Prostatitis

Prostatitis (Pic. 1) is inflammation of the prostate gland. In men who are younger than 50 years of age, prostatitis is the most common problem related to the urinary tract. 

Prostatitis has been classified by International Prostatitis Collaboration Network, into 5 subtypes. This classification is on the basis of timing of the symptoms and the presence of bacterial pathogens and other markers of infection and inflammation. 

The categories include 

•    acute bacterial prostatitis,
•    chronic bacterial prostatitis,
•    inflammatory chronic prostatitis/chronic pelvic pain syndrome,
•    non-inflammatory chronic prostatitis/chronic pelvic pain syndrome,
•    and asymptomatic inflammatory prostatitis.

The most common form of prostatitis is chronic prostatitis/chronic pelvic pain syndrome.

The pathogenesis of prostatitis is not completely understood. An infection ascending from the urethra, chemical damage caused by the reflux of urine through the ejaculatory ducts and prostatic ducts and autoimmune involvement are a few possible theories related to the pathogenesis of various types of prostatitis. The most common bacteria causing prostatitis are aerobic gram-negative bacilli, Escherichia coli is responsible for 50-80% incidents of bacterial prostatitis.

Prostatitis must be differentiated from various causes of dysuria including pyelonephritis, cystitis, urethritis, benign prostatic hyperplasia, prostatic abscess, bladder cancer, urinary tract stones, and a foreign body within the urinary tract.

Recurrent urinary tract infections, benign prostatic hyperplasia, urethral strictures, bladder neck hypertrophy, prostatic carcinoma, and catheterization are risk factors for prostatitis.

Acute prostatitis usually results in complete recovery without sequelae. If left untreated, patients with acute bacterial prostatitis may progress to develop chronic prostatitis, epididymitis, prostatic abscess, septicemia, urosepsis, urinary retention and metastasis of infection to spinal cord or sacroiliac joint. Patients with untreated chronic prostatitis may develop chronic pelvic pain, sexual dysfunction, infertility and recurrent urinary tract infections.Frequency, urgency, burning during urination, nocturia, urinary retention and pain in the genital area, groin, lower abdomen, or lower back may be the presenting features. Other features include fever, nausea, and vomiting in acute infection.

Laboratory findings show an increase in the number of leukocytes on CBC, bacteria on urine culture, elevated C-reactive protein, and transiently elevated PSA (prostate specific antigen) levels in case of bacterial prostatitis. While in chronic bacterial prostatitis negative pre-massage urine culture results, more than 10 to 20 leukocytes per high-power field in both the pre and the post massage urine specimen, bacteriuria in the postmassage urine specimen, and lower leukocyte and bacterial counts in voided bladder urine specimens as compared to bacterial count in post-prostatic massage voided urine or expressed prostatic secretions are seen. The absence of bacterial growth on cultures is diagnostic of chronic nonbacterial prostatitis.

Antimicrobial therapy is indicated for acute and chronic prostatitis.

Symptoms

• testicular pain
• penile pain
• dysuria
• arthralgia
• myalgia
• unexplained fatigue
• abdominal pain
• post- ejaculatory pain
• low libido
• sexual dysfunction
• erectile difficulties
• fever
  

Associated diseases

• hypothalamic pituitary adrenal axis dysfunction
• adrenocortical hormone abnormalities
• neurogenic inflammation
• myofacial pain syndrome
• chronic fatigue syndrome
• irritable bowel syndrome
• premature ejaculation
  

Complications

Common complications of prostatitis include:

• urinary retention
• sepsis
• prostatic abscess
• BPH
• prostatic cancer
• pelvic pain
• metastatic infections such as pyogenic vertebral osteomyelitis
• erectile dysfunction
• infertility
  

Risk factors

• transrectal ultrasonography guided biopsy of the prostate
• lower urinary tract due to surgery or trauma leading to nerve damage
• pelvic surgery
• previous instrumentation or catheterization
• alcohol
• smoking
• immobility
• prolonged urine holding
• decreased fluid intake
  

Prevention

For prevention is good to avoid coffee, spicy or acidic food and alcohol. To ease pressure on the prostate you should sit on a pillow and avoid long bicycling.

The fertility of a couple may be impaired if the man has a chronic bacterial prostatitis. Chronic prostatitis is presumed to be caused by a pathogenic organism and in most cases is associated with leukocytes in the semen. The prevalence of leukocytospermia among male infertility patients is about 10% to 20%. Although the exact role of WBCs in semen and its importance with respect to fertility is not clearly elucidated, there is some evidence that treating such patients with long term antibiotics does have a favourable impact on the semen parameters. According to a study the presence in semen of counts more than 10,000 colony-forming units/ml had a negative effect on IVF pregnancy rates when E. coli, Proteus, or S. aureus organisms were isolated. Again, there is some evidence that the occurrence of leucocytes in semenyields abnormal sperm function tests, possibly because of the damaging effects of free radicles of WBCs to the sperms in their journey through the epididymis. There is also substantial evidence that infection contributes to the development of sperm antibodies. Sperm antibodies have been detected in 48% of men with culture-positive asymptomatic infections, 47% of men with a history of urethritis or prostatitis, and in only 5% of men with no infection and a normal semen analysis.

Prostatitis is considered a correctable cause of male infertility, butthe pathophysiology and appropriate treatment options of prostatitis in male infertility remain unclear. Patients with acute prostatitis usually recover completely, without a sequelae. Patients with chronic prostatitis gradually recover over time and with time, the rate of relapse is high, reaching up to 50%.