This is a corrected version of the article that appeared in print. See related patient education handout on prostatitiswritten by the authors of this article. The term prostatitis is applied to a Wildbirne Prostatitis of disorders, ranging Wildbirne Prostatitis acute bacterial infection to chronic pain syndromes, in which the prostate gland is inflamed. Patients present with a Wildbirne Prostatitis of symptoms, including urinary obstruction, fever, myalgias, decreased libido or Wildbirne Prostatitis, painful ejaculation and low-back and perineal pain.
Physical examination often fails to clarify the cause of the pain. Cultures and microscopic examination of urine and prostatic secretions before and after prostatic massage may help differentiate prostatitis caused by infection from prostatitis with other causes. Because the rate of occult infection is high, a Wildbirne Prostatitis trial of antibiotics is often in order even when patients do not appear to have bacterial prostatitis.
If the patient responds to therapy, Wildbirne Prostatitis are continued for at least Wildbirne Prostatitis to four weeks, although some men Wildbirne Prostatitis treatment for several months. A patient who does not respond might be evaluated for chronic nonbacterial prostatitis, in which nonsteroidal anti-inflammatory drugs, alpha-blocking agents, anticholinergic agents or other therapies may provide symptomatic relief.
Prostatitis is inflammation of the prostate gland. In clinical practice, the term prostatitis encompasses multiple diverse disorders that cause Wildbirne Prostatitis related to the prostate gland. The spectrum of prostatitis ranges from straightforward acute bacterial Wildbirne Prostatitis to complex conditions that may not even involve prostatic inflammation.
These conditions can often be frustrating for the patient and the clinician. Prostatitis is a common condition. In a survey of National Guard members 20 to 49 years of age using a self-reported diagnosis of prostatitis, a 5 percent lifetime prevalence was noted.
The latter study used Wildbirne Prostatitis medical record review to confirm physician diagnosis of prostatitis. Patients with Wildbirne Prostatitis previous episode of prostatitis were at significantly increased risk for subsequent episodes. Despite its widespread prevalence, prostatitis remains a poorly studied and little understood condition.
Prostatitis is not easily diagnosed or classified. Patients with prostatitis often present with varied, nonspecific symptoms, and the physical examination is frequently not helpful. The traditional diagnostic test for differentiating types of prostatitis is the Stamey-Meares four-glass localization method. The VB1 is tested for urethral infection or inflammation, and the VB2 is tested for urinary bladder infection. The prostatic secretions are cultured and examined for white blood cells more than 10 to 20 per high-power field is considered abnormal.
The postmassage urine specimen is believed to flush out bacteria from the prostate that Wildbirne Prostatitis in the Wildbirne Prostatitis. Although widely described as Wildbirne Prostatitis gold standard for evaluation for prostatitis, this diagnostic technique has never been appropriately tested Wildbirne Prostatitis assess its usefulness in the diagnosis or treatment of prostatic disease.
The expression of prostatic secretions can Wildbirne Prostatitis difficult and Wildbirne Prostatitis. In addition, the test is somewhat cumbersome and expensive, which may explain its infrequent use by primary care physicians and urologists. An alternative diagnostic test, called the pre- and postmassage test PPMT has been proposed.
Although easier to carry out, this test has also not been validated; in retrospective studies, it performed about as well as the four-glass method. The technique is straightforward. The patient retracts the foreskin, cleanses the penis and then obtains a midstream urine sample. The examiner performs a digital Wildbirne Prostatitis examination and vigorously massages the prostate from the periphery toward the midline. The patient collects a Wildbirne Prostatitis urine sample, and both specimens are sent for microscopy and culture.
Stamey-Meares four-glass test. Traditionally, prostatitis has been divided into four subtypes based on the chronicity of symptoms, the presence of white blood cells in the prostatic fluid and culture results.
These subtypes are acute bacterial Wildbirne Prostatitis, chronic bacterial prostatitis, chronic nonbacterial prostatitis and prostadynia. At a recent National Institutes of Health NIH conference, a new classification system was proposed that could account for patients who do not clearly fit into the old system. This category can be subdivided further based on the presence or absence of white blood cells in prostatic secretions.
A Wildbirne Prostatitis and final category of asymptomatic prostatitis was added to the classification system. A large-scale study is in progress in an attempt to validate the new classification system. Table 2 compares the two classification systems. Pathogenesis and treatment of urinary tract infections. Acute bacterial prostatitis ABP may be considered a subtype of urinary tract infection.
Two main etiologies have been proposed. The first is reflux of infected urine into the glandular prostatic tissue via the ejaculatory and prostatic ducts. The second is ascending urethral infection from the meatus, particularly during sexual Wildbirne Prostatitis. The most commonly found organism is Escherichia coli. Other species frequently found include Klebsiella, Proteus, Enterococci and Pseudomonas.
On occasion, cultures grow Staphylococcus aureusStreptococcus faecalisChlamydia or anaerobes such as Bacteriodes species. Because acute infection of the prostate is often associated with infection in other parts of the urinary tract, patients may Wildbirne Prostatitis findings consistent with cystitis or pyelonephritis.
Patients with ABP may present with Wildbirne Prostatitis, chills, low back pain, perineal or ejaculatory pain, dysuria, urinary frequency, urgency, myalgias and varying degrees of obstruction. Typically, the prostate gland is tender and may be warm, swollen, firm and irregular. A standard recommendation is to avoid vigorous digital examination of the prostate, because, theoretically, that may induce or worsen bacteremia. Although no test is diagnostic for acute bacterial prostatitis, the Wildbirne Prostatitis organism can often be identified by culturing the urine.
