Prostatitis

Introduction

Prostatitis is a painful inflammation of the prostate, usually accompanied by recent bacterial infection. It can be acute, meaning it has a sudden onset and is associated with recent lower urinary tract symptoms like dysuria, or painful urination. In contrast, chronic prostatitis is characterised by irritation lasting ≥3 months and recurrent urinary tract infections or UTIs.

Patient: Mr. John Smith

Age: 65

Sex: Male

Presenting Complaint:

Mr. Smith presents to the emergency department complaining of severe, tearing abdominal pain radiating to his lower back. He describes the pain as sudden in onset and progressively worsening over the past few hours. He denies any recent trauma but reports a history of hypertension and smoking for the past 30 years.

Clinical Assessment:

Upon examination, Mr. Smith appears pale and diaphoretic. His blood pressure is 160/100 mmHg, heart rate is 110 beats per minute, and respiratory rate is 22 breaths per minute. Abdominal examination reveals a pulsatile mass in the periumbilical region with tenderness on palpation. There are no signs of peritoneal irritation.

Diagnostic Workup:

Given the presentation suggestive of an abdominal aortic aneurysm, Mr. Smith undergoes urgent diagnostic imaging. A bedside ultrasound confirms the presence of a large abdominal aortic aneurysm measuring approximately 7 cm in diameter. Further imaging with a computed tomography (CT) scan of the abdomen confirms the diagnosis and provides detailed information about the extent and location of the aneurysm.

The pathogenesis of Prostatitis commonly involves the spreading bacteria from UTIs into the gland, with E.Coli causing 80% of cases.

In rare instances, prostatitis is a complication of sexually transmitted infections like gonorrhoea.

On the other hand, chronic prostatitis can be due to nonbacterial causes like chronic pelvic pain syndrome.

Finally, it’s important to note that acute infection following instrumentation from things like transrectal ultrasound-guided biopsy of the prostate is often associated with sepsis and multidrug-resistant infection.

For investigation, consider a structured approach including urine tests, bloods, and imaging.

Urine samples can allow for Urinalysis which can quickly screen for infection and a midstream urine culture to identify the pathogen.

Performing the ‘two glass test’ can diagnose patients with chronic prostatitis. This involves taking urine samples before and after a prostatic massage. This is diagnostic if there are more than 20 leucocytes per high powered field on the post-massage urine sample.

Don’t forget that prostatic massage should not be performed in acute bacterial prostatitis as it can induce bacteraemia and sepsis.

Blood tests should include blood cultures if patients are febrile as they are often show the same organism as the urine culture.

Imaging, including transrectal ultrasounds are only used in patients not responding to treatment and can identify prostatic abscesses that may require drainage.

To manage acute prostatitis, stratify patients into non-severe and severe.

Cases are considered non-severe if the patient does not have fever, systemic features, or sepsis.

Management should include empirical antibiotics, like trimethoprim or cefalexin and analgesia for pain management. Urine culture 48 hours post-treatment is useful when combined with a clinical review.

Cases are considered severe if the patient does have fever, systemic features, or sepsis.

Patients will probably require hospitalisation for close monitoring and empirical antibiotics intravenously which might include gentamicin and amoxicillin.

Finally, for chronic bacterial prostatitis, antibiotics are also indicated but until a pathogen is recognised, don’t repeat courses.

Empirical options might include quinolones like ciprofloxacin.

The main clinical features of the condition include symptoms associated with a UTI like dysuria, frequency, and urgency.

It can also cause systemic features like fever, chills and sweats.

Moreover, obstructive urinary symptoms can occur due to compression of the urethra like weak stream, dribbling, or urinary retention.

Finally, signs of local inflammation like pelvic pressure, perineal tenderness, and prostate irritation on digital rectal examination. Some patients also complain of pain in the penis or in the lower back.

One rare complication is a prostatic abscess which will make patients complain of severe perianal pain. Rectal examination might reveal a fluctuant area in the prostate.

Obstructed UPS worker usually get acute prostatitis. This tells me the four cardinal features of the acute disease are urinary obstruction, UTI features like increased frequency, pain, and systemic signs of infection like temperature.

On the other hand, the diagnosis of chronic prostatitis has a 3,2,1 rule.

It is defined as having irritation for more than 3 months, it can be investigated with the “two glass test” and if symptoms are not getting better, consider looking for 1 big abscess.

Obstruction

UTI

Pain

Systemic

3 months

2 glass test

1 big abscess