What are the methods to assess for prostatitis (inflammation of the prostate gland)?

From the Guidelines

Assessing for prostatitis involves a comprehensive approach combining patient history, physical examination, and laboratory tests, with the Meares and Stamey 2- or 4-glass test being a strong recommendation for diagnosis in chronic bacterial prostatitis (CBP) as per the European Association of Urology guidelines 1.

Key Components of Assessment

• Taking a detailed history focusing on urinary symptoms (frequency, urgency, dysuria), pain (perineal, suprapubic, ejaculatory), and systemic symptoms like fever.
• Performing a physical examination including a digital rectal examination to assess for prostate tenderness, warmth, or irregularity.
• Laboratory evaluation should include urinalysis and urine culture to identify infection, and consider a midstream urine sample followed by post-prostatic massage urine to compare bacterial counts, although prostatic massage is not recommended in acute bacterial prostatitis (ABP) 1.
• Blood tests should include complete blood count, C-reactive protein, and PSA (though this may be elevated in prostatitis without cancer).

Diagnostic Tests

• The four-glass test is considered a gold standard diagnostic method, collecting pre-massage urine, midstream urine, expressed prostatic secretions, and post-massage urine for microscopy and culture.
• A simplified two-glass test (pre- and post-massage urine) may be used in clinical practice.
• Transrectal ultrasound may be performed in selected cases to rule out the presence of prostatic abscess 1.

Classification and Treatment

• Based on findings, prostatitis can be classified as acute bacterial, chronic bacterial, chronic pelvic pain syndrome (inflammatory or non-inflammatory), or asymptomatic inflammatory prostatitis, which guides appropriate treatment.
• The optimal durations of treatment for ABP or CBP are unknown and have not been established by high-quality studies, as noted in the guidelines for the prevention, diagnosis, and management of urinary tract infections 1.

Important Considerations

• The clinical presentation, diagnostic approach, and treatment for acute and chronic prostatitis have insufficient quality of evidence to enable clear recommendations in some aspects, highlighting the need for additional prospective studies 1.
• Urology consultation may be needed for definitive diagnosis and management, especially in cases of chronic bacterial prostatitis where accurate microbiological evaluation for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species is recommended 1.

From the Research

Assessment of Prostatitis

To assess for prostatitis, the following steps can be taken:

• A thorough history and examination should be performed, including a digital rectal examination after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy, and culture 2.
• The prostate should be checked for nodules during the digital rectal examination 2.
• Urine cultures should be obtained in all patients who are suspected of having acute bacterial prostatitis to determine the responsible bacteria and its antibiotic sensitivity pattern 3.
• Diagnosis is predominantly made based on history and physical examination, but may be aided by urinalysis 3.
• The National Institutes of Health Classification System for prostatitis can be used to categorize the condition into four categories: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis 4.

Evaluation of Chronic Prostatitis/Chronic Pelvic Pain Syndrome

For chronic prostatitis/chronic pelvic pain syndrome, the following evaluations can be performed:

• Mandatory evaluations include history and physical examination, urinalysis, and urine culture 4.
• Recommended evaluations include lower urinary tract localization tests, symptom index, flow rate, residual urine determination, and urine cytology 4.
• Optional evaluations include semen analysis and culture, urethral swab, urodynamics, cystoscopy, imaging, and prostate-specific antigen determination 4.

Diagnostic Strategy

The physician must individualize a rational diagnostic strategy for each patient, as there is no 'gold standard' for the diagnosis and evaluation of patients presenting with prostatitis 4, 5.

• The evaluation of a patient with prostatitis can be categorized as basic or mandatory evaluations, further or recommended evaluations, and optional evaluations in selected patients 5.
• Clinical, laboratory, and imaging evaluations can be used to diagnose and evaluate prostatitis, including a complete history, focused physical examination, and urinalysis/urine culture 5.