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 the systemic spread of an infection from a distant location.

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

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) classification may be used to categorise prostatitis.

To understand this classification you need to know about the four glass (or two glass) test. The four glass test involves:

• 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): the first 10ml of urine passed, represents urethra.
• Voided bladder 3 (VB3): the 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 is often diffuse and poorly localised. Many patients will describe pain in the perineum but it can also be in the external genitalia, back, lower abdomen or rectum.

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)

Clinicians must consider the need for urological investigations to identify underlying structural abnormalities that can predispose patients to prostatic infections.

Management is dependent on the underlying cause.

Chronic bacterial prostatitis

Patients should be referred for urology review. An antibiotic course is 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 can be prescribed and 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. Again stool softeners may offer some relief. Alpha-blockers (e.g. Tamsulosin) should be trialled if significant lower urinary tract symptoms are present.

A course of antibiotics is often given as infection can be difficult to conclusively exclude. Where concern exists, symptoms are severe or persistent, or the diagnosis is uncertain refer to urology.

Referral to Pain Team specialists is often needed, particularly if neuropathic pain is considered.