Description

• Painful or inflammatory condition affecting the prostate gland with or without bacterial etiology, often characterized by urogenital pain, voiding symptoms, and/or sexual dysfunction
• National Institutes of Health’s (NIH) classifications:
  • Class I: acute bacterial prostatitis: symptomatic with fever, perineal pain, dysuria, and obstructive symptoms; polymorphonuclear leukocytes (PMNL) and bacteria in urine
  • Class II: chronic bacterial prostatitis: symptomatic chronic or recurrent bacterial infection with pain and voiding disturbances; PMNL and bacteria in expressed prostatic secretions (EPS), or urine after prostate massage, or in semen
  • Class III: chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
    • Inflammatory (subtype IIIA): chronic symptoms with PMNL in EPS/urine after prostate massage or in semen
    • Noninflammatory (subtype IIIB): chronic symptoms without presence of PMNL in EPS/urine after prostate massage or in semen
  • Class IV: asymptomatic inflammatory prostatitis: incidental finding during prostate biopsy; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen
• System(s) affected: genitourinary, renal, reproductive

Epidemiology

Incidence

• 2 million cases annually in the United States, with bimodal distribution: 20 to 40 and >60 years old
• CD is more common after 50 years.
• Bacterial prostatitis is more frequent in HIV.

Prevalence

• Affects approximately 16%, up to 10% of those are acute bacterial prostatitis
• Accounts for 8% of visits to urologists and 1% of visits to primary care physicians

Etiology and Pathophysiology

• Acute bacterial prostatitis (NIH class I)
  • Most likely from ascending urethral infection with intraprostatic reflux of infected urine into prostatic ducts, often associated with cystitis
  • Can occur after instrumentation of prostate
  • Usually, gram-negative bacteria (Escherichia coli [most common]; Proteus, Klebsiella, Serratia, and Enterobacter species; Pseudomonas aeruginosa); Rarely, gram-positive (Staphylococcus aureus, Streptococcus, and Enterococcus spp.)
  • Staphylococcal prostatitis warrants evaluation for hematogenous spread (endovascular).
  • Atypical bacteria include Chlamydia trachomatis, Trichomonas vaginalis, Ureaplasma urealyticum, Mycobacterium tuberculosis and fungal etiologies in immunocompromised hosts.
  • Consider Neisseria gonorrhoeae or C. trachomatis in sexually active men aged <35 years.
• Chronic bacterial prostatitis (NIH class II)
  • Similar pathogens as NIH class I
  • Often recurrent episodes of same organism
  • Progression from acute to CP is poorly understood.
• CP/CPPS (NIH class III): most common
  • Unclear etiology
  • Inciting agent may cause inflammation or neurologic damage around the prostate and leads to pelvic floor neuromuscular and/or neuropathic pain.
  • No correlation between histologic inflammation of prostate and presence or absence of symptoms
  • Patients with chronic inflammation on histology have shorter time to symptomatic progression.

Risk Factors

• Urinary tract infections (including STIs)
• HIV infection
• Prostatic calculi
• Urethral stricture
• Urinary catheterization: indwelling and intermittent
• Genitourinary instrumentation: prostate biopsy (especially with prior quinolone intake), transurethral resection of the prostate (TURP), cystoscopy
• Urinary retention
• Benign prostatic hyperplasia
• Unprotected sexual intercourse
• Prostate cancer

General Prevention

• Antibiotic prophylaxis for genitourinary instrumentation and prostatic biopsy
• Increased physical activity associated with reduced risk for CP/CPPS

Commonly Associated Conditions

• Benign prostatic hyperplasia, cystitis, urethritis
• Sexual dysfunction (erectile dysfunction, premature ejaculation)