Prostatitis is the term given to a complex constellation of symptoms and ﬁndings related to the prostate. Currently, there are four general categories of clinically deﬁned prostatitis. They are differentiated based on symptoms and the urinalysis ﬁndings of bacteruria and pyuria. The categories are acute bacterial (NIH Class I), chronic bacterial (NIH Class II), inﬂammatory (NIH Class IIIA) or noninﬂammatory (NIH Class IIIB), and asymptomatic inﬂammatory prostatitis (NIH Class IV). Class III prostatitis is also termed chronic nonbacterial prostatitis/chronic prostatitis and pelvic pain syndrome (CPPS).
Acute bacterial prostatitis typically presents with acute urinary tract infection (UTI) symptoms and infected urine, typically with gram-negative organisms. It is unusual but may be related to urologic instrumentation and chronic catheter use. Clinically, it involves the acute onset of irritative voiding symptoms, dysuria, pelvic and perineal pain, fever, and hematuria. Not uncommonly, a rectal exam reveals a tender, “boggy” prostate. Cloudy, infected urine is a feature that differentiates it from prostatic infarction. Histologically, prostatic acini are ﬁlled with exudate, and the stroma is inﬁltrated with leukocytes. When severe, urinary retention may result, which is treated with urethral or suprapubic catheter drainage. The infection requires broad-spectrum, gram-negative antibiotics that are later adjusted to bacterial sensitivity. Chronic bacterial prostatitis can occur with or without an antecedent acute form and is characterized by acute or chronic symptoms and infected urine. Patients experience recurrent episodes of bacterial UTI caused by the same organism, usually Escherichia coli, another gram-negative organism, or enterococcus. Between symptomatic episodes, lower urinary tract cultures can document an infected prostate gland as the focus of recurrent infections. Indwelling catheters, instrumentation, recurrent UTIs, bladder stones, or spread from distant infections such as abscessed teeth, bronchitis, pneumonia, or sinusitis may underlie this diagnosis. Chronic prostatitis can be asymptomatic but is usually associated with complaints of scrotal, penile, low back, inguinal, or perineal pain; sexual dysfunction; and irritative or obstructive urinary symptoms. The ﬁnding of a boggy or ﬂuctuant prostate on rectal examination is unusual. Histologically, prostatic acini contain increased leukocytes and the stroma is inﬁltrated with plasma cells and varying degrees of ﬁbrosis. Prostatic ducts can also be chronically inﬂamed and dilated, indicating an infection that extends from the urethra.
Class III inﬂammatory or noninﬂammatory prostatitis is not primarily a disease of the prostate or the result of an inﬂammatory process but is a moniker for a symptom complex suggestive of bacterial prostatitis but in the absence of bacteruria. More than 90% of symptomatic patients fall into this category of prostatitis. Symptom duration and intensity can be signiﬁcant and can be associated with profound impacts on patient quality of life. Pyuria can be present (IIIA) or absent (IIIB) in the urine, semen, or in the urethral ﬂuid obtained after expressed prostatic massage. Urologic pain complaints are the primary component of this syndrome, and exclusion criteria include the presence of active urethritis, urogenital cancer, urinary tract disease, functionally signiﬁcant urethral stricture, or neurologic disease affecting the bladder. This prostatitis category recognizes the limited understanding of the causes of this syndrome and the possibility that organs other than the prostate gland may be causally important.
Asymptomatic inﬂammatory prostatitis is diagnosed in patients without a history of genitourinary tract pain complaints. The diagnosis is made during evaluation of other genitourinary tract issues, including (1) the ﬁnding of inﬂammation on a prostate biopsy for possible prostate cancer because of an elevated serum prostate-speciﬁc antigen (PSA) level and (2) elevated leukocytes in the seminal ﬂuid of infertility patients (pyospermia). Treatment is aimed at decreasing PSA levels or restoring normal semen quality, as pain is not a component of this diagnosis.
Prostatic abscess as a consequence of acute prostatitis is unusual with modern antibiotic therapy. Abscess can occur with metastasis from distant infectious foci or as a complication of immunosuppressive disease. Symptoms are similar to those of acute prostatitis, but stranguria and tenesmus are more common, along with acute urinary retention. Prostatic abscess can sometimes be detected on rectal examination with the ﬁnding of a boggy and tender gland. If untreated, the abscess usually spares rectal involvement due to Denonvilliers fascia posteriorly, but rupture and drainage into the posterior urethra is possible. Treatment with incision and drainage through endoscopic unrooﬁng or transrectal or perineal drainage may be required along with appropriate antibiotics.