What are the diagnostic evaluation and treatment options for patients presenting with symptoms of prostatitis?

Prostatitis: Symptoms and Diagnostic Evaluation

The diagnosis of prostatitis requires careful classification into one of four categories (acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, or asymptomatic inflammatory prostatitis), with chronic pelvic pain syndrome accounting for over 90% of cases. 1

Symptoms by Prostatitis Type

Acute Bacterial Prostatitis

• Pain in the perineum, suprapubic region, testicles or penis tip
• Pain exacerbated by urination or ejaculation
• Voiding symptoms (frequency, urgency, incomplete emptying)
• Systemic symptoms may include fever and chills
• Dysuria and urinary urgency 1

Chronic Bacterial Prostatitis

• Similar to acute but less severe symptoms
• Recurrent urinary tract infections
• Persistent pelvic or genital pain
• Ejaculatory pain
• Voiding difficulties 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

• Pelvic pain is the hallmark symptom (including pressure and discomfort)
• Pain throughout the pelvis (urethra, perineum, testicles)
• Pain may worsen with bladder filling or specific foods/drinks
• Pain may improve with urination
• Voiding symptoms (frequency, urgency, incomplete emptying)
• Sexual dysfunction 2

Diagnostic Algorithm

1. Initial Evaluation

• Symptom Assessment:

  • Use validated questionnaires: NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) 1, 3
  • AUA Symptom Index/International Prostate Symptom Score (IPSS) for quantifying urinary symptoms 2

• Physical Examination:

  • Digital rectal examination (tender, boggy prostate in acute cases; may be normal in chronic cases)
  • Examination of external genitalia and abdomen 1

2. Laboratory Tests

• For Acute Bacterial Prostatitis:

  • Midstream urine dipstick (nitrite and leukocytes)
  • Midstream urine culture to guide antibiotic selection
  • Blood culture and complete blood count
  • PSA measurement not recommended during active infection 1

• For Chronic Bacterial Prostatitis:

  • Meares and Stamey 2-glass or 4-glass test (strongly recommended) 1
    • First-void urine (VB1)
    • Midstream urine (VB2)
    • Expressed prostatic secretions (EPS)
    • Post-massage urine (VB3)
  • Microbiological evaluation for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) 1

• For CP/CPPS:

  • 4-glass or 2-glass test to rule out bacterial infections
  • Semen culture (optional, especially for men with fertility concerns) 3

3. Imaging Studies

• For Acute Bacterial Prostatitis:

  • Transrectal ultrasound in selected cases to rule out prostatic abscess 1
  • Initial imaging of the prostate to exclude abscess 3

• For Chronic Bacterial Prostatitis:

  • Imaging indicated to exclude abscess formations 3
  • Routine imaging not necessary for CP/CPPS 3

Differential Diagnosis

• Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS):

  • Similar symptoms to CP/CPPS
  • Pain related to bladder filling
  • Consider IC/BPS in men whose pain is perceived to be related to the bladder 2

• Benign Prostatic Hyperplasia (BPH):

  • May coexist with prostatitis
  • Focus on obstructive voiding symptoms
  • Assess with AUA Symptom Index/IPSS 2

• Urinary Tract Infection:

  • Rule out with appropriate cultures 1

• Testicular Torsion:

  • Surgical emergency that must be ruled out in all cases of acute scrotal pain 1

Common Pitfalls and Caveats

1. Misdiagnosis: Prostatitis is frequently misdiagnosed due to symptom overlap with other conditions. The 4-glass test remains the gold standard for diagnosis of bacterial prostatitis 1, 3.

2. Overlooking Non-bacterial Causes: Over 90% of prostatitis cases are non-bacterial (CP/CPPS), requiring different management approaches 1, 4.

3. Inadequate Testing: Failure to perform proper localization cultures can lead to incorrect diagnosis and treatment 5.

4. PSA Elevation: PSA may be elevated during acute prostatitis and should be rechecked 3 months after resolution 1.

5. Overlooking Atypical Pathogens: Testing for Chlamydia trachomatis and Mycoplasma species should be considered in resistant cases 1.

6. Failing to Rule Out Prostatic Abscess: Patients who fail to respond to appropriate antibiotic therapy should be evaluated for prostatic abscess 1.

By following this diagnostic approach, clinicians can accurately classify prostatitis and develop appropriate treatment strategies based on the specific category, leading to improved outcomes and quality of life for patients.