Introduction

Chronic prostatitis is very common, and the incidence increases with age.  Chronic prostatitis is a broad definition encompassing infection, inflammatory and non-inflammatory clinical syndromes comprising a complex of chronic pelvic pain, voiding disturbance and sexual dysfunction. Less than 10% of chronic prostatitis diagnoses have a bacterial aetiology.

Aetiology of chronic prostatitis syndromes

The aetiology of the chronic prostatitis syndromes is not well understood. Uncontaminated samples of prostatic fluid are difficult to obtain, so it is not clear if isolates (when found) are causative or associated with the syndrome.

Chronic bacterial prostatitis

Pathogenic bacteria are only found in a minority of cases (<10%) of chronic prostatitis: these are the patients defined as having chronic bacterial prostatitis. Organisms are those found in acute prostatitis:

• Escherichia coli and other Gram-negative organisms
• Staphylococcus aureus
• Enterococcus faecalis and other Enterococcus spp.

Chronic pelvic pain syndrome (CPPS)

Pathogenic bacteria are, by definition, not found.  Intracellular pathogens such as Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Staphylococcus epidermidis or fastidious Streptococcus spp. have been suggested as an explanation of negative cultures from patients exhibiting CPPS, but the evidence is not strong.  Other organisms implicated in CPPS include Trichomonas vaginalis, coryneforms, and rarely Neisseria gonorrhoeae, mycobacteria and fungi.

Other possible causes of CPPS include inflammatory reactions from urine reflux and autoimmune processes.

Diagnosis of chronic prostatitis syndromes

Clinical

Chronic prostatitis syndromes are associated with a long-term (>6 months) history of symptoms including:

• The prostate gland may be tender, but this is not always the case.
• A history of recurrent UTI increases the probability that pathogenic bacteria will be found.

Laboratory diagnosis

Pathogens are found in less than 10% of cases, but the following tests may help with diagnosis:

• Prostatic massage.
• Urine samples for microscopy and culture. 

The presence of pathogens defines chronic bacterial prostatitis.

Other potentially useful tests:

• ³10 polymorphonuclear leucocytes per high-power field in EPS
• The pH of expressed prostatic secretions ³8 (normally acidic)
• Swabs should be taken to exclude sexually-transmitted diseases.

Management of chronic prostatitis

Chronic bacterial prostatitis

Chronic bacterial prostatitis is more difficult to treat than acute prostatitis because the gland is either subacutely inflamed or not inflamed, which means that few antibiotics are able to penetrate the prostate well.

Antibiotic rationale and empirical therapy

The choice of antibiotic depends on penetration into the prostate gland and antimicrobial sensitivities. 

• The quinolones penetrate the prostate well, at least to levels achieved in the plasma, and ciprofloxacin achieves concentrations in seminal fluid up to nine times the plasma concentration. Quinolones such as ciprofloxacin cover the Gram-negative and Gram-positive uropathogens as well as some of the rarer pathogens such as gonococci, mycoplasma and chlamydia.
• Trimethoprim is active against many urinary tract pathogens and achieves high concentrations in the acidic pH of the normal prostate.  However, the neutral or alkaline pH often encountered in prostatic secretions from patients with chronic prostatitis means that prostatic fluid trimethoprim concentrations can be expected to be negligible, which may explain why clinical studies show trimethoprim/co-trimoxazole cure rates <50% in patients with chronic bacterial prostatitis.  Hence, trimethoprim/co-trimoxazole are generally not first-line choices for chronic prostatitis.
• Both minocycline and doxycycline have good penetration into the prostate but doxycycline is preferred because it is less toxic than minocycline and resistance to minocycline can be high in urinary tract pathogens.

First-line treatment:

• A fluoroquinolone such as ciprofloxacin
• Alternatively, for patients allergic to quinolones, either
  • doxycycline

    or

  • trimethoprim plus rifampicin.

For each alternative, a minimum of 28 days’ treatment is required. 

Chronic prostatitis/chronic pelvic pain syndrome (CPPS)

In CPPS, there are no firm guidelines but a recent Cochrane report has found no evidence to support antibiotic use.

Treatment options include:

• Transurethral microwave thermotherapy.
• Alpha-blockers:
  • Terazosin
  • Alfuzosin (in patients with confirmed urological abnormalities).
• Non-steroidal anti-inflammatories.

National guideline for the management of prostatitis.