alternative therapy should be considered, based upon in vitro susceptibility tests of the most recent isolate.
Complications — Although most patients with acute prostatitis respond well to antibiotic therapy, a variety of complications can occur, including bacteremia, epididymitis, chronic bacterial prostatitis (see below), and prostatic abscess. Prostatic abscess should be suspected when clinical and laboratory abnormalities persist despite appropriate antimicrobial therapy. The diagnosis of abscess is made by prostate ultrasonography or by computed tomography (CT) scan [21]. Transrectal prostatic ultrasonography is only indicated in acute prostatitis if prostatic abscess is suspected [22].
Although the clinical presentation of prostatic abscess can be confused with other diseases of the prostate, the incidence of prostatic abscess is currently low with the use of appropriate antibiotic therapy. Published case series of prostatic abscess since 1976 have fewer than five patients each, as compared with literature from the 1960s, which included dozens of patients in each of several studies [23]. Urology referral for surgical drainage is indicated if an abscess is persistent after one week or more of therapy.
Bacterial prostatitis and HIV infection — Bacterial prostatitis occurs more frequently in patients with HIV infection than in the general population [24]. Why this occurs is not clear. Anal sex does not seem to be the main triggering factor, since heterosexual men with HIV infection caused by drug abuse are similarly affected.
Signs and symptoms of acute prostatitis in these patients are identical to those described above. There are, however, some differences from the disease seen in non-HIV infected individuals:
•   Various gram-negative organisms have been identified, but some cases are due to unusual organisms, such as Haemophilus parainfluenzae [25].
•   Prostate abscess formation, though rare, appears to be more common in HIV-infected men [26]. It is seldom diagnosed until the patient has failed a trial of antimicrobial therapy.
•   Acute episodes respond favorably to antibiotics, but relapses occur frequently after discontinuation.
The prostate may serve as an asymptomatic reservoir for recurrent infection by certain organisms, such as Cryptococcus neoformans. In one series of AIDS patients, cryptococci were isolated from prostatic secretions at a time when they were not retrieved from blood or cerebrospinal fluid [27].
CHRONIC BACTERIAL PROSTATITIS — Chronic bacterial prostatitis may present as a complication of acute prostatitis, or in the absence of previously recognized initial infection. The diagnosis should be considered in men who have dysuria and frequency in the absence of the signs of acute prostatitis, in those with recurrent urinary tract infections in the absence of bladder catheterization, and in the setting of incidental bacteriuria. In a study of 38 men with recurrent UTIs, for example, about one-half had evidence of infection localized to the prostate (demonstrated by comparing cultures of urine and expressed prostatic secretions) [11].
Gram-negative rods are the most common etiologic agent, with Escherichia coli causing approximately 75 to 80 percent of episodes [28]. Other organisms, including enterococci, gram-negative rods (other than E. coli), and Chlamydia trachomatis have also been associated with chronic infection. Fastidious organisms also play an important role in chronic prostatitis. In a series of 597 patients with chronic prostatitis, for example, Ureaplasma urealyticum was detected using quantitative determination of expressed prostatic secretions and urine voided after prostatic massage from 13 percent of patients. Rarely, fungi or Mycobacterium tuberculosis may be involved [29].
Clinical presentation — Chronic bacterial prostatitis has more subtle clinical findings than acute prostatitis. Patients may be asymptomatic or have complaints typical of a lower urinary tract infection, such as frequency, dysuria, urgency, perineal discomfort, and perhaps a low-grade fever. In some cases, the diagnosis may be suspected by the incidental finding of bacteriuria. Sexual dysfunction may accompany chronic bacterial prostatitis [30]. Rectal examination may demonstrate prostatic hypertrophy, tenderness, and edema, but is frequently normal.
Diagnosis — The diagnosis of chronic prostatitis can be made by analyzing specimens obtained following prostatic massage for leukocytes and bacteria. The periurethral area is cleaned and four samples are taken -- the so-called four-glass test [28]. The initial 5 to 10 mL (VB1) and a midstream specimen (VB2) are obtained for quantitative culture. The patient should stop voiding before the bladder is empty and the prostate should then be massaged. Any prostatic secretions that are expressed (EPS) should be cultured and have a leukocyte count performed, as well as the first 5 to 10 mL of subsequently voided urine (VB3) (figure 1). (See "Urine sampling and culture in the diagnosis of urinary tract infection in adults".)
For the test to be interpretable, the colony count in VB2 must be less than 103/mL, since bladder bacteriuria prevents identification of the frequently small number of organisms from the prostate. Chronic prostatitis is suspected when VB3 has more than 12 leukocytes per high power field; more than 20 leukocytes per high power field is almost diagnostic unless leukocytes were also present in VB2 [12].
