Chronic prostatitis

Chronic prostatitis is characterised by > 3 months of urogenital pain, often associated with LUTS or sexual dysfunction.

Chronic prostatitis may be categorised as:

• Chronic prostatitis/chronic pelvic pain syndrome: clinical features of chronic prostatitis in the absence of an identifiable bacterial infection.
• Chronic bacterial prostatitis: relatively uncommon, accounting for around 10% of patients with chronic prostatitis.

The aetiology of non-bacterial associated chronic prostatitis is poorly understood.

Chronic prostatitis/chronic pelvic pain syndrome

The aetiology remains poorly understood. Infective and inflammatory triggers may be implicated. There are suggestions that some may have a neuropathic component. 

Chronic bacterial prostatitis

This may develop following an episode of acute bacterial prostatitis or present more insidiously. The urinary tract is frequently implicated as the source of infection but it may also arise lymphogenous spread from the rectum or as part of systemic spread off an infection.

Those with underlying urinary tract abnormalities are at greater risk. Men with HIV are at risk of a greater breadth of infection. Rarely STI’s are the infective agent.

The NIDDK classification may be used to categorised prostatitis.

To understand this classification you need to known about the four glass (or two glass) test. 

• Voided bladder 1 (VB1): first 10ml of urine passed, represents urethra.
• Voided bladder 2 (VB2): second 10ml of urine passed, represents bladder.
• Expressed prostatic secretions (EPS): first 10ml of urine passed, represents urethra.
• Voided bladder 3 (VB3): first 10ml of urine passed, after EPS.

The two glass test, just involving EPS and VB3 is commonly used.

Features are those of > 3 months of urogenital pain, often associated with LUTS and sexual dysfunction.

Urogential pain

Pain may affect diffuse and poorly localised. It is often described in the perineum but may also be in the external genitalia, back, lower abdomen or rectal.

Urinary symptoms

• Hesitancy 
• Dysuria
• Frequency

Sexual dysfunction 

• Pain on ejaculation
• Erectile dysfunction
• Premature ejaculation

The majority of investigations are aimed at identifying any underlying bacterial infection.

• Urine dipstick and MSU
• Expressed prostatic secretions
• Consider Semen MC+S
• STI screen (including blood borne viruses) 
• Consider PSA (may be elevated in prostatitis or malignancy)

Consider need for urological investigation to identify potential underlying structural abnormalities.

Management is dependent on the underlying cause.

Chronic bacterial prostatitis

Patients should be referred for urology review. Antibiotic course may be given dependent on the suspected organism. Courses of fluoroquinolone (e.g. ciprofloxacin) or doxycycline may be used. Length of antibiotics courses vary, discussion with microbiology can help guide management.

Analgesia and stool softeners may offer symptomatic relief. 

In rare and select cases surgical intervention may be indicated, typically in the form of a transurethral resection of the prostate (TURP) to remove an infective nidus.

Chronic prostatitis/chronic pelvic pain syndrome

Analgesia, beginning with paracetamol should be offered. NSAIDs may be given taking into consideration co-morbidities and age as well as the need for PPI cover. 

Referral to pain team specialist may be needed, particularly if neuropathic pain is considered. Stool softeners may offer some relief.

In those where concern over infection exists, consider antibiotics as discussed above. Where concern exists, symptoms are severe or persistent, or the diagnosis is uncertain refer to urology.

Alpha-blockers (e.g. Tamsulosin) may be trialled if significant LUTS are present.