Most patients with chronic bacterial prostatitis do not have a preceding acute inflammatory process. The causative pathogens include Escherichia coli, Proteus species, Klebsiella species, Staphylococcus, and Streptococcus. It may also result from infections caused by Neisseria gonorrhoeae, primarily due to retrograde urethral infection. Histologically, the prostate is divided into an inner layer and a peripheral layer. The ducts of the inner layer allow anterograde flow, whereas the ducts in the peripheral layer exhibit retrograde flow. During ejaculation, infected pathogens in the posterior urethra may be propelled in large amounts toward the peripheral layer. In cases of incomplete bladder emptying, infected urine may retrogradely flow into the prostatic ducts, making the infection harder to control. Additionally, the lipid-like membrane of the prostatic epithelium acts as a barrier to many antibiotics entering the prostatic acini, which contributes to the challenges in curing chronic prostatitis effectively and completely.
Clinical Manifestations
Changes in Urination and Urethral Discharge
Symptoms include urinary frequency, urgency, dysuria, and discomfort or burning sensations in the urethra during urination. After urination or defecation, a white discharge may sometimes be observed seeping from the urethral opening, a phenomenon referred to as "urethral dribbling." Hematospermia may occur when seminal vesiculitis coexists.
Pain
Dull pain or discomfort in the perineum and lower abdomen is common. Occasionally, similar sensations may be experienced in the lumbosacral region, the suprapubic area, or the groin.
Sexual Dysfunction
Erective dysfunction, premature ejaculation, nocturnal emissions, or pain during ejaculation may occur.
Neurological and Psychological Symptoms
Symptoms such as dizziness, a heavy sensation in the head, fatigue, lethargy, insomnia, low mood, irritability, and excessive worry may develop.
Complications
Complications include epididymitis and infertility.
Diagnosis
The diagnosis of chronic bacterial prostatitis is based on:
- Recurrent urinary tract infections.
- Persistent presence of pathogens in prostatic massage fluid.
However, accurate diagnosis can be challenging in clinical practice.
Digital Rectal Examination (DRE)
The prostate may appear enlarged, soft, and mildly tender during rectal examination. In prolonged cases, the prostate may shrink, harden, and exhibit uneven consistency with small nodules. Prostatic massage is used to collect prostatic fluid for laboratory examination.
Prostatic Fluid Analysis
In the presence of prostatitis, prostatic fluid typically shows more than 10 white blood cells per high-power field under microscopy, and reduced lecithin bodies. However, no direct correlation exists between the severity of prostatitis symptoms and the number of white blood cells in the fluid.
A segmented urine test, along with prostatic fluid culture, may be performed. Preceding the test, adequate hydration is required. The first 10 ml of urine (referred to as VB1, voided bladder one) is collected, followed by voiding 200 ml of urine. The next 10 ml of midstream urine sample (VB2, voided bladder two) is collected. Subsequently, prostatic massage is performed, and the expressed prostatic secretion (EPS) is obtained. Finally, 10 ml of post-massage urine (VB3, voided bladder three) is collected. All samples are sent for bacterial culture and colony counts. A colonization count of EPS or VB3 that is 10 times greater than VB1 and VB2 supports a diagnosis of bacterial prostatitis. If VB1 and VB2 cultures are negative but VB3 and prostatic fluid cultures are positive, the diagnosis is confirmed. This diagnostic approach is also known as the Meares-Stamey "four-glass test."
Ultrasound
An unclear or disrupted prostatic tissue boundary and the presence of calcifications may suggest prostatitis. Cystoscopy may reveal congestion and swelling of the posterior urethra and the verumontanum.
Treatment
Antibiotics with strong tissue penetration, such as fluoroquinolones or trimethoprim-sulfamethoxazole, are often chosen. Other clinically used antibiotics include erythromycin, doxycycline, or cephalosporins. Combination or rotational use of antibiotics may reduce resistance development.
Comprehensive management includes:
- Warm sitz baths and physiotherapy to reduce local inflammation.
- Prostatic massage, performed weekly, to drain inflammatory secretions.
- Avoidance of alcohol and spicy foods, avoidance of prolonged sitting (especially on bicycles), and maintaining consistent sexual activity.