Cultures of urine or expressed prostatic secretions are almost always positive in chronic bacterial prostatitis (table 1). However, negative cultures do not necessarily exclude the possibility of bacterial prostatitis. One study found that some patients with chronic bacterial prostatitis had positive cultures of prostate tissue despite negative cultures of expressed prostatic fluid [31].
Although the four-glass test is described extensively in the literature, it is not clear that it is frequently used in practice. In one survey of urologists in which 64 percent responded, 33 and 47 percent, respectively, said that they never or rarely performed the four-glass test [32]. Furthermore, the results of the test apparently did not influence the use of antibiotics, since urologists who used the test routinely did not differ in antibiotic prescribing from others who used it less often.
Ultrasonography may also be useful for evaluation of prostatitis sequelae, including prostatic abscess (see 'Complications' above) and prostatic calcification [33].
Chlamydia infection — Although it has not been clearly established that Chlamydia trachomatis can cause chronic bacterial prostatitis, it is thought to be a possible cause in cases in which routine cultures are negative. Chlamydial genital infections are common and may involve the epididymis and the urethra. C. trachomatis has been isolated from the prostate, and there is some evidence that it resides in prostate tissue rather than being brought along with other urethral contaminants [34,35]. Cultures for Chlamydia or other unusual pathogens are seldom obtained until a thorough diagnostic workup has been completed. Culturing for C. trachomatis is beyond the capacity of most laboratories because of the technical demands involved. On the other hand, diagnostic tests to look for chlamydial antigens or nucleic acids have been developed and these tests can easily be done on genital secretions or urine. Because these tests are highly sensitive and specific, they may be able to settle the question of whether C. trachomatis causes prostatitis if the tests can be performed on prostate tissue and show positive results when Chlamydia are not found in urine or other genital secretions. (See "Genital Chlamydia trachomatis infections in men".)
Treatment — Selection of agents for and duration of therapy for chronic prostatitis have not been studied using comparative trials. In case series, there has been a general sense that various fluoroquinolone regimens (eg, ciprofloxacin 500 mg PO every 12 hours or levofloxacin 500 mg PO daily) have a satisfactory outcome in about two-thirds of patients who can tolerate them for four weeks or longer. Failures of therapy appear to be related to underlying prostate disease, infecting agent, incomplete adherence, drug interactions that reduce fluoroquinolone bioavailability, or to some other less understood component. (See "Fluoroquinolones", section on 'Drug interactions'.)
Recurrences of chronic bacterial prostatitis are common and are generally treated with a second course of antibiotics. If the first course was less than six weeks, a longer second course is recommended, preferably with an antibiotic from a different class with efficacy against usual pathogens responsible for prostatitis (eg, trimethoprim-sulfamethoxazole); in some cases, a second course of a fluoroquinolone can be given. Courses exceeding four weeks should also be considered in patients who have previously failed treatment, who have a relatively difficult to treat organism, or who cannot tolerate first line therapy and need other agents. In patients requiring an extended course of antibiotics due to relapse or failure to respond to a course of a fluoroquinolone, causes of impaired bioavailability of the fluoroquinolone should be sought (see "Fluoroquinolones", section on 'Drug interactions'). Tendinitis and tendon rupture are important adverse effects that have been reported in patients requiring prolonged fluoroquinolone therapy, especially in patients >60 years of age [36]. Among patients in this age group, those receiving glucocorticoids are at the highest risk. (see "Fluoroquinolones", section on 'Tendinopathy and tendon rupture'). In patients with pelvic pain syndromes in whom there is no evidence of prostatic inflammation or infection, the success rate of any antimicrobial therapy is much lower.
C. trachomatis infection can be treated with doxycycline, minocycline, or azithromycin [37,38], but use of these drugs in prostatic infections is not reported separately. One study compared azithromycin (500 mg daily for three days each week for three weeks) with ciprofloxacin (500 mg twice daily for 20 days) in 89 patients with chronic prostatitis and laboratory evidence of C. trachomatis infection [39]. The rate of bacterial eradication and clinical cure was significantly higher among the patients treated with azithromycin.
Chronic bacterial prostatitis often recurs and is usually treated with a second course of antibiotics. A fluoroquinolone is once again the treatment of choice. One report, for example, evaluated 33 patients with chronic bacterial prostatitis who had failed therapy with trimethoprim, TMP-SMX, or norfloxacin; the patients were retreated with ciprofloxacin (500 mg twice daily) for two to four weeks [40]. The following results were noted:
•   Of 26 patients with E. coli as the pathogen, 17 were cured at greater than one year follow-up. In another two, a second treatment course with ciprofloxacin was successful. Two patients withdrew from therapy due to adverse drug reactions.
•   Therapy was successful in two of five with pathogens other than E. coli.
