Prostatitis

Prostatitis is an inflammation of the prostate. It comprises a set of syndromes, diseases and functional disorders that affect the prostate or the perineal area with similar symptoms and with an unknown etiology in some cases.

It usually occurs in young adults or middle-aged males. It is the most common urinary tract infection in men between the second and fourth decades of life.

For the diagnosis, urine and blood tests are used, digital rectal examination with prostate massage to obtain prostate secretion, transrectal ultrasound of the prostate and, in a few cases, biopsy, CT or MRI are used.

Types of prostatitis

There are different types of prostatitis:

Acute prostatitis (type I)

Acute prostatitis is a common type of acute bacterial infection that is easily diagnosed and usually responds well to antibiotic treatment. The clinical picture is characterized by sudden onset with high fever, chills or shivering, general malaise, low back pain and intense micturition discomfort that can lead to acute urinary retention.

Pyuria, bacteriuria, and hematuria are common in the urine. On rectal examination the prostate is soft, painful and congested; purulent discharge may appear from the urethral meatus. Aggressive digital rectal examination should be avoided because of the possibility of sepsis. In plasma, the PSA level is usually elevated.

Common germs found in cultures are Escherichia coli, Enterococcus, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa and Staphylococcus aureus. The infection subsides quickly with antibiotics that must be maintained for a relatively long time between six and eight weeks.

Acute bacterial prostatitis can be caused by a sexually transmitted disease, although it is also very common in patients with benign prostatic hyperplasia, after a urinary infection.

It has an incidence of 1-2 cases per 10,000 males.

Bacterial infection accounts for 5 to 10% of all cases of prostatitis. Therefore, we can say that 90 to 95% of men with symptoms do not have bacteria.

Chronic bacterial prostatitis (type II)

Chronic prostatitis is characterized by symptoms that have an insidious onset with urinary frequency and urgency, urethral “burning” sensation or dysuria, and sometimes low-grade fever, over months in most patients.

There is often redness of the urethral meatus and surrounding mucosa, and some discharge indicative of urethritis. Many patients report a fine voiding stream and postvoid dribbling; imprecise vague pain of variable intensity and the sensation of coldness or perineal heaviness is a common manifestation in these patients. The location that repeats is in the deep perineum, inguinal areas, suprapubic, scrotum and penis; all very vague and imprecise. Pain at the end of ejaculation or hemospermia is also repeated in its manifestations and can disrupt your sexual life.

Dretal examination reveals a soft or fibrotic prostate, sometimes with some crepitus and a granular consistency due to the presence of granules. Sometimes in the vast majority of patients rectal examination is normal. Polymorphonuclear leukocytes and macrophages may appear in prostatic secretion. Often there is also abundant sloughing of epithelial cells from the acinis or prostatic ducts. The prostate massage produces a secretion of between 0.1 and 1 cm³. To avoid contamination of the urethra, the patient is asked to urinate before the massage.

The secretion is squeezed and spread on a slide, stained and observed under a microscope.

Prostate biopsy is not indicated in the diagnosis of patients suspected of chronic prostatitis, since it is usually focal and not palpable. It is indicated when suspicious areas are palpated (to differentiate a tumor from chronic granulomatous prostatitis, for example).

Chronic bacterial prostatitis is characterized by the presence in the prostatic fraction, post-massage urine, or semen, of one or more gram-negative bacteria that do not grow in the initial or middle fractions of the urine.

The microorganisms identified in chronic bacterial prostatitis are:

• Gramnegative aerobics: Escherichia coli; enterobacter; Pseudomonas; Klebsiellas.
• The role of grampositive bacilos is doubtful.
• Discussions continue with Ureaplasma urealyticum a widely distributed microorganism in the male reproductive tract– and Chlamydia tracomatis since it has been shown to be causing most uretritis and epididymitis in males below the age of 35. There have also been high levels of specific IgA for clamidia in 45% of male ejaculated with non-bacterial prostatitis symptoms.

Chronic prostatitis can be caused by bacterial prostatitis that has not healed well, chronic inflammation of the prostate, or stress (which contracts the pelvic floor muscles) and continued irregular sexual activity, with retention of ejaculation.

Chronic abacterial prostatitis and prostatodynia (type III)

Abacterial prostatitis is the presence of polymorphonuclear cells in prostatic secretion viewed under a microscope, with negative cultures. Prostatodynia did not present polymorphonuclear cells or positive culture. Most patients who consult the doctor have abacterial prostatitis and prostatodynia.

Men with this condition suffer from discomfort in the perineum, or pain in the penis, testicles, perianal area, scrotum, suprapubic area, etc. during urination or outside of it. Urodynamic studies show an abnormal contracture of the external sphincter –striated– of the urethra, low micturition flows and dyssynergia of the micturition muscles (absence of sphincter relaxation during micturition). This disorder is believed to be related to pelvic floor muscle tension pain, dependent on sympathetic input. Its pathogenesis is not completely clear, with an important psychological component, and the response to treatment is variable.

Treatment of prostatitis

Acute bacterial prostatitis

As acute bacterial prostatitis is a bacteremia of prostatic origin, it should be treated with antibiotics. Since it is generally due to gram-negative bacilli, bactericidal antibiotics are preferably given intramuscularly or intravenously because they have better bioavailability: aminoglycosides, third-generation cephalosporins, monobactams, fluorinated quinolones, and sulfas... In addition to etiological treatment, antipyretics, analgesics and anti-inflammatories will be very useful. It must be considered that during acute inflammation the hematoprostatic barrier –lipoepithelial membrane– is altered, so the diffusion of antibiotics is good. In 24-48 hours the clinical picture will revert and after a treatment of 12-14 days, the lipoepithelial membrane will recompose and then spread the antibiotics worse; This will be the time when antibiotics with good prostatic diffusion must be used: oral fluorinated quinolones and doxycycline, to continue treatment for another 6-8 weeks.

Abacterial prostatitis/prostatodynia

There is no single treatment for this condition and it is considered within the group of heterogeneous pathologies that cause chronic pelvic pain in men. As non-pharmacological treatment, education, physiotherapy and psychotherapy stand out. As pharmacological treatments: Alpha blockers, Phytotherapy, 5 alpha reductase inhibitors, Anti-inflammatories, Botulinum toxin, among others. Antibiotics are not routinely recommended.

Granulomatous Prostatitis

Among the atypical forms of prostatitis, granulomatous prostatitis deserves special attention. Its etiopathogenesis is not clearly established. Microorganisms such as Mycobacterium tuberculosis, fungi (blastomycosis, coccidioidomycosis, cryptococcosis, histoplasmosis...) have been implicated. It should be noted that digital rectal examination is very suspicious and is confused with a prostate carcinoma that only a biopsy will differentiate. It is also interesting because a large number of patients with vesicoprostatic urothelial tumors are treated with BCG (Bacillus Calmette and Guerin) immunotherapy in intravesical instillations that cause a granulomatous-type response in the prostate.