Inflammatory Conditions of the Male GU Tract Campbell’s Ch. 9

1. 0 Inflammatory Conditions of the Male GU TractCampbell’s Ch. 9 Christi Hughart, D.O.

2. 0 Prostatitis • Historical Tx- prostate massage antimicrobials. • MC urologic Dx in men <50 yrs, 3rd MC in men >50 yrs (BPH, prostate cancer)= 8% male urologic visits. • 4-16% (average 9%) lifetime incidence. • Pain waxes and wanes- 1/3 to ½ experience relief in 1 yr period. • 20% of men with BPH have prostatitis-like symptoms. • Pathologist definition- increased # inflamatory cells within prostatic parenchyma (seen in 44% of autopsie specimens)- lymphocytic infiltrate in stroma adjacent to prostatic acini (scattered or nodules).

3. 0 Prostatitis Continued • Corpora amylacea- deposition of prostatic secretions around an irritant can lead to prostatitis. • Prostatic calcifications can obstruct central prostate ducts and lead to prostatitis. • Granulomatous prostatitis- abundant histiocytes/lymphocytes/plasma cells- form granulomas- common consequence of Sx or BCG therapy, rare consequence of systemic TB.

4. 0 Prostatitis Etiology • Microbiologic causes- • Gram - uropathogens (Enterobacter- MC E coli in 65-80%- GI origin)- acute- associated UTI and sepsis, chronic- recurrent UTIs with bacteria residing in prostate gland. • 10-15%- Pseudomonas, Serratia, Klebsiella, Enterobacter aerogenes. • Gram + - 5-10% Enterococci (commensal organisms in anterior urethra) • Coag – staph- Staph saprophyticus, hemolytic strep, Staph aureus. • ? Cause vs just colonization (eradication  good outcome). • Anaerobes- unknown role. • Corynebacterium- ID with PCR of prostatic secretions- ½ respond to antimicrobials.

5. 0 Prostatitis Etiology Continued • Chlamydia- found in 20-30% of men with chronic prostatitis vs 3% without vs other studies that do not show this relationship- ? • Ureaplasma- ? • Candida/aspergillosis/coccidiomycosis- ? • Viruses- ? • Trichomonas-? • Nonculturable Microorganisms- 60% with previously treated prostatitis with sterile expressed prostatic secretions were found to have positive cultures on prostate biopsy- biofilms in ducts/acini. • Altered Prostatic Host Defense- intraprostatic ductal reflux, specific blood groups, phimosis, unprotected rectal intercourse, UTIs, epididymitis, indwelling catheters, condom catheter, transurethral Sx if urine not sterile, altered prostatic secretory function. (alkaline pH hampers antimicrobial penetration).

6. 0 Prostatitis Etiology Continued • Dysfunctional Voiding- anatomic or neurophysiologic obstruction- decreased flow rates/obstructive patterns, vesicourethral dyssynergic patterns, 60% with bladder neck hypertrophy (reflux or chronic neuropathic pain). • Intraprostatic Duct Reflux- urine and bacteria. • Immunologic Alterations- IgG/IgA/PSA elevated- PSA returns to normal after 6 wks of Tx, IgG several months, IgA 2 yrs. May be an autoimmune disease- IL-10, IL-1 beta, TNF alpha. Chronic pelvic pain syndrome. • Chemically Induced- noxious substances in urine that have refluxed into prostatic duct. • Neural Dysregulation/Pelvic Floor Musculature Abnormalities- pelvic muscular attachment points- myofascial trigger points; pudendal nerve entrapments.

7. 0 Prostatitis Etiology Continued • Interstitial Cystitis-Like-possible cause of pain. • Psychological- depression and psychological disturbances common.

8. 0 Prostatitis Traditional Classification • Meares-Stamey four-glass test- segmental assessment of inflammation/cultures of lower tract: • Acute bacterial- clinically purulent, systemic signs of infection, bacteria cultured from fluid. • Chronic bacterial- bacteria in fluid but no concomitant UTI or systemic signs. • Nonbacterial- no signif bacteria on culture but fluid microscopic purulence. • Prostatodynia- pain but no bacteria or purulence.

9. 0 Prostatitis- NIH Classification • Category I- acute bacterial. • Category II- chronic bacterial. • Category III- GU pain without bacteria: • A- Inflammatory chronic pelvic pain- excess leukocytes. • B- noninflammatory chronic pelvic pain- prostodynia. • Category IV- asymptomatic inflammatory.

10. 0 Category I • Acute onset pain/irritative or obstructive voiding symptoms/febrile • Frequency/urgency/dysuria • Perineal/suprapubic/genital pain • 5% progress to chronic

11. 0 Category II • History of documented recurrent UTIs (25-43%). • May be asymptomatic between episodes. • Bacteriuria in 4.4%.

