Prostatitis

Definition/diagnostic criteria Prostatitis encompasses a group of conditions affecting the prostate gland, presenting as an array of urinary and pain symptoms. It is categorised into acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis presents with sudden onset of symptoms, while chronic prostatitis has a prolonged and often fluctuating course.

Epidemiology Prostatitis is a common condition, affecting men of all ages but more prevalent in those under 50. Acute bacterial prostatitis is less common but constitutes a medical emergency. Chronic prostatitis/chronic pelvic pain syndrome is the most prevalent form, though its exact incidence is uncertain due to underdiagnosis.

Diagnosis
Clinical features: Acute bacterial prostatitis presents with severe lower urinary tract symptoms, perineal pain, fever, and occasionally urinary retention. Chronic prostatitis may manifest as recurrent urinary tract infections, persistent pain in the pelvis, genitals, or lower back, and sexual dysfunction.

Investigations: Diagnosis is primarily clinical. Urine dipstick and culture help identify urinary tract infections. For chronic prostatitis, the National Institute for Health and Care Excellence (NICE) recommends a trial of antibiotic therapy if bacterial infection is suspected, with a subsequent reassessment. Prostate-specific antigen (PSA) may be elevated, especially in acute cases. Ultrasound can be useful if abscess formation is suspected.

Treatment

• Acute bacterial prostatitis: requires immediate empirical antibiotic therapy, typically with a fluoroquinolone or trimethoprim for 14 days. Severe cases may necessitate hospital admission and intravenous antibiotics.
• Chronic bacterial prostatitis: a four to six weeks course of antibiotics (trimethoprim or doxycycline) is recommended. Alpha-blockers can be considered if voiding symptoms are predominant.
• Chronic prostatitis/chronic pelvic pain syndrome: Management is more complex and may include a combination of alpha-blockers, pain management, and pelvic floor physiotherapy. Psychological support may be beneficial due to the chronic nature of the disease and its impact on quality of life.

Prognosis The prognosis for acute bacterial prostatitis is generally good with prompt treatment, though it can recur. Chronic bacterial prostatitis has a variable course and may require prolonged treatment. Chronic prostatitis/chronic pelvic pain syndrome is challenging to treat with a variable prognosis, and symptoms can persist for many years, necessitating a multidisciplinary approach to management.