INTRODUCTION
In 1999 the Journal of Urology aptly summed the knowledge and frustration over prostatitis in one sentence. "Chronic abacterial prostatitis is a syndrome characterized by pelvic pain and voiding symptoms, which is poorly defined, poorly understood, poorly treated and bothersome."
The busy practicing physician needs a logical and rapid workup and treatment approach to this confusing and often debilitating problem.
THE GREAT DEBATE:
ETIOLOGY
The current classification of prostatitis is based on the unpublished findings of an NIH consensus conference convened in 1995. This updated version over the classic by Drach et al has been suggested to include the symptomatic patient without a clear etiology. See Table A
Table A (1, 2)
NIH Consensus Classification
1. Type I - Acute Bacterial Prostatitis
2. Type II - Chronic Bacterial Prostatitis
3. Type III - Chronic Non-Bacterial Prostatitis
a. Type III a - With Leukocytes In EPS or Vb3
b. Type III b - Without Leukocytes In EPS or Vb3
4. Type IV - Asymptomatic Inflammatory Prostatitis
THINK TWICE
Think of prostatitis as two diseases.
First, think of it as an infectious urinary tract disease. This is the classic. It is the set of symptoms; fever chills, dysuria, frequency and a tender prostate (3, 4) which most clinicians think of first, although it only accounts for 5-10% of prostatitis. This is TYPE I & II
Second think of it as episodic, waxing and waning occurrences of pelvic pain (most commonly in the perineum) and voiding symptoms.(5) Voiding symptoms are more commonly irritative, such as penile pain, mild dysuria and urgency rather then obstructive (weak stream, difficulty starting, etc). Sexual impairment is common although potency is rarely an issue. Pain with ejaculation and erection may cause secondary sexual dysfunction such as delayed ejaculation, anejaculation or erectile dysfunction.
This category, TYPE III a & b, is by far the most common (90-95%) and the most confusing for both diagnosis and treatment.
WORKUP
Get a complete history. Consider using the new NIH Chronic Prostatitis Index (1)(see form) and the AUA Prostate Symptom Index Form (6)(see form). Dig for long forgotten episodes of STD, NSU or unexplained bladder/UTI infections. TYPE I & II are rarely a diagnostic mystery. TYPE III requires being more sensitive to fluctuating pelvic and bladder symptoms.
For all men, get a mid stream urine for complete analysis and for culture. Exclude STD's with the more accurate DNA probes for GC and Chlamydia. Make a clinical assessment for how constitutionally ill or toxic your patient may be. Use this as a guide when doing the prostate exam. Avoid massage with an attempt to get EPS for examination in this individual.
ACUTE AND CHRONIC PROSTATITIS
TYPE I & II
Midstream urine is usually infected in both I & II. Most common organisms are gram negative rods with E-Coli being the most common. Treat empirically and allow culture and sensitivity to guide you.
Trimethoprim-sulfa, fluroquinalones and tetracyclines are the common broad spectrum antibiotics used today Length of treatment can be confusing. The primary care clinician should keep in mind that the treatment should be longer then the common cystitis/UTI seen in the office. Recurrence could be associated with inadequate treatment. Two weeks is probably the minimum and rarely is there a necessity to go beyond one month.
Type II, chronic bacterial prostatitis is probably the rarest presentation of prostatitis. Keep this in mind when your patient is asking for his third, fourth or fifth round of antibiotics.
At best the response rate for antibiotic therapy is 80 %( 21). Relapses after six months are common. Bacterial eradication frequently does not eliminate all symptoms. In acute or chronic bacterial prostatitis, antibiotic prophylaxis may be necessary. Although recommended and done for decades, the effectiveness of adjunctive prostatitic massage remains unclear. It is likely that ejaculation is as or more effective then massage.
CHRONIC NON BACTERIAL PROSTATITIS - TYPE III
(CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME)
TYPE III is widely acknowledged as the most common prostatitis presentation. According to Collins et al 1998 it accounts for over two million office visits per year.
SYMPTOMS
This is a disease of younger men with a mean age of 43. The most common symptom is PAIN or DISCOMFORT in the pelvic or perineum lasting for 2 or more months. The periodic nature of TYPE III is important to keep in mind. Frequently the irritative symptoms of urination may be so mild that they are disregarded until they increase in frequency or severity such that they interfere with daily activities or disrupt sleep.(1)
Persistent penile shaft ache, especially distal penile or glans pain, vague pelvic discomfort after ejaculation or frank pain with erection and ejaculation are common. Secondary sexual dysfunction can be dramatic, severe and frightening to your patient. Younger men may avoid being sexual because of pain or begin to prematurely lose erections or have trouble ejaculating.(1, 7, 8)
EVALUATION
Because the etiology of chronic pelvic pain syndrome is unknown and treatment is symptomatic, the only purpose of the evaluation is to exclude a treatable cause of symptoms. Localization cultures and evaluation of EPS is important. For cultures to be valid a patient must be off all antibiotic therapy for at least 2 weeks. (See focus on localization- The Meares-Stamey VB method.) (9)
Identify all organisms. Forget about the 100,000 colonies per ml rule. Colony counts 100 fold higher in EPS or VB 3 are said to be diagnostic of a bacterial infection as the etiology.(11) On examination the prostate may be tender or more frequently the patient may experience pelvic discomfort after your examination. The prostate does not need to be swollen or "soft" to the examining finger.