12. 0 Category III • Perineal/suprapubic/penile/scrotal/inguinal/low back pain. • Pain during/after ejaculation. • Irritative/obstructive voiding symptoms. • Chronic= >3 months.

13. 0 Category IV • Asymptomatic • Presents with BPH, elevated PSA, prostate ca, infertility • See inflammation on BPH chips, cancer specimens, prostate bx’s.

14. 0 Symptom Assessment • NIH-CPSI- useful research and clinical tool.

15. 0 Lower Urinary Tract Evaluation • Physical exam- rule out perineal/anal/ neurologic/pelvic/prostate abnormalities • Prostate on DRE- hot, boggy, exquisitely tender. • Expression of prostatic fluid unnecessary/ harmful. • Category II/III- unremarkable except pain- do DRE after prostatic massage specimens obtained (before prostatic massage- check carefully for discrete nodules). • Category I- urine culture only: • VB1 (voided bladder)- first 10 mL (urethral). • VB2- bladder urine. • VB3- first 10 mL after prostatic massage (prostatic urethra). • Three specimens are spun for 5 minutes and examined micriscopically.

16. 0 Diagnosis • Category II- 10 x’s increase in bacteria on EPS or VB3 compared to VB1 or 2. • Categroy IIIA- no bacteria are cultured but >5-10 WBC per high powered field in EPS or VB3. • Category IIIB- no bacteria/no leukocytosis in EPS or VB3. • 4 glass test remains gold standard but mostly abandoned. • 2 glass test- effective- pre-prostatic massage specimen and post-prostatic massage specimen. • +/- semen analysis (increases percentage of patients ID’d as Cat IIIA). • +/- urine cytology.

17. 0 Diagnosis • Urodynamics- detrusor vesical neck or external sphincter dyssynergia, prox/distal urethral obstruction, fibrosis/hypertrophy of vesical neck- • 50%- nonrelaxing perineal floor. • 36%- bladder hyperreflexia/normal sphincter relaxation. • Elevated urethral pressures. • Hyperreflexia of external sphincter. • Intraprostatic reflux. • 54%- primary vesical neck obstruction. • 24%- membranous urethral pseudodyssynergia. • 17%- impaired bladder contractility. • 5%- acontractile bladder. • 49%- detrusor instability.

18. 0 Diagnosis • Endoscopy- only if history indicates need- hematuria, urodynamics suggest other dx; or if refractory to standard therapy. • Transrectal ultrasound- (no proven utility) inhomogenous echo structures, constant dilation of periprostatic venous plexus, elongated seminal vesicles, thickened inner septa, prostatic calculi- can however dx medical prostatic cysts, prostatic abscesses, obstructed seminal vesicles. • Prostate biopsy- not a contraindication to biopsy. Only used for cultures in research scenario. • Immunologic assay- chronic abacterial prostatitis- no antibodies to gr neg bateria, bacterial- antibodies present. • Endotoxin levels- high in bacterial prostatitis.

19. 0 Evaluation • Mandatory: • History. • Physical- DRE. • UA/C&S. • Recommended: • Lower urinary tract localization. • Symptom inventory/index. • Flow rate. • PVR. • Urine cytology. • Optional: • Semen analysis/culture. • Urethral swab for culture. • Pressure flow studies. • Video urodynamics. • Cystoscopy. • Transrectal u/s. • Pelvic imaging. • PSA.

20. 0 Medical Therapy • Antimicrobial: 2-4 weeks • Initial therapy (parenteral)- penicillin (amp) and aminoglycoside (gent), 2nd/3rd gen ceph, FQ. • Followed by po FQ or Bactrim. • C. trachomatis- macrolides (erythromycin, azithromycin, clarithromycin). • 3 ways antibiotics benefit patient- placebo, eradication/suppression of noncultured organisms, anti-inflamatory effects. • Do not treat previously treated men of long duration.

21. 0 Medical Therapy • Alpha-Adrenergic Blockers: • Have luts- due to poor relaxation of bladder neck during voiding- reflux of urine into prostatic ducts causing intraprostatic inflammation. • Anti-Inflammatory and Immune Modulators: • Decrease dysuria, strangury, painful ejaculation. • Not proven by prospective trials. • Muscle Relaxants: • Assumes prostatitis is reflection of smooth/skeletal neuromuscular dysregulatory phenomenon in perineum/pelvic floor. • Not proven. • Allopurinol: • Intraprostatic ductal reflux of urine increases concentration of metabolites containing purine and pyrimidine bases in prostatic ducts causing inflammation.