In another report, 15 patients refractory to TMP-SMX and/or carbenicillin were treated with norfloxacin (400 mg twice daily) for 28 days. Of the 14 patients followed for at least six months, nine (64 percent) infected with E. coli were cured [41]. Similar results have been noted in other studies [42].
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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
•   Basics topic (see "Patient information: Prostatitis (The Basics)")
ALTERNATIVE PERSPECTIVE ON THE TREATMENT OF BACTERIAL PROSTATITIS — As noted above, it is frequently difficult to distinguish which patients with chronic symptoms actually have chronic bacterial prostatitis. A group of urologists in Canada utilized leukocyte counts, cultures, and antibody determinations for common uropathogens before and after prostatic massage to try to differentiate among these patients and then treated all with ofloxacin (300 mg PO twice daily for 12 weeks) [43]. Fifty-seven percent of the 102 patients reported a moderate to marked improvement in symptoms which did not correlate with any of the measures of bacterial infection. The authors

Acute and chronic bacterial prostatitis
Authors
Alain Meyrier, MD
Thomas Fekete, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. |This topic last updated:Φεβ 1, 2012.
INTRODUCTION — The prostate is subject to various inflammatory disorders [1]. In one five-year survey of 58,955 ambulatory visits to clinicians by men over the age of 18 years, genitourinary tract symptoms accounted for 5 percent of all complaints [2]. Prostatitis was listed as a diagnosis in nearly two million encounters annually in the United States National Ambulatory Medical Care Surveys.
Prostatitis syndromes tend to occur in young and middle-aged men. The symptoms of prostatitis are common and often not recognized by clinicians. These symptoms include pain (in the perineum, lower abdomen, testicles, penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen. Impotence is occasionally attributed to prostatitis; however, it occurs no more commonly than in men of a similar age without prostatitis [3]. In a large population-based Canadian questionnaire study, over 20 percent of the men had complaints compatible with chronic prostatitis, and 8 to 10 percent had moderate to severe symptoms [4]. The men with the most severe symptoms also had poorer general health and recurrent complaints.
Definitions of these syndromes, acute prostatitis, and chronic bacterial prostatitis, will be reviewed here. Chronic prostatitis/pelvic pain syndrome is discussed separately. (See "Chronic prostatitis/chronic pelvic pain syndrome".)
DEFINITIONS — Inflammatory or irritative conditions of the prostate were traditionally classified according to the following schema (table 1) [5]:
•   Acute prostatitis.
•   Chronic bacterial prostatitis.
•   Nonbacterial prostatitis, which presents with similar symptoms and signs as chronic prostatitis (including pyuria) except that cultures of urine and expressed prostatic secretions are negative.
•   Prostatodynia, which also presents with similar symptoms and signs as chronic prostatitis except that the cultures are negative and pyuria is absent.
A classification approach supported by the National Institutes of Health (NIH) to standardize definitions and facilitate research made the following recommendations [6]:
•   Adding an entity called asymptomatic inflammatory prostatitis.
•   Combining nonbacterial prostatitis and prostatodynia into an entity called chronic prostatitis/pelvic pain syndrome.
The inflammatory subset of this syndrome included patients with significant numbers of inflammatory cells in expressed prostatic secretions, post-prostate massage urine or seminal fluid. The noninflammatory chronic prostatitis/pelvic pain subset included the remainder of the patients with chronic prostatitis or pelvic pain. (See "Chronic prostatitis/chronic pelvic pain syndrome".)
Thus, the newer schema defined the following categories:
•   I. Acute prostatitis
•   II. Chronic bacterial prostatitis
•   IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory
•   IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory
•   IV. Asymptomatic inflammatory prostatitis
Maneuvers performed in the urology office can help refine the categorization of patients. For example, including post-massage urine and seminal fluid for the assessment of inflammatory cells effectively doubles the number of people in the inflammatory subset (as compared with the older distinction using only purulent prostatic secretions) [7].
ACUTE PROSTATITIS — Entry of microorganisms into the prostate gland almost always occurs via the urethra. In most cases, bacteria migrate from the urethra or bladder through the prostatic ducts, with intraprostatic reflux of urine. As a result, there may be concomitant infection in the bladder or epididymis.
Risk factors for acute prostatitis are said to include trauma (eg, bicycle or horseback riding), dehydration, and sexual abstinence. However, these have not been established by well controlled studies. Prostatitis can also occur in patients with chronic indwelling bladder catheters and in those who perform intermittent catheterization [8]. A urethral stricture is a possible etiology that should be sought after the acute episode by means of contrast medium urethrography.
Microbiology — The flora of acute prostatitis reflects the spectrum of agents causing urethritis, urinary tract infection, and deeper genital infection. Gram-negative infections, especially with Enterobacteriaceae (typically Escherichia coli or Proteus spp), are most common [9]. Rarely, organisms, such as Burkholderia pseudomallei, have been reported to cause acute prostatitis and prostatic abscess in association with bacteremia [10]. Recurrent infection after completion of therapy is usually caused by the same organism that was found in the original infection [11].
