Prostataerkrankungen: Ursachen und Behandlung
Patient information: See related handout on prostatitis. Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and Diagnose der Prostatitis massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, Diagnose der Prostatitis tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract.
The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions e. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials.
Small studies provide limited support for the use of nonpharmacologic modalities. Diagnose der Prostatitis prostatitis is an incidental finding in a patient Diagnose der Prostatitis evaluated Diagnose der Prostatitis other urologic problems. The prevalence of prostatitis is approximately 8. The 2-glass pre- and post-prostatic massage test is a reasonable alternative to the preferred Meares-Stamey 4-glass test for diagnosing prostatitis.
Optimal duration of antibiotic treatment for acute bacterial prostatitis is six weeks. In acute bacterial prostatitis, patients should be evaluated with imaging for abscess if fevers persist more than 36 hours after appropriate antibiotic coverage. To prevent symptom flare-up, suppressive low-dose antibiotics should be considered in men with chronic bacterial prostatitis whose cultures remain positive. Diagnose der Prostatitis is a broad diagnosis that encompasses four clinical entities, including acute illness Diagnose der Prostatitis immediate attention acute bacterial prostatitistwo chronic conditions chronic bacterial prostatitis, chronic pelvic pain syndromeand an incidental finding asymptomatic prostatitis noted during the evaluation and treatment of other urologic conditions.
This article will familiarize primary care physicians with the categories of prostatitis as defined by the National Institutes of Health NIH; Table 1 5 and elucidate the epidemiology, clinical presentation, diagnosis, and treatment of each.
Lower urinary tract cultures. In: Nickel JC, ed. Textbook of Prostatitis. Oxford, England: Isis Medical Media; A number of diagnostic tests are available to differentiate and categorize the four types of prostatitis. These include localization tests and expressed prostatic secretions, the 2-glass pre- and post-prostatic massage and Meares-Stamey 4-glass tests Table 2 78 and Figure 1and urine Gram stain and culture.
Measurement Diagnose der Prostatitis postvoid residual urine is recommended when obstruction is suspected. Preferred test; lack of validating evidence.
Good concordance with Meares-Stamey 4-glass test; reasonable alternative. Alternative 2 glasses 7. Higher Diagnose der Prostatitis than EPS for gram-negative organisms 97 vs.
Information from references 7 and 8. The Meares-Stamey 4-glass test. Semen analysis, prostate-specific antigen PSA level, and transrectal ultrasonography—guided biopsy are not specifically recommended Diagnose der Prostatitis the evaluation of patients with prostatitis; however, these tests may already have been obtained in patients being evaluated for other urologic problems.
Similarly, imaging has a role only in the exclusion of other urologic diagnoses, 9 and when a patient with acute bacterial prostatitis does not respond appropriately to initial antimicrobial therapy. Other laboratory testing e. The role of individual tests for the diagnosis and management of prostatitis is further discussed in the setting of each NIH classification Table 3. Urinary: straining, urgency, dysuria, hesitancy, frequency, obstruction, irritation Systemic: fever, malaise, arthralgia, myalgia, intense suprapubic pain, mildly to acutely ill appearance, chills, nausea, emesis, and signs of sepsis tachycardia and hypotension.
Tender, boggy, enlarged prostate on digital rectal examination; distended bladder; prostatic massage contraindicated. Antimicrobial therapy Hospitalization for severe cases of prostate infection. Benign prostatic hyperplasia, stones or foreign body within the urinary tract, bladder cancer, prostatic abscess, enterovesical fistula.
Irritative voiding symptoms; testicular, low back, or perineal pain; recurrent urinary tract infection; urethritis; epididymitis; distal penile pain. Prostatic massage; prostate can be normal, tender, or boggy on digital rectal examination. Benign prostatic hyperplasia, voiding dysfunction, bladder or prostate cancer, prostatic or müllerian duct remnants, interstitial cystitis, radiation cystitis, eosinophilic cystitis, chronic proliferative cystitis, neuropathic pain, ejaculatory duct obstruction.
Abdominal and digital rectal examination to exclude underlying pathology; no tenderness to diffuse tenderness; findings variable. Asymptomatic prostatitis. No symptoms; incidental finding during evaluation for other conditions i. No specific therapy required; treatment depends on underlying conditions and reasons for initial evaluation. Information from reference Acute bacterial prostatitis, NIH type I, is an acute bacterial infection of the prostate; patients are typically Diagnose der Prostatitis in the outpatient setting or emergency department.
Left untreated, it can lead to overwhelming sepsis or the development of prostatic abscess. The prevalence and incidence of acute bacterial prostatitis are not fully known. Escherichia coli is the most commonly isolated organism, but other gram-negative organisms, such as KlebsiellaProteusand Diagnose der Prostatitisand gram-positive Enterococcus species are often isolated as well. Other gram-positive organisms, many of which comprise normal skin Diagnose der Prostatitis, have also been isolated from patients with suspected bacterial prostatitis and should be treated accordingly.
