Etiology and Treatment of Acute Prostatitis

Definition

Acute prostatitis refers to a recent-onset infection caused by bacterial invasion of the prostate gland. The only route to the prostate is through the urethra. It is therefore relatively rare that the patient will not recall an episode of urethritis (non-specific urethritis,  NSU) prior to the onset of prostate symptoms. Often the patient can vividly describe the events that took place within hours or days following a sexual encounter. Bacteria entering the urethra will travel along the urethral wall and the patient recalls the urethral involvement as it progresses. Once the infection arrives to the posterior/prostatic urethra the bacteria will spread into the prostate and into the urinary bladder. It is not uncommon for the patient to be diagnosed with acute cystitis and non-specific urethritis before the prostatitis diagnosis is given. 

Symptoms

Symptoms related to the prostate are pain at the base of the penis, around the anus and/or above the pubic bone. The pain may radiate to the tip of the penis and along the ductus deferens to the testicles. Passing stool may be painful. Fever can develop with general aches and pain. Discharge from the penis is not uncommon. Often a bloody discharge is also reported.  The patient may be systemically toxic, that is, flushed, febrile, tachycardic, tachypneic, and even hypotensive. The patient usually has suprapubic discomfort and perhaps has clinically detectable acute urinary retention. Perineal pain and anal sphincter spasm may complicate the digital rectal examination. The development of bilateral lower back back pain usually signals involvement by the Seminal Vesicles.

Physical Examination

Transrectal examination of the prostate itself usually reveals a hot, boggy, and extremely tender organ. The expression of prostatic secretion (EPS) causes significant pain and is often impossible to obtain. I believe in light of the obvious clinical picture it is unnecessary and perhaps even harmful.

Laboratory Examination

Laboratory examination will reveal a profusion of white or red blood cells, or both in the urethral secretion and  almost always there are abundant white blood cells in the urine and semen specimen. A midstream urine specimen will show significant uropathogens. In acute infections, clumping of spermatozoa or morphological changes of sperm are rare. Similarly,  if obtained, EPS will show white, red and epithelial cells. In acute infections sloughing of tubular epithelial cells is often seen, Though white blood cell or epithelial cell casts are rare.

A sonogram may show a slightly swollen prostate that is tender when pressed upon with the sonogram probe. A  biopsy taken at this time would show edematous tissues with an abundance of white blood cells both inside and outside the prostatic acini. 

A urine culture is the only laboratory evaluation of the lower urinary tract required by the AUA( American Urological Association). It has been suggested that the vigorous prostatic massage necessary to produce EPS can exacerbate the clinical situation, although such fears have never been substantiated in the literature.

Bacteria Causing Acute Prostatitis

In our experience semen, EPS and urethral swab cultures are by far more rewarding than testing urine samples. Prior to effective surveillance, Gonorrhea was the number one cause of both acute urethritis and prostatitis. In our clinical experience, today —

1. Chlamydia trachomatis is the number one cause of acute prostatitis. Therefore, cystoscopies hardly ever alter the treatment course.
2. Entrobacteriaceae (originate in the colon)
3. Escherichia coli,  Pseudomonas aeruginosa, Serratia species, Klebsiella species
4. Enterobacter aerogenes
5. There are also sometimes gram-positive uropathogens such as  Enterococcus spp. implicated.
6. The role of other gram-positive organisms is less certain:  Staphylococcus saprophyticus, hemolytic Streptococci, Staphylococcus aureus, and other coagulase-negative staphylococci
7. Ureaplasma and Mycoplasma group:  Uncertain significance

Treatment for Acute Prostatitis

At the MacLeod Laboratory we rarely encounter patients in the early stages of prostate infection. Patients with acute prostatitis usually visit a family physician, general practitioner, or a urologist first and often undergo the customary therapy which includes a single drug regimen administered orally for a maximum duration of two to three weeks. At those visits culture studies are rarely ordered.  EPS examination, semen analysis, or manual rectal examinations are not routine. I have not encountered any patient who has undergone rectal ultrasonography at this stage of the disease. The extent of the microbial examination is usually limited to the urine sediment, examined under a microscope.

  In our practice the protocol calls for urine/semen/EPS cultures, manual rectal examination, and rectal ultrasonography.

When a patient with recent onset prostatitis with typical physical signs and symptoms visits us, we do not wait for the return of the culture studies. We consider acute prostatitis both a medical and a reproductive emergency. It is our belief that the great majority of men suffering from chronic prostatitis became victims of this debilitating disease at the very first episode, during the acute phase of the infection, when the opportunity for complete cure was mishandled.

Since the culture studies can take as long as three weeks to be completed, in acute cases  with generalized clinical symptoms and fever,  we initiate antibiotic therapy promptly. An antibiotic cocktail is directly injected into the prostate gland and intravenous broad spectrum antibiotic therapy begins simultaneously for a ten-day course. The  prostatic injections of the antibiotic cocktail are repeated daily through the ten-day treatment course.

Based on our clinical experience there is a high frequency of Chlamydia isolation in patients with prostatitis, therefore, there are at least three different drugs active against Chlamydia in the antibiotic cocktail we use. The therapy also covers anaerobic bacteria, a large number of aerobic bacteria, the Mycoplasma group, yeast, and Trichomonas, the most frequently encountered genital tract parasite.

Usually by the end of this intense therapy, we have the initial culture results showing whether Chlamydia was recovered. Based on these laboratory findings, at least  a four-week oral antibiotic regimen usually follows.

For patients whose culture is  positive for Chlamydia, the oral therapy will contain at least two different antibiotics to reduce the chance of resistant bacteria developing. Even if a complete symptom free state is achieved through our therapy, we recommend booster injections three, six, and nine months following therapy.