Clinical presentation — The typical signs and symptoms of acute prostatitis include spiking fever, chills, malaise, myalgia, dysuria, pelvic or perineal pain, and cloudy urine. With the exception of fever and chills, these symptoms are similar to those of lower urinary tract infection; it is important to appreciate, however, that isolated acute cystitis does not commonly occur in men, in whom virtually all lower UTIs are due to prostatitis [12,13]. Men with acute cystitis often have a functional or anatomic abnormality, with prostatic hypertrophy and genitourinary instrumentation being the major predispositions to these complicated UTIs.
Swelling of the acutely inflamed prostate can cause obstructive symptoms, ranging from dribbling and hesitancy to acute urinary retention. Rarely, patients lack these local symptoms, and present with the clinical picture of a constitutional or flu-like illness. Clearly, the diagnosis of prostatitis is challenging in this setting.
Early diagnosis and treatment of acute prostatitis are important for both symptom control and the prevention of secondary problems, such as gram-negative sepsis, prostatic abscess, or metastatic infection (eg, spinal or sacroiliac infection) [14].
Diagnosis — Clinical symptoms, together with an edematous and tender prostate on physical examination, should prompt a presumptive diagnosis of acute prostatitis. Digital rectal examination should be performed gently; vigorous prostate massage should be avoided since it is uncomfortable, allows no additional diagnostic or therapeutic benefit, and increases risk for bacteremia.
A urine Gram stain and culture should be obtained in all men suspected of having acute prostatitis. Gram stain of the urine, if positive, can be used as a guide to initial therapy. Confirmatory laboratory findings include pyuria, peripheral leukocytosis, and occasionally, positive blood cultures.
An elevated serum prostate specific antigen (PSA) level is also potentially consistent with a diagnosis of acute prostatitis, although a PSA should not be considered to be a standard diagnostic test for prostatitis. Elective serum PSA for prostate cancer screening should be deferred for one month following acute prostatitis [15]. (See "Measurement of prostate specific antigen".)
Treatment — A variety of antimicrobials may be used for treatment of acute prostatitis. The barrier between the microcirculation and the prostate gland stroma limits drug entry to passive diffusion, which only permits non-protein-bound, lipophilic antimicrobial agents to reach therapeutic levels within the gland. In addition, the low pH of prostatic fluid permits antibiotics with alkaline pKas (such as quinolones and sulfonamides) to achieve high concentrations in prostatic tissue more readily than antibiotics with acidic pKas. However, antibiotic prostatic penetration in the setting of inflammation occurs more readily [16].
Patients with acute bacterial prostatitis may need to be hospitalized for parenteral antibiotic therapy if they cannot tolerate oral medication or if they demonstrate signs of sepsis, such as hypotension or altered mental status. In such cases, shock due to gram-negative bacteremia may occur abruptly and be life threatening.
In general, antibiotic coverage should be administered empirically pending the culture results. A Gram stain of the urine may be helpful in choosing empiric antibiotic coverage. Regional patterns of resistance to various antimicrobials can help in the initial selection of empiric therapy, but clinical response and culture reports will be useful in guiding therapeutic changes.
•   Patients with gram-negative rods should be treated with trimethoprim-sulfamethoxazole (TMP-SMX or cotrimoxazole; one double-strength tab PO every 12 hours) or a fluoroquinolone (ciprofloxacin 500 mg PO every 12 hours or levofloxacin 500 mg PO once daily) if oral therapy is indicated. Other agents with good to excellent penetration into prostatic fluid and tissue include tetracyclines, macrolides, sulfonamides, and nitrofurantoin [17]. For patients who need parenteral therapy, an aminoglycoside (gentamicin or tobramycin 5 mg/kg daily) may be combined with intravenous levofloxacin or ciprofloxacin.
If a urine Gram stain is not performed, the patient should be treated as if infected with gram-negative rods until additional culture data are available.
•   Gram-positive cocci in chains usually indicate enterococcal infection, which should be treated with amoxicillin 500 mg PO every eight hours. If parenteral therapy is necessary, ampicillin can be given at a dose of 2 g IV every six hours.
•   Gram-positive cocci in clusters are most often due to Staphylococcus aureus or coagulase-negative staphylococci (eg, S. epidermidis), which should be treated with a cephalosporin (eg, cephalexin 500 mg PO every six hours) or a penicillinase-resistant penicillin (eg, dicloxacillin 500 mg PO every six hours). Choices for parenteral therapy include cefazolin (1 g IV every eight hours), nafcillin (2 g IV every four to six hours), or for methicillin-resistant S. aureus, vancomycin (30 mg/kg/d in two divided doses with adjustments made for renal insufficiency).