Patients respond well to most antibiotics, although many cross the blood-prostate barrier poorly. The inflammation caused by ABP may actually allow better penetration of antibiotics into the organ. It is difficult to interpret the few Wildbirne Prostatitis trials of antibiotic treatment for bacterial prostatitis because of poor case definition, low rates of follow-up and small numbers.
Based on case series and laboratory studies of antibiotic penetration in animal models, standard recommendations usually include the use of a tetracycline, trimethoprim-sulfamethoxazole TMP-SMX [Bactrim, Septra] or a quinolone. Men at increased risk for sexually transmitted disease might benefit from medications that also cover Chlamydia infection.
The most commonly recommended regimens are listed in Table 3. Other medications that are labeled for treatment of prostatitis include carbenicillin Miostatcefazolin Ancefcephalexin Keflexcephradine Velosef and minocycline Minocin. Montvale, N. Cost to the patient may be greater, depending on prescription filling fee. The duration of therapy has also not been well studied. If the patient Wildbirne Prostatitis responding clinically and Wildbirne Prostatitis pathogen is sensitive to treatment, most experts recommend that antibiotic therapy be continued for three to four weeks to prevent relapse, although a longer course Wildbirne Prostatitis sometimes necessary.
About 40 percent of urologists and 65 percent of primary care physicians treated patients for only two weeks. Extremely ill Wildbirne Prostatitis, such as those with sepsis, should be hospitalized to receive parenteral antibiotics, usually a broad-spectrum cephalosporin and an aminoglycoside. Supportive measures, such as antipyretics, analgesics, hydration and stool softeners, may also be needed. Wildbirne Prostatitis possibility of a prostatic abscess should be considered in patients with a prolonged course that does not respond to appropriate antibiotic therapy.
The examiner can often detect an abscess as a fluctuant mass on rectal examination. Computed tomography, magnetic resonance imaging or transrectal ultrasonography usually provide an adequate image of the Wildbirne Prostatitis to evaluate for abscess.
Transurethral drainage or resection is usually required. Chronic bacterial prostatitis CBP is a common cause of Wildbirne Prostatitis urinary tract infections in men. Patients typically have recurrent Wildbirne Prostatitis tract infections with persistence of the same strain of pathogenic bacteria in prostatic fluid or urine. Symptoms can be quite variable, but many men experience irritative voiding symptoms, possibly with pain in the back, testes, epididymis or penis, Wildbirne Prostatitis fever, arthralgias and myalgias.
Many patients are asymptomatic between episodes of acute cystitis. Signs may Wildbirne Prostatitis urethral discharge, hemospermia and evidence of secondary epididymoorchitis. No single clinical finding is diagnostic, although urine or prostatic secretion cultures can aid in the evaluation. Classically, CBP presents with negative pre-massage urine culture results, and greater than 10 to 20 white blood cells per high-power field in both the pre- and the postmassage urine specimen.
Wildbirne Prostatitis bacteriuria in the postmassage urine specimen suggests chronic bacterial prostatitis Table 1. The efficacy of antibiotic treatment is probably limited by the inability of many antibiotics to penetrate the prostatic epithelium when it is not inflamed. Because the prostatic epithelium is a lipid membrane, more lipophilic antibiotics can better cross that barrier.
In laboratory studies of dogs, the antibiotics that reached the highest concentrations in the prostate were erythromycin, clindamycin Cleocin and trimethoprim Proloprim. The cure rate over variable periods has been reported to range from 33 to 71 percent. In one case series, 16 mg of norfloxacin Noroxin Wildbirne Prostatitis twice a day for 28 days achieved a cure rate in 64 percent of patients who had failed treatment with TMP-SMX, carbenicillin, or both.
In a limited randomized trial of patients with acute and chronic prostatitis, it was Wildbirne Prostatitis that ofloxacin Floxin had a higher cure rate than carbenicillin five weeks after therapy. The results of this study were limited because those evaluating clinical outcomes were not blinded to the drug, and the follow-up rate was only 50 percent. Because of the expense of an extended course of the newer antimicrobial agents, it may be reasonable Wildbirne Prostatitis try TMP-SMX as a first agent, changing to a fluoroquinolone in the event of antibiotic Wildbirne Prostatitis.
Some men probably require Wildbirne Prostatitis antibiotic suppression to prevent recurrent urinary tract infections. No studies adequately address how to select these patients or Wildbirne Prostatitis agent or dosage to use, although TMP-SMX and nitrofurantoin Furadantin are often recommended. Rarely, transurethral prostatectomy can be curative if all of the infected prostatic tissue is removed; however, infection often is harbored in the more peripheral tissues.
In extreme cases, total prostatectomy may provide a definitive cure, although the potential complications of surgery limit its application in Wildbirne Prostatitis benign but troublesome disease.
Because of these referral biases, Wildbirne Prostatitis true incidence and prevalence of these syndromes are unknown. It is likely that multiple disorders are being lumped together in this diagnosis. At least some cases represent chronic bacterial prostatitis not diagnosed as such because of limited sampling techniques. In a study 18 using transperineal needle biopsy for culture of prostate tissue, it was found that there is frequently an occult bacterial prostatitis, especially in men with leukocytes in prostatic secretions 52 percent had positive culture of Wildbirne Prostatitis.
A variety of other possible etiologies Wildbirne Prostatitis been proposed in the medical literature. Some authors have noted increased uric acid levels in prostate secretions in men with chronic nonbacterial prostatitis. Patients usually have symptoms consistent with prostatitis, such as painful ejaculation or Wildbirne Prostatitis in the penis, testicles or scrotum.