What is chronic prostatitis?

Chronic Prostatitis: Definition and Classification

Chronic prostatitis is a complex condition characterized by pain in the perineum, suprapubic region, testicles or tip of the penis, often exacerbated by urination or ejaculation, with associated urinary symptoms that persist for at least 3 months. 1, 2

Types of Chronic Prostatitis

Chronic prostatitis is classified into two main categories:

1. Chronic Bacterial Prostatitis (Category II)

   • Defined as a persistent bacterial infection of the prostate
   • Presents as recurrent urinary tract infections from the same bacterial strain
   • Up to 74% of cases are caused by gram-negative organisms, particularly E. coli 2
   • Diagnosed through the Meares-Stamey 4-glass test or its 2-specimen variant 1
   • Positive if there is a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1

2. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) (Category III)

   • Non-bacterial form that accounts for most cases
   • Primary defining characteristic is pain 1
   • Often includes urinary symptoms such as frequency, urgency, and sense of incomplete bladder emptying 1
   • Further subdivided into:
     • Category IIIA: Inflammatory (white blood cells in semen/EPS/post-prostatic massage urine)
     • Category IIIB: Non-inflammatory (no white blood cells)
   • Not frequently caused by a culturable infectious agent 1

Clinical Presentation

• Pain: Located in perineum, suprapubic region, testicles, penis, lower abdomen or back 1
• Urinary symptoms: Frequency, urgency, hesitancy, and sense of incomplete emptying 1, 3
• Sexual dysfunction: Pain during or after ejaculation 1
• Duration: Symptoms persist for at least 3 months 2

Diagnostic Approach

1. Laboratory Testing:

   • Midstream urine culture to rule out urinary tract infection 1, 4
   • Expressed prostatic secretions for microscopy and culture 1
   • Meares-Stamey 4-glass test or 2-specimen variant for bacterial prostatitis 1

2. Symptom Assessment:

   • National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) to quantify symptoms and monitor treatment response 5, 2

3. Exclusion of Other Conditions:

   • Rectal examination to assess prostate and pelvic floor muscles 4
   • Measurement of post-void residual urine 4, 2
   • Exclusion of underlying urological conditions 4

Treatment Approaches

For Chronic Bacterial Prostatitis:

• Antibiotic Therapy:
  • First-line: Fluoroquinolones (levofloxacin or ciprofloxacin) for minimum 4 weeks 6, 2
  • Ciprofloxacin 500 mg twice daily for 28 days is FDA-approved for this indication 6
  • Treatment duration should be 2-4 weeks initially, with extension for another 2-4 weeks if improvement occurs 4

For CP/CPPS:

• Multimodal approach based on symptom presentation:
  • Alpha-blockers (tamsulosin, alfuzosin) for urinary symptoms 5, 2
  • Anti-inflammatory drugs for pain management 5, 2
  • Amitriptyline (starting at 10 mg, titrating to 75-100 mg if tolerated) 5
  • Physical therapy targeting pelvic floor muscle relaxation for patients with pelvic floor tenderness 5
  • Behavioral modifications including stress management, dietary changes, and regular physical exercise 5

Common Pitfalls and Caveats

1. Overuse of antibiotics: Antibiotics should not be given for CP/CPPS without evidence of bacterial infection, as they show no benefit in non-bacterial prostatitis 4, 3

2. Inadequate treatment duration: For chronic bacterial prostatitis, treatment should be continued for at least 4 weeks, with regular assessment of effectiveness 4

3. Prostatocentric approach: CP/CPPS may involve pelvic floor dysfunction, myofascial pain, or functional somatic syndromes rather than prostatic pathology 7

4. Failure to reassess: Antibiotic treatment should not be given for 6-8 weeks without appraising its effectiveness 4

5. Symptom overlap: CP/CPPS shares symptoms with other conditions like interstitial cystitis/bladder pain syndrome, requiring careful differential diagnosis 1

Chronic prostatitis significantly impacts quality of life and requires a comprehensive diagnostic approach and targeted treatment based on the specific type and symptom profile. The condition often requires long-term management with regular reassessment of treatment effectiveness.