Overview

Chronic prostatitis is defined as ≥3 months of urogenital pain (e.g. perineal, rectal, penile, testicular pain) and is associated with lower urinary tract symptoms and sexual dysfunction.

It can be further divided into:

  • Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) – 90% of cases
    • Also known as abacterial prostatitis or prostate pain syndrome
    • There is no proven bacterial infection
  • Chronic bacterial prostatitis – <10% of cases

Prostate pain syndrome is a term that may be used instead of CP/CPPS, however, this is not used in the UK.

Causes

Overview

The exact pathophysiology is unknown but is thought to be due to persisting inflammation after an acute infection has resolved. Some evidence suggests that pain is neuropathic.

In chronic bacterial prostatitis, causes may include:

Common organisms in chronic bacterial prostatitis are similar to those implicated in UTI, such as Escherichia coli.

Epidemiology

  • Chronic prostatitis is more common than acute prostatitis
  • Up to 10% of people experience problems similar to chronic prostatitis during their life
  • The risk of prostatitis is 3 times higher in people aged 50-60 years old compared to those who are 20-40 years old

Presentation

Overview

The features of chronic prostatitis persist for at least 3 months and may include:

  • Pelvic pain – commonly in the perineum, may be inguinal, scrotal, penile, in the lower abdomen, lower back, or rectum
  • Lower urinary tract symptoms (LUTS) – voiding symptoms, storage symptoms, dysuria:
  • Sexual dysfunction – erectile dysfunction, painful ejaculation, premature ejaculation, decreased libido
  • Features of irritable bowel syndrome – such as painful bowel movements, seen in up to 30% of people
  • Digital rectal exam – the prostate may be enlarged and tender, hard from calcification, or normal

Differential Diagnoses

Acute prostatitis

  • Patients present more acutely with more severe symptoms and often with systemic upset (e.g. fever, tachycardia)
  • The prostate may be very tender and boggy

Investigations

Overview

The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) can be used to assess the impact of chronic prostatitis on a person’s life.

Investigations include:

  • Urine dipstick:
    • May identify features suggesting bacterial infection such as nitrites and leukocytes
  • Mid-stream urine sample for microscopy, culture, and sensitivity:
    • Screens for urinary tract infection
  • Sexually transmitted infection (STI) screen:
    • Consider if STI is suspected, particularly people <35 years old with multiple sexual partners or a recent partner change
    • Done with a first pass urine sample and nucleic acid amplification test (NAAT) testing for Chlamydia and gonorrhoea. A urethral swab may be considered for trichomoniasis.

If there is suspicion of prostate cancer, prostate-specific antigen (PSA) should be checked, however, both forms of prostatitis can lead to elevated PSA.

Management

Overview

Initial management of chronic prostatitis in primary care may involve:

  • Analgesia – paracetamol or NSAIDs
  • Alpha-blockers – if significant LUTS are present
  • Antibiotics if symptoms have been present for <6 months (trimethoprim or doxycycline)
  • Laxatives – for painful defecation
  • Cognitive behavioural therapy, counselling, and/or antidepressants if necessary

Referral

Refer to a urologist if any of the following apply:

  • Diagnostic uncertainty
  • Severe symptoms – use clinical judgement for urgency of referral
  • Symptoms persist after initial management

Complications

The main complications of chronic prostatitis are a reduced quality of life and psychosocial complications including depression and anxiety.

Prognosis

  • For CP/CPPS some studies (n=286) have shown that symptoms improve in most men after 6 months of treatment
  • For CPB, eradications rates with antibiotics are up to 80% and symptoms have been reported to improve, but not many of these trials use the validated NIH-CPSI tool

Author