When S. aureus is recovered from a urine culture, it is important to perform blood cultures to be certain the bacteriuria reflects local infection and not seeding of the urine in association with bacteremia. (See "Complications of Staphylococcus aureus bacteremia".)
Nonsteroidal antiinflammatory drugs (NSAIDs) can be given to relieve pain, speed the clearing of inflammation, and liquefy prostatic secretions [18]. Rarely, acute urinary retention develops during an episode of acute prostatitis. In this setting, bladder drainage must be done by suprapubic catheterization. Passage of a catheter through the inflamed urethra into the bladder is contraindicated in patients with acute prostatitis.
Patients initiated on parenteral antibiotics may be switched to oral antibiotics following improvement in fever and clinical symptoms. Antibiotics should be administered for four to six weeks to ensure eradication of the infection [19]. Prolonged therapy is required because of limited antimicrobial penetration into the prostate and the development of protected microcolonies deep within the inflamed gland that are difficult to reach with antimicrobials.
Clinical course — In most cases, fever abates and dysuria disappears within two to six days after the start of therapy. Acute phase reactants (eg, sedimentation rate, C reactive protein) and the PSA, if obtained, return to normal more gradually [15]. Clinical studies using a fluoroquinolone suggest that a negative urine culture at seven days following initiation of therapy predicts cure at the conclusion of the full four to six week course of therapy [20]. If the urine culture is still positive at seven days,

Όπως βλέπετε σημαντική θέση έχουν Alpha1-Blockers, όπως δηλαδή το omnic tocas ή το Xatral OD μία φορά την ημέρα. Εμένα γνωστός ουρολόγος που πρότεινε να πάρω OMNIC TOKAS. Το ξεκίνησα και βλέπω μάλιστα αποτελέσματα.
Κανένας που να το έχει πάρει για να μας πει τις εντυπώσεις του;;;;

•   In patients with CP/CPPS, we suggest initial treatment with combination alpha-blocker and antibiotic therapy (Grade 2B). We use tamsulosin 0.4 mg daily and ciprofloxacin 500 mg twice daily. After initial treatment, we suggest NOT repeating a course of antibiotics unless there is a subsequent positive urine culture (Grade 2C). (See 'Medical treatment' above.)
•   Anti-inflammatory medications, finasteride, and phytotherapies also appear to have modest, but lesser, effects on symptoms. Physical therapy aimed at myofascial release may have benefit in patients with pelvic floor muscle spasm. A cognitive behavioral treatment program may be beneficial in some patients with concomitant psychosocial problems. (See 'Management' above.)
•   Patients whose symptoms persist despite these initial treatments, or who are found to have abnormalities such as hematuria or an elevated PSA, should be referred to a urologist. (See 'Referral' above.)
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"Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis", section on 'Clinical presentation')
Unlike patients with these other disorders, patients with CP/CPPS are unlikely to have systemic or neurologic symptoms (eg, fever, weight loss, fatigue, incontinence).
EVALUATION — As chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a diagnosis of exclusion, the evaluation is designed to rule out identifiable causes of pelvic pain. The evaluation includes the history, physical examination, urinalysis, urine culture, and, in select cases, diagnostic imaging.
History — The clinician should ask about pain, urinary complaints, sexual function, depressive symptoms, and overall quality of life. The NIH developed and validated the Chronic Prostatitis Symptom Index (NIH-CPSI) which can be useful in the evaluation of patients presenting to general medicine and urology clinics [29]. The NIH-CPSI specifically assesses pain, voiding, and quality of life. The maximum possible symptom score is 43, where higher numbers indicate more severe symptoms.
Physical examination — The focused examination should evaluate areas of pain, search for unexpected masses, and assess for possible urinary tract abnormalities (including urinary retention).
The evaluation consists of an examination of the abdomen, including careful palpation of the groin, spermatic cord, epididymis, and testes. Clinicians should specifically search for hernias, testicular masses, and hemorrhoids.
On digital rectal examination, the prostate is usually not tender but may sometimes be mildly tender; severe tenderness suggests acute prostatitis. In addition to the prostate, the digital rectal examination should also assess for rectal masses and muscle spasm or myofascial tenderness by palpation of the perineum, pelvic floor, and pelvic sidewalls.
Laboratory studies — A urinalysis should be performed in any patient suspected of prostatitis [30]. A urine culture is also required to rule out urinary tract infection [30]. Patients with recurrent urinary tract infections should be evaluated for chronic bacterial prostatitis. (See "Acute and chronic bacterial prostatitis".)
Patients with hematuria should have an evaluation that includes urine cytology (looking for carcinoma in situ of the bladder), cystoscopy, and possibly upper tract imaging with intravenous pyelography or CT. (See "Etiology and evaluation of hematuria in adults".)
