- 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) 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; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen
- System(s) affected: genitourinary, renal, reproductive
- 2 million cases annually in the United States, Bimodal: 20 to 40 and >60 years old
- Chronic is more common after the age of 50 years.
- Bacterial prostatitis more frequent in HIV
- 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)
- Etiology 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 bacteria (Staphylococcus aureus, Streptococcus, and Enterococcus species)
- 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 class I
- Often as 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.
- Urinary tract infections (including sexually transmitted infections [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 hypertrophy
- Unprotected sexual intercourse
- Prostate cancer
- Antibiotic prophylaxis for genitourinary instrumentation and prostatic biopsy
- Increased physical activity associated with reduced risk for CP/CPPS
Commonly Associated Conditions
- Benign prostatic hypertrophy, cystitis, urethritis
- Sexual dysfunction (erectile dysfunction, premature ejaculation)
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