PROSTATITIS
Jason R. Ouellette, M.D.
WEEK 10: 03/07 – 03/11/05
Learning Objectives:
1. Participants will be able to recognize the clinical features of prostatitis and understand when to suspect the diagnosis.
2. Participants will be able to understand the differences between acute and chronic prostatitis.
3. Participants will be able to understand the role of prostatic massage in making the diagnosis of prostatitis.
4. Participants will be able to appropriately treat patients with prostatitis.
CASE ONE:
P.P. Dribble is a 61-year-old man who is seen in your office complaining of fever, chills, and dysuria. He also notes increased frequency and a feeling of incomplete urination. His past medical history is significant for COPD and mild HTN. His medications include amlodipine 5mg qd and an albuterol/ipratropium mdi.
Physical Exam: T=100.7 BP=149/87 HR=62
HEENT- unremarkable
Lungs- clear bilaterally
Abdomen- normal bowel sounds, soft, nontender, nondistended
Rectal- brown, heme-negative stool; prostate is of normal size, symmetric and tender to palpation
Questions:
1. What additional history would be helpful to obtain in this patient and why?
Additional questions should be directed at differentiating urethritis, acute bacterial prostatitis, and sexually transmitted diseases. These should include questions about sexual activity, urethral discharge, urinary obstruction, painful ejaculation, low back or perineal pain. Residents should also ask about duration of symptoms and history of previous episodes, treatments, etc.
2. What are the typical symptoms and physical exam findings in acute bacterial prostatitis?
Symptoms of acute bacterial prostatitis include symptoms of urinary obstruction, dysuria, dribbling, frequency, fever, myalgias, decreased libido or impotence, painful ejaculation, low-back or perineal pain. Usually, the patient will have a prostate that is tender to palpation.
3. What laboratory data would you order in this patient and how would this be obtained?
Initial laboratory data should include a urinalysis. A urinalysis demonstrating pyuria would support the diagnosis. A urine culture should also be sent. CBC and blood cultures should be obtained on a case-by-case basis depending on whether or not they may change therapy (e.g. if urine gram stain revealed Staph or urine culture grew Staph aureus, blood cultures to rule out bacteremia with Staph aureus and possible seeding of the urine, would be appropriate). Participants should also discuss the utility of the pre- and post-prostatic massage test as described in the article. This diagnostic technique has never been appropriately tested to assess its usefulness in the diagnosis or treatment of prostatic disease and has little role in the diagnosis of acute prostatitis.
4. What is your treatment plan for this patient and why?
Acute bacterial prostatitis should be treated with an appropriate course of antibiotic therapy. The causitive organisms are primarily gram-negative bacteria, most commonly E.coli, but also including Klebsiella, Proteus, Pseudomonas and Enterococci. Typical regimens include TMP/Sulfa or Quinolones, but any antibiotic that covers the above organisms is appropriate. Men at risk for STDs should be tested for Chlamydia as a cause of urethritis, which can be difficult to differentiate clinically from prostatitis. If positive, patients should be treated and educated appropriately. Antibiotics should be continued for 3-4 weeks. These patients are commonly treated with an inappropriately short course.
CASE TWO:
The patient returns three months later with frequency and possibly some low-grade fevers. Upon questioning, he states that he responded well to his previous antibiotic therapy, which he completed, and had been asymptomatic until a few weeks ago when he started to note frequency, again, and malaise. He has no other complaints. He is currently afebrile and physical exam is unchanged from the previous visit, although his prostate is much less tender on digital rectal exam.
5. What are you now concerned about in this patient and why?
Recurrent symptoms of UTIs in men should raise one’s suspicion for chronic prostatitis. Many patients are asymptomatic between episodes. Often the prostate is normal on digital rectal exam. Other possibilities include a new episode of acute prostatitis or cystitis. Chronic nonbacterial prostatitis/chronic pelvic pain syndrome should also be discussed.
6. What is your diagnostic and treatment plan for this patient?
There should be further discussion regarding acute vs. chronic prostatitis. Patients with chronic prostatitis typically have the same strain of pathogenic bacteria in the prostatic fluid and urine. Other discussion should include the possibility of prostatic hypertrophy and whether or not the patient should be referred to a urologist. Note: PSA will be elevated in the setting of prostatitis and does not necessarily indicate prostatic hypertrophy. Long-term antibiotic therapy is required for these patients, often 6-12 weeks. Rarely, there is a role for transurethral prostatectomy.
References:
1. Stevermer, J. and Easley, S. Treatment of prostatitis. American Family Physician. 2000; 61:3015-3022