A prostate specific antigen (PSA) test is not indicated for the assessment of CP/CPPS, and if a PSA is measured and found to be elevated, the elevation should not be ascribed to CP/CPPS [31]. (See "Measurement of prostate specific antigen".)
The classic "four glass test" (examining and culturing the first void, midstream, and post-massage urine samples along with expressed prostatic secretions) is no longer routinely performed.
Diagnostic imaging — Imaging studies are appropriate in certain patients:
•   Patients with concomitant abdominal pain may require imaging with CT to exclude an intra-abdominal process. (See "Diagnostic approach to abdominal pain in adults".)
•   Testicular pain should be evaluated with a scrotal ultrasound. (See "Evaluation of nonacute scrotal pathology in adult men".)
•   A bladder ultrasound or catheterization may be performed to check a post-void residual in patients who report a sensation of incomplete bladder emptying. (See "Diagnosis of urinary tract obstruction and hydronephrosis".)
•   Lumbar radiculopathy can produce pelvic pain, so patients with signs and symptoms suggesting radiculopathy (eg, lower extremity paresthesias or weakness) may require imaging of the spine with MRI. (See "Diagnostic testing for low back pain".)
MANAGEMENT — A number of therapies are available for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); however, there is no uniformly-accepted treatment regimen. Alpha blockers and antibiotics are the main first-line agents for treatment of CP/CPPS, and can be used in combination. Physical therapy and psychological support are also used in certain cases of CP/CPPS.
The NIH chronic prostatitis symptoms index (NIH-CPSI) can be used to follow symptoms (ie, pain, voiding, and quality of life) and measure response to treatment [32].
In primary care practice, patients suspected of having acute or chronic bacterial prostatitis will frequently receive an empiric trial of an antibiotic (such as ciprofloxacin), and the diagnosis of CP/CPPS will only be entertained in those patients who relapse or do not respond to such therapy. (See "Acute and chronic bacterial prostatitis".)
Medical treatment — Alpha blockers, antibiotics, and finasteride (a 5-alpha-reductase inhibitor) are the most efficacious medications for treatment of CP/CPPS.
In a meta-analysis including 23 randomized trials of patients with CP/CPPS, several treatments were found to reduce NIH-CPSI scores compared to placebo, including alpha blockers (-11.0, 95% CI -13.9 to -8.1), antibiotics (-9.8, 95% CI -15.1 to -4.6), and finasteride (-4.6, 95% CI -8.7 to -0.5) [33]. The overall decrease in symptom scores was relatively small for each of the medications and likely of modest clinical significance. The greatest improvement in NIH-CPSI score occurred with combination alpha blocker and antibiotic treatment compared with placebo (-13.8, 95% CI -17.5 to -10.2). Symptomatic improvement with combination alpha blocker and antibiotic treatment was significantly greater than for each of the other treatments alone.
The choice of treatment in clinical practice may vary based on etiology of CP/CPPS and specific symptoms (eg, alpha blockers for those with pain and voiding symptoms, antibiotics for those with a history of urinary tract infection). However, given these data, we suggest the use of combination alpha blocker and antibiotic as initial treatment. An alpha blocker (either receptor specific or non-specific) plus a quinolone for six weeks initially is a reasonable option (tamsulosin 0.4 mg daily and ciprofloxacin 500 mg twice daily). If initial treatment is not effective, patients should be referred to a urologist for further evaluation and management.
Some clinicians decide to continue initial treatment despite lack of response. It is reasonable to continue an alpha blocker in patients with continued pain and voiding symptoms. Patients should be reevaluated after three months of continued alpha blocker therapy. We suggest not administering further antibiotics if the first course is ineffective and subsequent urine cultures are negative. Several antibiotic classes such as quinolones and tetracyclines (two of the most commonly-used antibiotics for CP/CPPS) are considered anti-inflammatory drugs and may improve symptoms regardless of infection [34]. Thus, in the absence of fever and positive urine culture, the patient does not likely have an infection, particularly if a patient feels better on antibiotics and feels worse the day after stopping them.
Finasteride, anti-inflammatory medications, and phytotherapies may have modest, but lesser, benefits in patients with CP/CPPS [33]. Finasteride is common treatment for older men with urinary symptoms, but is not recommended in young men who are still trying to have children given the effects on semen volume. Most of the anti-inflammatory medications studied for CP/CPPS treatment include cyclooxygenase-2 inhibitors (eg, celecoxib) and glucocorticoids (eg, prednisolone). Anti-inflammatory medications are generally given when pain is not controlled with initial therapy. Other medications found to be effective include phytotherapies and medication for neuropathic pain (eg, pregabalin). Specific phytotherapies found to be effective include cernilton (pollen extract) and quercetin (bioflavonoid) [35,36].
A small randomized trial suggested some benefits with mepartricin, an antifungal agent that lowers estrogen levels in the prostate [37]. Mepartricin is not available in the United States.
