Download Week 10: Prostatitis

PROSTATITIS
Jason R. Ouellette, M.D.
WEEK 10: 03/07 – 03/11/05
Learning Objectives:
1. Participants will be able to recognize the clinical features of prostatitis and
understand when to suspect the diagnosis.
2. Participants will be able to understand the differences between acute and
chronic prostatitis.
3. Participants will be able to understand the role of prostatic massage in
making the diagnosis of prostatitis.
4. Participants will be able to appropriately treat patients with prostatitis.
CASE ONE:
P.P. Dribble is a 61-year-old man who is seen in your office complaining of fever,
chills, and dysuria. He also notes increased frequency and a feeling of incomplete
urination. His past medical history is significant for COPD and mild HTN. His
medications include amlodipine 5mg qd and an albuterol/ipratropium mdi.
Physical Exam: T=100.7 BP=149/87 HR=62
HEENT- unremarkable
Lungs- clear bilaterally
Abdomen- normal bowel sounds, soft, nontender, nondistended
Rectal- brown, heme-negative stool; prostate is of normal size, symmetric and
tender to palpation
Questions:
1.
What additional history would be helpful to obtain in this patient and
why?
Additional questions should be directed at differentiating urethritis, acute
bacterial prostatitis, and sexually transmitted diseases. These should
include questions about sexual activity, urethral discharge, urinary
obstruction, painful ejaculation, low back or perineal pain. Residents
should also ask about duration of symptoms and history of previous
episodes, treatments, etc.
2.
What are the typical symptoms and physical exam findings in acute
bacterial prostatitis?
Symptoms of acute bacterial prostatitis include symptoms of urinary
obstruction, dysuria, dribbling, frequency, fever, myalgias, decreased
libido or impotence, painful ejaculation, low-back or perineal pain.
Usually, the patient will have a prostate that is tender to palpation.
3.
What laboratory data would you order in this patient and how would
this be obtained?
Initial laboratory data should include a urinalysis. A urinalysis
demonstrating pyuria would support the diagnosis. A urine culture should
also be sent. CBC and blood cultures should be obtained on a case-bycase basis depending on whether or not they may change therapy (e.g. if
urine gram stain revealed Staph or urine culture grew Staph aureus, blood
cultures to rule out bacteremia with Staph aureus and possible seeding of
the urine, would be appropriate). Participants should also discuss the
utility of the pre- and post-prostatic massage test as described in the
article. This diagnostic technique has never been appropriately tested to
assess its usefulness in the diagnosis or treatment of prostatic disease and
has little role in the diagnosis of acute prostatitis.
4.
What is your treatment plan for this patient and why?
Acute bacterial prostatitis should be treated with an appropriate course of
antibiotic therapy. The causitive organisms are primarily gram-negative
bacteria, most commonly E.coli, but also including Klebsiella, Proteus,
Pseudomonas and Enterococci. Typical regimens include TMP/Sulfa or
Quinolones, but any antibiotic that covers the above organisms is
appropriate. Men at risk for STDs should be tested for Chlamydia as a
cause of urethritis, which can be difficult to differentiate clinically from
prostatitis. If positive, patients should be treated and educated
appropriately. Antibiotics should be continued for 3-4 weeks. These
patients are commonly treated with an inappropriately short course.
CASE TWO:
The patient returns three months later with frequency and possibly some low-grade
fevers. Upon questioning, he states that he responded well to his previous antibiotic
therapy, which he completed, and had been asymptomatic until a few weeks ago
when he started to note frequency, again, and malaise. He has no other complaints.
He is currently afebrile and physical exam is unchanged from the previous visit,
although his prostate is much less tender on digital rectal exam.
5.
What are you now concerned about in this patient and why?
Recurrent symptoms of UTIs in men should raise one’s suspicion for
chronic prostatitis. Many patients are asymptomatic between episodes.
Often the prostate is normal on digital rectal exam. Other possibilities
include a new episode of acute prostatitis or cystitis. Chronic
nonbacterial prostatitis/chronic pelvic pain syndrome should also be
discussed.
6.
What is your diagnostic and treatment plan for this patient?
There should be further discussion regarding acute vs. chronic prostatitis.
Patients with chronic prostatitis typically have the same strain of
pathogenic bacteria in the prostatic fluid and urine. Other discussion
should include the possibility of prostatic hypertrophy and whether or not
the patient should be referred to a urologist. Note: PSA will be elevated
in the setting of prostatitis and does not necessarily indicate prostatic
hypertrophy. Long-term antibiotic therapy is required for these patients,
often 6-12 weeks. Rarely, there is a role for transurethral prostatectomy.
References:
1. Stevermer, J. and Easley, S. Treatment of prostatitis. American Family
Physician. 2000; 61:3015-3022