Prostatitis

In both acute and chronic prostatitis the seminal vesicles and posterior urethra are usually also involved.

Acute prostatitis

A etiology

Acute prostatitis is common, but underdiagnosed. The usual organism responsible is Escherichia coli, but Staphylococcus aureus and albus, Streptococcal faecalis and Neisseria gonorrhoea may be responsible. The infection may be haematogenous from a distant focus or it may be secondary to acute urinary infection.

Clinical features

General manifestations overshadow the local: the patient feels ill, shivers, may have a rigor, has ‘aches’ all over, especially in the back, and may easily be diagnosed as having influenza. The temperature may be up to 390C. Pain on micturition is usual, but not invariable. The urine contains threads in the initial voided sample which should be cultured. Perineal heaviness, rectal irritation and pain on defecation can occur; a urethral discharge is rare. Frequency occurs when the infection involves the bladder. Rectal examination reveals a tender prostate, one lobe may be swollen more than the other and the seminal vesicles may be involved. A frankly fluctuant abscess is uncommon.

Treatment

Treatment must be rigorous and prolonged or the infection will not be eradicated and recurrent attacks may ensue. Spread of infection to the epididymes and testes may occur. Prolonged treatment with an antibiotic which penetrates the prostate well is indicated (trimethoprim or ciprofloxacin).

Prostatic abscess

In addition to the foregoing symptoms and signs, the advent of a prostatic abscess is heralded by the temperature rising steeply with rigors. Antibiotics disguise these features. Severe, unremitting perineal and rectal pain with occasional tenesmus often cause the condition to be confused with an anorectal abscess. Nevertheless, if a rectal examination is performed, the prostate will be felt to be enlarged, hot, extremely tender and perhaps fluctuant. Retention of urine is likely to occur and in such men suprapubic catheterization is best.

Treatment. The abscess should be drained without delay.

1.  The abscess can be drained by perurethral resection —un-roofing the whole cavity.

2.       The perineal route is rarely indicated unless there is marked periprostatic spread.

Chronic prostatitis

Many urologists find the syndromes of chronic prostatitis and ‘prostatodynia’ very difficult, for many men present with perigenital pain, testicular pain, prostatic pain exacerbated by sexual intercourse or pain which apparently renders sexual intercourse out of the question. Psychosexual dysfunction in such patients may be the underlying problem. The diagnosis of chronic prostatitis has to be based on:

  persistent threads in voided urine;

  prostatic massage showing pus cells with or without bacteria in the absence of urinary infection.

Aetiology

This is thought to be sequel of inadequately treated acute prostatitis. While pus is present in the prostatic secretion, often the responsible organism is difficult to find. Other

organisms such as Chlamydia species may be responsible for chronic abacterial prostatitis.

Clinical features

The clinical features are extremely varied. Only men with symptoms of posterior urethritis, prostatic pain and perigeni­tal pain accompanied by intermittent fever and pus cells or bacteria in the postprostatic massage specimen should be diagnosed as having chronic prostatitis.

Diagnosis

  1. The three-glass urine test is valuable. If the first glass with the initial voided sample shows urine containing prostatic threads, prostatitis is present.

2.  Rectal examination of the prostate may be normal or may show a soft, boggy and tender prostate.

3.    Examination of the prostatic fluid obtained by prostatic massage should show pus cells and bacteria.

4.    Urethroscopy may reveal inflammation of the prostatic urethra, and pus may be seen exuding from the prostatic ducts. The verumontanum is likely to be enlarged and oedematous. In many men with the symptoms described above all investigations are normal.

Treatment

Antibiotic therapy should only be administered in accordance with bacteriological sensitivity tests. Trimethoprim pene­trates well into the prostate. Where trichomonas or anaer­obes are the responsible agent, a rapid response is obtained from administration of flagyl (metronidazole, 200 mg t.d.s. for 7 days to both partners). If Chlamydia is suspected, doxycycline is the antibiotic treatment of choice. It is uncertain whether prostatic massage helps in eradicating the infection.

Prostatodynia

This diagnosis is made by the presence of perigenital pain in the absence of any objective evidence of prostatic inflammation. Whether the syn­drome has any relationship with the prostate is unclear.