Can a man still have prostatitis if his urinalysis (UA) shows only trace leukocytes?

Prostatitis Can Occur with Only Trace Leukocytes on Urinalysis

Yes, a man can definitely have prostatitis even with only trace leukocytes on urinalysis. The diagnosis of prostatitis, particularly chronic prostatitis/chronic pelvic pain syndrome, cannot be ruled out based solely on minimal findings on urinalysis 1.

Understanding Prostatitis and Urinalysis Findings

Prostatitis presents in several forms:

• Acute bacterial prostatitis: Usually has clear urinalysis findings
• Chronic bacterial prostatitis: May have minimal urinalysis findings
• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): Often has minimal or no urinalysis findings

Limitations of Urinalysis in Prostatitis Diagnosis

Urinalysis has significant limitations for diagnosing prostatitis:

• Leukocyte esterase on dipstick has only 72-97% sensitivity and 41-86% specificity for detecting inflammation 1
• Trace leukocytes can be present in both symptomatic patients and asymptomatic controls 2
• Studies show that leukocyte counts do not correlate well with symptom severity in men with chronic prostatitis 3

Evidence Supporting Diagnosis Despite Minimal UA Findings

Research clearly demonstrates that prostatitis can exist with minimal urinalysis findings:

• In a National Institutes of Health study, only 50% of men with confirmed CP/CPPS had ≥5 WBCs per high-power field in expressed prostatic secretions, and only 32% had ≥10 WBCs 2
• Histopathological studies of prostate biopsies from men with CP/CPPS found inflammation in only 33% of patients, with moderate to severe inflammation in just 5% 4
• Leukocytes and bacterial counts do not correlate with symptom severity in men with chronic prostatitis 3

Diagnostic Approach When UA Shows Only Trace Leukocytes

When a man presents with prostatitis symptoms but only trace leukocytes on UA:

1. Evaluate clinical symptoms: Focus on dysuria, perineal pain, ejaculatory pain, and voiding symptoms

2. Consider additional testing:

   • Expressed prostatic secretions (EPS) examination if available
   • Post-prostatic massage urine specimen (VB3)
   • Semen analysis for inflammatory markers in selected cases 5

3. Rule out other conditions:

   • Urethritis (particularly non-gonococcal urethritis) 1
   • Epididymitis 1
   • Urinary tract infection 1

Clinical Pearls and Pitfalls

• Major pitfall: Dismissing prostatitis based solely on minimal UA findings - this can lead to missed diagnoses and prolonged patient suffering

• Important consideration: The European Association of Urology guidelines recognize that prostatitis diagnosis is often clinical and not solely dependent on laboratory findings 1

• Key insight: Research shows a high prevalence of leukocytes in the EPS of asymptomatic men (40%), raising questions about the diagnostic value of leukocyte counts alone 2

• Practical approach: When clinical suspicion for prostatitis is high but UA shows only trace leukocytes, proceed with appropriate treatment based on clinical presentation rather than waiting for more definitive laboratory findings 6

In summary, trace leukocytes on urinalysis should not rule out prostatitis when clinical symptoms are present. The diagnosis of prostatitis, particularly chronic prostatitis/chronic pelvic pain syndrome, remains primarily clinical and may exist with minimal laboratory findings.