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- Painful or inflammatory condition affecting the prostate gland with or without bacterial etiology, often characterized by urogenital pain, voiding symptoms, and/or sexual dysfunction
- Significant impact on quality of life
- <10% bacteria-proven infection
- National Institutes of Health’s classification
- 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 for infertility, cancer workup; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen
- System(s) affected: genitourinary, renal, reproductive
- Two million cases annually in the United States
- Predominant age: 30 to 50 years old, sexually active; chronic is more common in those >50 years.
- Bacterial prostatitis occurs more frequently in patients with HIV.
- Affects approximately 8.2% of males
- Lifetime probability of diagnosis >25%
- Accounts for 8% of visits to urologists and 1% of visits to primary care physicians
- Percentage of cases by class: class I: <1%, class II: 5–10%, class III: 80–90%, class IV: 10%
Etiology and Pathophysiology
- Acute bacterial prostatitis (class I)
- Likely, etiology 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 bacteria (Staphylococcus aureus, Streptococcus, and Enterococcus species)
- Confirmed staphylococcal prostatitis should warrant evaluation for hematogenous spread, including endovascular source.
- Atypical bacteria include Chlamydia trachomatis, Trichomonas vaginalis, and Ureaplasma urealyticum.
- Consider Neisseria gonorrhoeae or C. trachomatis in sexually active men <35 years.
- Chronic bacterial prostatitis (class II)
- Similar pathogens as discussed earlier
- Often occurs as recurrent episodes of infection by same organism
- Progression from acute to chronic prostatitis is poorly understood but could result from inadequate treatment of acute prostatitis.
- CP/CPPS (class III)
- Unclear etiology, possibly due to difficult-to-culture infection but noninfectious etiology also proposed
- Inciting agent may cause inflammation or neurologic damage in or 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.
- Urinary tract infections
- HIV infection
- Prostatic calculi
- Urethral stricture
- Urinary catheterization: indwelling, intermittent
- Genitourinary instrumentation, including prostate biopsy (especially in patients with prior quinolone intake), transurethral resection of prostate, cystoscopy
- Urinary retention
- Benign prostatic hypertrophy
- Unprotected sexual intercourse
- Trauma (e.g., bicycle, horseback riding)
Antibiotic prophylaxis for genitourinary instrumentation and prostatic biopsy
Commonly Associated Conditions
- Benign prostatic hypertrophy
- Sexual dysfunction, including erectile dysfunction and premature ejaculation