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
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.