Prostatitis and Prostatic Abscess Dr Khoo Say Chuan Department of Urology Hospital Selayang

Prostatitis and Prostatic Abscess
Dr Khoo Say Chuan
Department of Urology
Hospital Selayang
Introduction
• Most common urological diagnosis in men <
50 yrs and 3rd most common urologic
diagnosis in men >50 yrs after BPH and PCa
• Incidence 10-30 %
• Affect men of all ages
Definition
• Prostatitis is an infection or inflammation of
the prostate gland that presents as several
syndromes which have different causes,
clinical features and therapeutic strategy in
managing the syndromes
NIDDK Categorization and Criteria for
the Prostatitis Syndromes
• Category 1 : Acute bacterial Prostatitis
acute symptomatic bacterial infection
LUTS
associated with profound SIR
• Category 2 : Chronic bacterial Prostatitis
Hx recurrent UTI
Meares-Stamey 4 glass test vs 2 glass test
NIDDK Categorization and Criteria for
the Prostatitis Syndromes
• Category 3 : CPPS (Chronic abacterial
prostatitis)
IIIA : inflammatory type
WBC in EPS/VB3
Culture negative
IIIB : non inflammatory type
no WBC in EPS/VB3
NIDDK Categorization and Criteria for
the Prostatitis Syndromes
• Category 4 : Asymptomatic inflammatory
Prostatits (Histological Prostatitis)
incidental detection on Bx or prostatic fluid
examination
treatment not warranted
Acute Bacterial Prostatitis
• Eetiology
KEEPS: Klebsiella, E. coli (80%), Enterococci,
Pseudomonas, Proteus, S. Fecalis
ascending urethral infection and reflux into
prostatic ducts
invasion of rectal bacteria
most infections occur in the peripheral zone
medical procedures
Acute Bacterial Prostatitis
• Clinical features
rectal, low back and perineal pain
urinary irritative symptoms
systemic symptoms: myalgia, arthralgia, fevers,
chills
hematuria
Acute Bacterial Prostatitis
• Diagnosis
rectal exam
enlarged, tender, warm prostate
prostatic massage is not recommended due to extreme
tenderness and risk of inducing sepsis, abscess or
epididymo-orchitis
urine C&S
blood C&S
Acute Bacterial Prostatitis
• Treatment
PO antibiotics
treat for 4-6 wks to prevent complications
supportive measures (antipyretics, analgesics,
stool softeners)
admission criteria: sepsis, urinary retention,
immunodeficiency
IV antibiotics; VB2 urine C&S 1 and 3 months
post-antibiotic therapy to R/O chronic prostatitis
Chronic Bacterial Prostatitis
• Diagnosis
split urines for C&S to determine site of infection;
collect 4 specimens (Meares-Stamey 4 glass test)
colony
colony counts in expressed prostatic secretions
(EPS) and VB3 should exceed those of VB1 and
VB2 by 10-fold
Alternative : 2 cups test
Technique and interpretation of the Meares-Stamey four-glass lower urinary tract
localization test for chronic prostatitis / CPPS
(CAT, category; EPS, expressed prostatic secretion; VB, voided bladder; WBC, white blood cell)
*If culture positive, consider repeating after a short course of antibiotic
Four Glass Urine Test
• Introduced in 1968 by Meares & Stamey
• Is the most accurate (gold standard) test for differentiating between
chronic bacterial prostatitis, inflammatory types of chronic
nonbacterial prostatitis and non-inflammatory types of chronic
nonbacterial prostatitis (prostatodynia)
• When the patient attends for prostatic massage:
No antibiotics should have been taken for 1 month
No evidence of urethritis or urinary tract infection is presence
The patient should not have ejaculated for 2 days
The patient should have a full but not distended bladder
Chronic Bacterial Prostatitis
Treatment
prolonged course of antibiotics (3-4 months)
fluoroquinolones, TMP; addition of an α-blocker
reduces symptoms
Chronic Bacterial Prostatitis – Options
of Treatment
• Medical Therapy
Antimicrobials Therapy
Alpha Blockers
Anti-Inflammatory
Phytotherapeutic Agents
Hormonal Therapy
Muscle Relaxants
• Minimally Invasive Therapy
Balloon Dilatation
Transurethral Needle
Ablation (TUNA) of prostate
Microwave Hyperthermia &
Thermotherapy
• Surgery
• Physical Therapy
Prostatic Massage
Trigger Point Release
Biofeedback
Chronic Pelvic Pain Syndrome CPPS
Pain lasting > 3/12
inflammatory type previously called nonbacterial prostatitis
noninflammatory type previously called prostatodynia
most common of the prostatic syndromes and most poorly
understood
• Chlamydia, Ureaplasma and Mycoplasma may be culprits
• autoimmune inflammatory reaction ± intraprostatic reflux of urine ±
urethral hypertonia
• similar symptoms as chronic bacterial prostatitis
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• Treatment
trial of antibiotic therapy
fluoroquinolone or doxycycline if chlamydia is suspected
α-adrenergic blocker (e.g. prazosin) to relieve sphincter spasms and
symptoms
NSAIDs may provide symptomatic relief
Chronic Pelvic Pain Syndrome CPPS
• Antibiotics therapy may benefits Class III
(CPPS) chronic prostatitis patients by 3
different mechanisms:
A strong placebo effect
The eradication or suppression of non-cultured
microorganisms
Independent anti-inflammatory effect of some
antibiotics
Asymptomatic inflammatory Prostatits
• This type of prostatitis is not included in the Traditional
Classification of Prostatitis
• By definition patient is asymptomatic
• Patient usually present for investigation or
management of infertility, BPH, elevated PSA or
prostate cancer
• Subsequent microscopy of EPS or semen, histologic
examination of BPH chips, prostate biopsy or prostate
cancer specimens disclose evidence of prostatic
inflammation +/- infection
• By definition not require treatment for the prostatitis
Prostatic Abscess
Introduction
• Rare due to antibiotic treatment and decrease
incidence of gonoccocal infections
• Preantibiotic era : N Gonorrhoea (75%)
• Antibiotic era : gram –ve (60-80%)
• Common in DM, immune compromised,
chronic catheters
Introduction
• Complications of acute bacterial prostatitis
that were inadequately or inappropriately
treated
• Retrograde flow of contaminated urine
• Recent biopsy or instrumentation of lower
tract
• Hematogeneous spread
Introduction
• Differential diagnosis btw acute bacterial
prostatitis and prostatic abscess difficult
• High mortality rate
• Severe complication, urosepsis
• DRE : tender, fluactuant
Management
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Imaging : TRUS or pelvic CT
antibiotic and drainage
Transrectal drainage
TUR if transrectal drainage inadequate
Management
• TRUS drainage vs TUR
• TUR :
TUR shorter hospital stay
less recurrence
more invasive, GA, surgical complications
• TRUS :
less invasive, LA, sedation
placement of drainage tube