Prostatitis CKS | A4 Medicine

1. Prostatitis CKS | A4 Medicine a4medicine.co.uk

2. Prostatitis CKS describes a combination of infectious diseases
 ( acute or bacterial prostatitis ) chronic pelvic pain syndrome and asymptomatic inflammation 
( Krieger et al 2008 ) Prevalence is high , comparable to rates of IHD and diabetes Third most important condition of the prostate AAFP reports prevalence of 8.2 % ( range from 2.2 to 9.7 % ) Rosebud et al quote a prevalence of 5 % to 9 % among unselected men in the community The lifetime probability of a man being diagnosed as prostatitis exceeds 25 % and prostatitis accounts for about ~ 25 % of men seeking medical attention for genitourinary complaints. a4medicine.co.uk

3. Type 1 or Acute bacterial prostatitis acute infection of the prostate / urinary tract infection can be medical emergency with severe symptoms , systemic upset true incidence is not known but it is estimated that this may constitute about10 % of all cases of prostatitis. Type II Chronic bacterial prostatitis persistent bacterial infection of the prostate gland causing recurrent UTI’s caused by the same strain of bacteria duration > 3 months. Type IIIChronic prostatitis/chronic pelvic pain syndrome most common subtype no identifiable infection further subdivided into
○ Type A : inflammatory CPS previously known as chronic non bacterial prostatitis○ Type B non inflammatory CPS previously called prostatodynia Type IV asymptomatic inflammatory prostatitis no symptoms but documented inflammation in prostatic tissue abnormal semen analysis , elevated PSA or incidental finding of prostatitis on examination of a biopsy specimen a4medicine.co.uk

4. What causes prostatitis is a matter of ongoing debate Multiple etiologies both infectious & non-infectious Some cases clearly infectious Majority of cases have no evidence of genitourinary infection and the cause is usually not known Risk factors include
○ genetic, behavioral and environmental factors
○ inflammatory mediators
○ urinary tract instrumentation
○ men with chronic indwelling catheters
○ diabetes
○ cirrhosis
○ a h/o sexually transmitted infections
○ having a urethral stricture Acute bacterial prostatitis –Acute prostatitis is used interchangeably with acute acute bacterial prostatitis ( ABP ) in literature NICE in its draft for consultation ( May 2018 ) mentions that
○ acute prostatitis is a bacterial infection of the prostate needing treatment with antibiotics
○ usually caused by bacteria which enter the prostate from the urinary tract
○ ABP can happen spontaneously or after medical procedures as prostate biopsy 
○ it can last for several weeks
○ complications include urinary retention & prostatic abscess ABP can be a life threatening event – requires prompt recognition and treatment. a4medicine.co.uk

5. First choice -Ciprofloxacin 500 mg bd X 14 days Ofloxacin 200 mg bd x 14 days Alternative 1st choice -Trimethoprim 200 mg bd x 14 days Second choice -Following discussion with specialist
 Levofloxacin 500 mg od x 14 days Co-trimoxazole 960 mg bd x 14 days. Fluoroquinolones – consider restrictions and precautions as per MHRA advice
○ rare reports of disabling & potentially long-lasting irreversible SEs of musculoskeletal and nervous systems
○ advice to stop at 1st sign of serious adverse reaction such as tendonitis
○ prescribe with special caution in over 60s
○ avoid co-administration with a corticosteroid
 Co-trimoxazole – only use if there is bacteriological evidence of sensitivity & good reasons to prefer this combination. Review if symptoms worsen and consider
○ alternative diagnoses
○ complications as acute urinary retention , prostatic abscess or sepsis
○ antibiotic resistance
 Following 2 week antibiotic use
○ stop or continue for additional 14 days if needed based on history , symptoms , clinical examination , urine and blood tests. Chronic bacterial prostatitis -Symptoms persist > 3 months CBP – most common presentation is recurrent urinary tract infection from the same organism Rees et al report that the pain is a predominant symptom of both CBP and CP/ CPPS with the four main symptoms domains of CBP & Cp/ CPPS being
○ urogenital pain (perineal , inguinal , suprapubic , scrotum , testis , penile tip , lower back , rectum )
○ lower urinary tract symptoms ( LUTS )
○ psychological issues
○ sexual dysfunction CBP can be a complication of ABP in about 5 % of men About 10 % of CP have a bacterial cause. a4medicine.co.uk

6. Cause -ascending urethral infection lymphogenous spread of rectal bacteria hematogenous spread of bacteria from a remote source undertreated acute bacterial prostatitis recurrent UTI with prostatic reflux. Pathogens -similar to ABP E Coli responsible for majority of cases other identified pathogens include Chlamydia trachomatis , Ureaplasma species , Trichomonas vaginalis and Mycobacterium tuberculosis. Diagnosis -Can be challenging as history and examination can be highly variable. Meares-Stamey ( 1968 ) four glass test- finds mention in most papers as being gold standard but nor rarely used Urinalysis Expressed prostatic secretions culture Semen culture Further testing based on clinical suspicion for e.g PSA , STI screen , cystometric studies. Treatment -can be difficult includes trial of antibiotics , alpha adrenergic agents for refractory cases options tried include
○ alternative agents as fosfomycin
○ direct antimicrobial injections into the prostate
○ surgical removal of infected prostate tissue
 ○ chronic oral antibiotic suppression
○ novel therapies as utilizing bacteriophages to target antibiotic resistant bacteria. Complex condition of largely unknown cause – usually diagnosis of exclusion. a4medicine.co.uk