Psychological support — As CP/CPPS is associated with depression and a poor quality of life [38], behavioral counseling may be beneficial in select patients with concomitant psychosocial problems. A cognitive behavioral program specifically targeting CP/CPPS can improve both symptoms and quality of life [39]. This approach addresses approaches to pain, urinary difficulties, depressive symptoms, social support, sexual functioning, and overall quality of life issues. Prior to widespread use of behavioral counseling, further studies are needed to determine which patients with CP/CPPS might benefit from this type of program.
Other — A few other treatments may be helpful in managing CP/CPPS:
•   Small randomized trials have found that acupuncture is more effective than sham acupuncture [40].
•   Physical therapy aimed at achieving myofascial trigger point release may have benefit in patients with pelvic floor muscle spasm [41,42]. This therapy is usually performed by a physical therapist, rather than a urologist or primary care clinician. (See 'Physical examination' above.)
•   Small randomized trials have found that transurethral microwave thermotherapy of the prostate may be effective in reducing symptoms of CP/CPPS [43,44]. Further trials are needed to document long-term efficacy and safety of thermotherapy, in comparison to medical therapy.
•   Sitz baths have anecdotally been reported to provide some relief, although there have been no studies on efficacy for chronic symptoms.
Surgical intervention for CP/CPPS is reserved only for those patients with a specific indication (eg, urethral stricture, bladder neck obstruction) [45].
Transurethral needle ablation of the prostate is not more effective compared to sham treatment in patients with CP/CPPS [46].
Referral — Patients whose symptoms persist despite initial treatment, or who are found to have abnormalities such as hematuria or an elevated PSA, should be referred to a urologist.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
•   Basics topic (see "Patient information: Prostatitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
•   Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a clinical syndrome, defined primarily on the basis of urologic symptoms and/or pelvic pain. It is the most common diagnosis in men presenting with prostatitis; acute and chronic bacterial prostatitis are less common. (See 'Definitions' above and "Acute and chronic bacterial prostatitis".)
•   The etiology of CP/CPPS is unknown. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms. (See 'Etiology' above.)
•   CP/CPPS is a diagnosis of exclusion. Patients should have a physical examination directed at identifying other etiologies of pelvic pain. Any patient suspected of prostatitis should also have a urinalysis and urine culture. Diagnostic imaging is used in selected patients. (See 'Differential diagnosis' above and 'Evaluation' above.)

Chronic prostatitis/chronic pelvic pain syndrome
Author
Michel Pontari, MD
Section Editor
Michael P O'Leary, MD, MPH
Deputy Editor
David M Rind, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2012. |This topic last updated:Μαϊ 14, 2012.
INTRODUCTION — Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a clinical syndrome, defined primarily on the basis of urologic symptoms and/or pain or discomfort in the pelvic region. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms [1].
The clinical manifestations, evaluation, and management of CP/CPPS will be reviewed here. Acute prostatitis and chronic bacterial prostatitis are discussed separately. (See "Acute and chronic bacterial prostatitis".)
DEFINITIONS — A number of terms have been used to describe the syndrome now commonly called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). These include prostatodynia (painful prostate) and abacterial prostatitis.
A classification approach supported by the National Institutes of Health (NIH) to standardize definitions and facilitate research is the currently accepted categorization of prostate syndromes [2]. This schema defines the following categories:
•   I. Acute prostatitis
•   II. Chronic bacterial prostatitis
•   IIIA. Chronic prostatitis/pelvic pain syndrome, inflammatory
•   IIIB. Chronic prostatitis/pelvic pain syndrome, noninflammatory
•   IV. Asymptomatic inflammatory prostatitis
Acute and chronic bacterial prostatitis (classes I and II, respectively) are discussed in detail elsewhere. (See "Acute and chronic bacterial prostatitis".)
Research guidelines define CP/CPPS as chronic pelvic pain for at least three of the preceding six months in the absence of other identifiable causes [3]. The inflammatory subset of CP/CPPS (class IIIA) includes patients with inflammatory cells in expressed prostatic secretions, postprostate massage urine, or seminal fluid. The noninflammatory CP/CPPS (class IIIB) subset includes the remainder of the patients with chronic prostatitis or pelvic pain. The distinction between inflammatory and noninflammatory CP/CPPS is generally for research purposes only, as there is no evidence that patients in the two subgroups have different symptoms or respond differently to therapy.
In contrast to the symptomatic patient presenting with CP/CPPS, asymptomatic inflammatory prostatitis (class IV) is typically diagnosed incidentally during prostate biopsy or an infertility or cancer work-up. This entity is not sufficiently studied to have an adequate understanding of its natural history, need for therapy, or response to treatment.
EPIDEMIOLOGY — Chronic prostatitis is a common condition worldwide, affecting approximately 2 to 10 percent of all adult men [4].
