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.