PSA testing can be both helpful and confusing. If you are relatively sure of your diagnosis I would strongly suggest not measuring PSA. If there is any uncertainty, an elevated PSA can help make the diagnosis. An elevated PSA, it must be followed to make sure it goes down, if it does not your patient must be evaluated for prostate cancer. Prostatitis does not increase the incidence of prostate cancer, but they can coexist.(10)
TREATMENT
Before initial therapy, make time and talk to your patient. If there was ever a need to help your patient understand a disease which is not well understood, it is when your patient presents with prostatitis. Expectations are of paramount importance. Helping your patient understand the chronic nature of this problem and reassuring him that you will be available to educate and treat him is as import as the medications you use. Thirty to fifty percent of patients with chronic prostatitis may suffer depression.(12) It is important to make this diagnosis if present and treat it if necessary.
INITIAL THERAPY
ANTIBIOTICS
Even though etiology may be unclear an initial trial of an antibiotic is suggested. There may be as much as a 50% response.(13,14,15,20) Duration of therapy is unclear. Extended, 4-12 weeks courses of antibiotics have been suggested. The antibiotics of choice are fluroquinolones and sulfamethoxazol/trimethoprim. A promising therapeutic option is clarithromycin.
ALPHA BLOCKERS
If antibiotics fail, alpha blockade may also be used as a second line therapy. There is an approximate 50% response to alpha blockade not related to a 1 or a 2 selectivity. Therefore, it is reasonable to try the less expensive Prazosin or Terazosin first. Tamulazosin may be of value because it causes less postural hypotension.(16,17)
ANTI-INFLAMMATORY MEDICATIONS
NSAID are another second line therapy.(19) Efficacy is unclear. There has been some recent interest in the use of COX 2 inhibitors in the treatment of Type III prostatitis.(13) In theory it should be more effective in III a (Leukocytes in the EPS), however in a small Viox study it was more effective in III b.
ANTICHOLENERGIC MEDICATIONS
A low dose of anticholenergic medications such as oxybutinin or tolteridine may be helpful if trycyclic antidepressant medications are not used.(19)
PERSISTANT SYMPTOMS
If symptoms persist after the use of antibiotics, alpha blockers and NSAID's focus on and treat specific symptoms.
PAIN
Tricyclic antidepressants are a good choice for pain control because their anticholinergic activity may also help reduce frequency, nocturia and urgency. Side effects include sexual dysfunction, sedation, dry mouth and constipation. Common tricyclic antidepressants used for pain are Amitriptyline, Nortriptyline and Imipramine. Generally start at low doses and titrate up.
Neurontin, now commonly used in pain management may be employed at dosages up to 3600mg per day divided into 3 doses. Caution your patient to the potential sexual dysfunction side effects of this drug.
Leskinen in 1999 reported a significant drop in Prostatitis symptoms and pain on Finasteride given 5mg per day for one year. Finasteride requires a long trial to determine its effectiveness.(22) Six months is the minimum amount of time your patient should be on this medication before you decide to discontinue it.
While narcotic pain medications can be useful the chronic nature of this problem makes dependence is a real possibility.
Recent unstudied Physical therapy use of Pelvic Floor Muscular relaxation exercises and myofascial release of trigger points has gained positive anecdotal reports.(18) This effect should not be thought unusual when one considers a randomized trial in 1985 by Simmons which compared the effectiveness of Minocycline to Diazepam. The study found 60% improvement with minocycline vs. 75% with diazepam. This nondrug therapy also has the added value of active involvement of the patient. The treatment is benign and potentially effective.
URINARY SYMPTOMS
If your patient has persistent urinary symptoms after initial therapy, a urological consultation is indicated. Urodynamic studies as well as cystoscopy may be necessary to difine the problem and rule out more serious conditions such as carcinoma in situ of the bladder. Keep in mind that although less frequent in men Interstitial Cystitis may be a comorbid problem significantly complicating symptom relief.
MISCELLANEOUS
Although there is little supporting data, conservative measures must be reviewed with the patient. Relaxation exercises, anxiety and depression control through cognitive and muscle relaxation techniques are important to mention. Dietary measures such as restriction of caffeine, spicy foods and alcohol may be helpful. Finally a stern prohibition of smoking or any other form of nicotine abuse is also important.(19)
Various urological treatments such as intravesical DMSO and microwave thermotherapy are not in the scope of this article.
CONCLUSION
Prostatitis is likely to be confusing and frustrating for both the patient and provider. Acknowledge the psychological impact of this disease on your patient's life as you would any other chronic disease and treat anxiety and depression as necessary.
Time spent on patient education may help you avoid the endless us of antibiotics. Be familiar with as many potential treatments as possible to offer and help your patient.
More often then not prostatitis will present as symptoms of pelvic discomfort and voiding symptoms. Do not miss the diagnosis because classic signs of infection are not present.
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6. AUA developed the International Prostate Symptom Score
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13. Nickel JC, Gittleman M, Malek G, Moon T, Murdock M, Tomera K, Pontari M et al. Rofecoxib in the treatment of chronic nonbacterial prostatitis: A phase II randomized placebo controlled study. Abstract presented at the 3rd International Prostatitis Collaborative Network, Washington, DC, Oct 23-25, 2000, p25.
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