In one United States survey of 58,955 ambulatory visits to physicians by men over the age of 18 years, genitourinary tract symptoms accounted for 5 percent of all complaints, and prostatitis was listed as a diagnosis in nearly two million encounters annually [5]. Most men diagnosed with "prostatitis" have CP/CPPS rather than acute or chronic bacterial prostatitis [2].
In a large population-based Canadian study, 10 percent of the men had complaints compatible with chronic prostatitis, and 7 percent had moderate to severe symptoms [6]. The prevalence seems to peak in the fifth decade, but declines thereafter:
•   11 percent ages 20 to 39
•   13 percent ages 40 to 49
•   10 percent ages 50 to 59
•   9 percent ages 60 to 69
•   7 percent ages 70 to 74
ETIOLOGY — The etiology of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is unknown. Despite the use of the term "prostatitis," it is unclear to what degree the prostate is the source of symptoms [1].
Although bacterial infection has been suspected, particularly in the inflammatory subset of CP/CPPS, a bacterial etiology has not been consistently identified. Most experts believe that inflammatory and noninflammatory CP/CPPS are both noninfectious disorders [7,8]. Studies of Chlamydia, Mycoplasma, and Ureaplasma, which have all been implicated in chronic prostatitis, have generally concluded that they are not responsible for CP/CPPS [9-12]. Several investigators have performed polymerase chain reaction (PCR) testing looking for evidence of bacteria in prostatic tissues, but these have yielded negative results [13,14]. One study cultured prostatic biopsy specimens obtained via the transperineal approach from men with CP/CPPS and from normal volunteers [15]. There was no difference in the number of patients from whom bacteria were cultured (38 versus 36 percent, respectively).
Additionally, there appears to be little correlation between histologic prostatic inflammation and presence or absence of CP/CPPS symptoms [16]. Leukocytes can be found in the prostatic fluid of asymptomatic men, and there appears to be no correlation between the presence of leukocytes and symptoms [17].
Noninfectious etiologies have been proposed for CP/CPPS, but none has been proven [17]. These include inflammation due to trauma, autoimmunity, reaction to normal prostate flora or some other factor, neurogenic pain, increased prostate tissue pressure, and the interplay of somatic and psychologic factors [17-19]. Psychological stress, including anxiety and fear of severe illness, appears to be common in men with symptoms of CP/CPPS and may be a contributing factor [20,21].
CLINICAL MANIFESTATIONS — The symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) include pain (in the perineum, lower abdomen, testicles, penis, and with ejaculation), voiding difficulty (including bladder irritation and bladder outlet obstruction), and sometimes blood in the semen. Chronic prostatitis may also lead to problems with daily activities, depression, and overall quality of life [22]. CP/CPPS is also associated with erectile dysfunction and ejaculatory pain [23-25].
There is an association of chronic pelvic pain syndromes with other pain syndromes, such as irritable bowel syndrome (IBS), chronic fatigue syndrome, and fibromyalgia [26]. Given the overlapping innervation of the bowel and bladder [27], irritation of the bowel can result in lower abdominal pain and urinary symptoms as well. (See "Clinical manifestations and diagnosis of irritable bowel syndrome" and "Clinical features and diagnosis of chronic fatigue syndrome" and "Clinical manifestations and diagnosis of fibromyalgia in adults".)
The clinical course of CP/CPPS, with or without treatment, is not well-defined [28]. The patient usually will experience a relapsing-remitting pattern where the severity and frequency of flares decreases, usually over many months.
DIFFERENTIAL DIAGNOSIS — Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a diagnosis of exclusion.
The clinical presentation of CP/CPPS can be similar to that of chronic bacterial prostatitis, as both may present with urinary frequency, dysuria, and perineal pain. However, CP/CPPS does not present with low-grade fever, which can occur with chronic bacterial prostatitis. In patients with chronic bacterial prostatitis, the rectal examination may also demonstrate prostatic hypertrophy, tenderness, and edema, which does not occur in CP/CPPS. The evaluation of chronic bacterial prostatitis is discussed in detail elsewhere. (See "Acute and chronic bacterial prostatitis", section on 'Chronic bacterial prostatitis'.)
Other causes should also be considered prior to making a diagnosis of CP/CPPS [2]:
•   Urethritis (see "Infectious causes of dysuria in adult men")
•   Urogenital cancer (see "Clinical presentation, diagnosis, and staging of bladder cancer" and "Urethral cancer in men")
•   Urinary tract disease (see "Lower urinary tract symptoms in men")
•   Urethral stricture (see "Treatment of urethral stricture disease in men")
•   Neurologic disease affecting the bladder, such as spinal cord injury and lumbar spinal stenosis (see "Chronic complications of spinal cord injury", section on 'Urinary complications' and

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