinely infective. Treat as for chronic bacterial prostatitis with a quinolone or tetracycline.

Other treatments include:

  • Transurethral microwave thermotherapy [(chronic abacterial prostatitis/chronic pelvic pain syndrome-inflammatory) (Level of Evidence Ib, Grade of Recommendation A)] (Nickel & Sorensen, 1996)
  • Alpha Blockers:
    • Terazosin 2 to 10 mg for 28 days. The dose should be increased gradually according to symptomatic response (chronic abacterial prostatitis/chronic pelvic pain syndrome-inflammatory and non-inflammatory) (Level of Evidence Ib, Grade of Recommendation A) (Neal & Moon, 1994; Lacquaniti et al., 1999).
    • Alfuzosin 2.5 mg three times daily for 42 days in patients with confirmed urodynamic abnormalities (Level of Evidence Ib, Grade of Recommendation A) (De la Rosette et al., 1992).
  • Non-steroidal anti-inflammatory drugs (chronic abacterial prostatitis/chronic pelvic pain syndrome-inflammatory). No specific non-steroidal anti-inflammatory drug can be recommended as the evidence base uses a drug not licensed in the United Kingdom (Level of Evidence III, Grade of Recommendation B) (Canale et al., 1993).
  • Cernilton (pollen extract) probably acts as an anti-inflammatory. One tablet three times daily for 6 months (chronic abacterial prostatitis/chronic pelvic pain syndrome) (Level of Evidence III, Grade of Recommendation B) (Buck, Rees, & Ebeling, 1989; Rugendorf et al., 1993).
  • The bioflavonoid, quercetin 500 mg twice daily for 28 days (chronic abacterial prostatitis/chronic pelvic pain syndrome-inflammatory and non-inflammatory) (Level of Evidence Ib, Grade of Recommendation A) (Shoskes et al., 1999).
  • Stress management (Miller, 1988). No specific therapy has been tested or advocated although referral for psychological assessment may be appropriate in some (Level of Evidence IV, Grade of Recommendation C). Diazepam 5 mg twice daily for 90 days has produced symptomatic benefit (Thin & Simmons, 1983) although benzodiazepines are not recommended in clinical practice because of dependency.
  • The role of allopurinol (chronic abacterial prostatitis/chronic pelvic pain syndrome) remains controversial (Persson, Rondquist, & Ekblon, 1996; Nickel, Siemens, & Lundie, 1996). A Cochrane Systematic Review, published in 1999, recommended that further studies are needed (McNaughton Collins & Wilt, 1999).

Sexual partners

Partner notification and empirical treatment is not required unless a specific sexually transmitted pathogen is found at initial screening. Management should be according to the guidelines for that specific infection.

Follow-up

Chronic prostatitis is a difficult to manage; relapsing conditions and patients are typically followed up for long periods of time. No specific follow-up recommendations can be made. The U.S. National Institutes of Health has produced a chronic prostatitis symptom index which can be used as a robust outcome measure (Litwin et al., 1999).

Definitions:

The following rating scheme was used for major management recommendations.

Levels of Evidence:

Ia

  • Evidence obtained from meta-analysis of randomised controlled trials

Ib

  • Evidence obtained from at least one randomised controlled trial

IIa

  • Evidence obtained from at least one well designed controlled study without randomisation

IIb

  • Evidence obtained from at least one other type of well designed quasi-experimental study

III

  • Evidence obtained from well designed non-experimental descriptive studies such as comparative studies, correlation studies, and case control studies

IV

  • Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Grading of Recommendations:

A (Evidence Levels Ia, Ib)

  • Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.

B (Evidence Levels IIa, IIb, III)

  • Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.

C (Evidence Level IV)

  • Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities.
  • Indicates absence of directly applicable studies of good quality.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

 

REFERENCES SUPPORTING THE RECOMMENDATIONS

 

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is graded and identified for select recommendations (see "Major Recommendations").

IDENTIFYING INFORMATION AND AVAILABILITY

 

BIBLIOGRAPHIC SOURCE(S)

  • Association for Genitourinary Medicine (AGUM), Medical Society for the Study of Venereal Disease (MSSVD). 2002 national guideline for the management of prostatitis. London: Association for Genitourinary Medicine (AGUM), Medical Society for the Study of Venereal Disease (MSSVD); 2002. Various p. [93 references]

 

ADAPTATION

Not applicable: The guideline was not adapted from another source.

 

DATE RELEASED

1999 Aug (revised 2002)

 

GUIDELINE DEVELOPER(S)

British Association of Sexual Health and HIV - Medical Specialty Society

 

SOURCE(S) OF FUNDING

Not stated

 

GUIDELINE COMMITTEE

Clinical Effectiveness Group (CEG)

 

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Authors: Paul Walker; Janet Wilson

Clinical Effectiveness Group (CEG) Members: Keith Radcliffe (Chairman); Imtyaz Ahmed-Jushuf; Jan Welch; Mark FitzGerald; Janet Wilson

 

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Conflicts of Interest: None

 

GUIDELINE STATUS

This is the current release of the guideline. This guideline updates a previously released version.

An update is not in progress at this time.

 

GUIDELINE AVAILABILITY

Electronic copies: Available in HTML format from the Association for Genitourinary Medicine (AGUM) Web site. Also available in Portable Document Format (PDF) from the Medical Society for the Study of Venereal Diseases (MSSVD) Web site.

 

AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

  • UK national guidelines on sexually transmitted infections and closely related conditions. Introduction. Sex Transm Infect 1999 Aug;75(Suppl 1):S2-3.

Electronic copies: Available in Portable Document Format (PDF) from the Medical Society for the Study of Venereal Diseases (MSSVD) Web site.

The following is also available:

  • Revised UK national guidelines on sexually transmitted infections and closely related conditions 2002. Sex Transm Infect 2002;78:81-2

Print copies: For further information, please contact the journal publisher, BMJ Publishing Group.

 

PATIENT RESOURCES

None available

 

NGC STATUS

This summary was completed by ECRI on December 8, 2000. The information was verified by the guideline developer on January 12, 2001. This summary was updated on June 24, 2002.

 

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developers and/or BMJ Publishing Group's copyright restrictions. Reproduction and use of this guideline is permitted provided that (a) the original content is not changed or edited; and, (b) any content derived from the original guideline is acknowledged as that of the author(s) and responsible organizations.

Readers wishing to download and reproduce material for purposes other than personal study or education should contact BMJPG to seek permission first. Contact: BMJ Publishing Group, BMA House, Tavistock Square, WC1H 9JR, UK.

 

 

-------------------

About NGC

The National Guideline Clearinghouse꽓 (NGC꽓) is a comprehensive database of evidence-based clinical practice guidelines and related documents. NGC is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. NGC was originally created by AHRQ in partnership with the American Medical Association and the American Association of Health Plans (now America's Health Insurance Plans [AHIP]).

The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.

 

 

 
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