The diagnosis of acute bacterial prostatitis is often based on Diagnose der Prostatitis alone. Urinary symptoms may be irritative e. Pain may be present in the suprapubic or perineal region, or in the external genitalia. Systemic symptoms of fever, chills, malaise, nausea, emesis, and signs of sepsis tachycardia and hypotension may be present as well. On physical examination, the prostate should be gently palpated. Prostatic massage should not be performed and may be harmful 14 ; the prostate is tender, enlarged, and boggy.
On abdominal examination, a palpable, distended bladder indicates urinary retention. Midstream urine culture Diagnose der Prostatitis be obtained. The presence of more than 10 white blood cells per high-power field suggests a positive diagnosis. Residual urine should be documented if a patient has a palpable bladder or symptoms consistent with incomplete emptying.
Empiric therapy should be started at the time of evaluation Figure 2 Diagnose der Prostatitis coverage can be tailored Diagnose der Prostatitis the isolated organisms once urine culture results are available. Mildly to moderately ill patients may be treated in the outpatient setting; severely ill patients or those with possible urosepsis require hospitalization and parenteral antibiotics. Once patients have become afebrile, they may be transitioned to oral antibiotics based on the culture results.
Minimal duration of treatment is four weeks 15 ; however, the optimal period has been shown to be six weeks, because of the possible persistence of bacteria, with repeat evaluation recommended at that time. Diagnosis and treatment algorithm Diagnose der Prostatitis acute bacterial prostatitis. If fever persists or the maximal temperature fails to show a downward trend after 36 hours, prostatic abscess should be suspected. Prostatic abscess requires urology consultation for drainage.
No specific guideline exists for the treatment of gram-positive organisms, but the fluoroquinolones have adequate gram-positive coverage, as well as excellent gram-negative coverage, and they Diagnose der Prostatitis the prostate well.
Immunocompromised patients, especially those who have uncontrolled diabetes mellitus, among other immunodeficiencies, seem to be more susceptible to the development of acute bacterial prostatitis and prostatic abscess. Rarely, transrectal ultrasonography—guided biopsy of the prostate results in acute bacterial prostatitis and septicemia. These patients are often ill enough to warrant hospital admission and the initiation of parenteral therapy. Chronic bacterial prostatitis, NIH type II, is a Diagnose der Prostatitis bacterial infection of the prostate lasting more than three months.
Urine cultures obtained over the course of illness repeatedly grow the same bacterial strain. Other possibilities include seeding from the bladder, Diagnose der Prostatitis, blood, or lymphatic system. In contrast to men with acute bacterial prostatitis, those with chronic bacterial Diagnose der Prostatitis do not Diagnose der Prostatitis to be ill.
They present with recurrent or relapsing urinary tract infections, urethritis, or epididymitis with the same bacterial strain. Between symptomatic episodes, detectable pathogens persist on localization tests. Patients may have irritative voiding symptoms and testicular, perineal, low back, and occasionally distal penile pain. On physical examination, patients are usually afebrile, and on digital rectal examination the prostate may feel normal, tender, or Diagnose der Prostatitis.
The diagnosis is based on history and physical examination, a voiding test such as the 2-glass pre- and post-prostatic massage test Table 2 78and a positive urine culture.
Because chronic bacterial prostatitis is a bacterial infection, Diagnose der Prostatitis appropriate antibiotic with good tissue penetration in the prostate should be selected Table 4. Fluoroquinolones have demonstrated the best tissue concentration and are recommended as first-line agents. A four- to six-week course of therapy is usually recommended; however, a six- to week course is often needed to eradicate the causative organism and to prevent recurrence, especially if symptoms persist after completion of the initial therapy.
No guideline exists for treating gram-positive organisms, but ciprofloxacin Cipro and levofloxacin Levaquin have adequate gram-positive coverage, as well as excellent gram-negative coverage, and both medications penetrate the prostate tissue well. Ciprofloxacin Cipro. Levofloxacin Levaquin. Norfloxacin Noroxin. Clarithromycin Biaxin. In men whose cultures remain positive, suppressive therapy with low-dose antibiotics, such as fluoroquinolones, should be considered in an effort to prevent symptom flare-up.
Patients who test positive for human immunodeficiency virus HIV infection deserve special mention because they are susceptible to additional pathogens, such as Serratia marcescensSalmonella typhiMycobacterium tuberculosisand Mycobacterium avium. Nonbacterial organisms e.
Differentiation between these groups has been made based on the presence of leukocytes in expressed and post-massage prostatic secretions, urine, or semen. On examination, tenderness of the prostate, or less commonly the pelvis, is present in about one half of patients. Many of the diagnostic tests performed in affected patients are geared toward excluding other treatable pathology e. The group found that leukocytes and bacterial counts did not correlate with symptoms, 32 and Diagnose der Prostatitis findings were often present in asymptomatic control patients.
Table 5 34 — 36 identifies testing as recommended by a North Diagnose der Prostatitis consensus panel 34 and an international consensus panel. Semen analysis and culture, urethral evaluation with first 10 mL of voided urine or swab for culture, urine cytology, prostate-specific antigen level.