22. 0 Medical Therapy • Hormone Therapy: • Anti-androgens (5 alpha-reductase inhibitors)- regression of prostatic glandular tissue, improved voiding, reduced intraprostatic ductal reflux- not recommended unless patient has BPH. • ? Estrogen.

23. 0 Medical Therapy • Phytotherapeutics: • Cernilton- bee pollen extract • Serenoa repens- saw palmetto berry extract. • Randomized controlled trials need to be performed.

24. 0 Medical Therapy Summary • Marked benefit: none. • Moderate benefit: alpha-blockers. • Modest benefit: anti-inflammatory, phytotherapies.

25. 0 Physical Therapy • Prostate Massage: • drains occluded prostatic ducts, improves circulation, increased antibiotic penetration. • 2-3 times per week for 4-6 weeks with antibiotic therapy. • Frequent Ejaculation. • Biofeedback: repetitive perineal muscle spasm. • Accupuncture. • Psychological Support. • Pudendal Nerve Entrapment Therapy: • Between sacrotuberous and sacrospinous ligaments (canal of Alcock) or falciform process of sacrotuberous ligament. • Pudendal nerve block or surgical neurolysis. • Perineal/Pelvic Floor Massage and Myofacial Trigger Point Release: • Can be related to mechanical abnormality in hip/lower extremities, chronic urinary holding patterns, sex abuse, repeat trauma, constipation, unusual sexual activity, recurrent infections/sx, stress.

26. 0 Minimally Invasive Therapy • Balloon dilation. • ? TUNA (transurethral needle ablation), YAG laser. • Microwave Hyperthermia (TUMT) and Thermotherapy- accelerates process of fibrosis or scar formation in area of chronic inflammation- shortens natural resolution time, heat alters afferent nerve fibers that convey objective symptom of pain, kills nonculturable or cryptic bacteria- do only in refractory or end-stage disease.

27. 0 Surgery • Transurethral Incision of prostatic abscess. • Transperineal incision and drainage- when abscess has penetrated beyond prostatic capsule or penetrating thru levator ani muscle. • Percutaneous drainage. • Tx of urethral strictures. • Endoscopic incision of bladder neck.

28. Related Conditions • Seminal Vesiculitis- • Secondary to prostatitis or epididymitis. • Can present as abscess. • Dx- ejaculate culure, seminal vesiculography, CT, TRUS, Cipro radioisotope scan. • Tx- antib, transrectal aspiration, open or l/s vesiculectomy.

29. Related Conditions • Orchitis- • Acute- pain/swelling/inflammation. • Chronic- pain/inflammation, no swelling- >6 wks. • Chronic orchialgia. • Non-bacterial- hematogenous, mc b/l- viral- mumps, mono; parasitic- filariasis; rickettsial. • Most due to ipsilateral epididymitis- E. coli, Pseudomonas, Staph, Strep. • Boys/elderly- UTI. • Young male- STD- gonorrhea, Chlamydia, Treponema pallidum. • Non-infectious- trauma, autoimmune, idiopathic. • Mycobacterium- TB > leprosy. • Fungal. • Dx- Physical exam- febrile, toxic, erythema, edema, tenderness- should assess for prostatitis/urethritis.UA C&S, urethral swab if young, ultrasound if diagnosis unclear (r/o malignancy if chronic, r/o torsion if young). • Tx- • Acute-bed rest, scrotal support, hydration, antipyretics, anti-inflammatory, analgesics, antibiotics (empiric- FQ). Abscess- perc or open drainage. • Chronic- anti-inflammatory, analgesics, scrotal support, heat, nerve blocks; refractory pain- orchiectomy.

30. Related Conditions • Epididymitis- • Acute- pain/swelling/inflammation. • Chronic- pain/infammation, no swelling. (>6 wks). • Acute bacterial- UTI/STD. • Nonbacterial/infectious- viral/fungal/parasitic. • Non-infectious- idiopathic/trauma/autoimmune/amiodarone/Bechet’s disease/chronic epididymitis. • Chronic epididymalgia. • Cause- spread of infection from bladder/urethra/prostate via ejaculatory ducts/vas to epididymis (starts at tail). • Infants/boys- UTI/congenital anomalies/foreskin. • Elderly- BPH, UTI, catheterization. • Young- STD: • Female partner- gonorrhea, chlamydia. • Male partner- E. coli, H. flu.

31. Related Conditions • Dx- localized pain, painful/swollen spermatic cord. • Gram stain urethral swab (intracellular gr neg diplococci- gonorrhea, WBCs- chlamydia), midstream urine. • Infant/young boy- abd/pelvic u/s, VCUG, cysto. +/- testicular u/s. • Tx- 4-6 weeks antibiotics, anti-inflam, analgesics, support, nerve block. Epididymectomy- when conservative measures fail (50% of the time- cures pain).