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The Diagnosis of Prostatitis: Category I ABP

The document discusses the diagnosis and evaluation of different categories of prostatitis: 1. Category I ABP presents with signs of localized and systemic infection like pelvic pain and fever. Examination finds a painful, boggy prostate and urine/blood cultures are needed. 2. Category II CBP involves recurrent UTIs with the same organism. Evaluation includes urine and prostate massage cultures to identify the infecting organism. 3. Category III CP/CPPS is the most common type, involving long-term pelvic pain and urinary symptoms. Evaluation focuses on ruling out infection via urine and prostate massage cultures, with symptom questionnaires also used.

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Daphne Celine
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47 views

The Diagnosis of Prostatitis: Category I ABP

The document discusses the diagnosis and evaluation of different categories of prostatitis: 1. Category I ABP presents with signs of localized and systemic infection like pelvic pain and fever. Examination finds a painful, boggy prostate and urine/blood cultures are needed. 2. Category II CBP involves recurrent UTIs with the same organism. Evaluation includes urine and prostate massage cultures to identify the infecting organism. 3. Category III CP/CPPS is the most common type, involving long-term pelvic pain and urinary symptoms. Evaluation focuses on ruling out infection via urine and prostate massage cultures, with symptom questionnaires also used.

Uploaded by

Daphne Celine
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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The Diagnosis of Prostatitis

Category I ABP

The patient presenting with category I ABP will have signs and symptoms of
both localized and systemic infection. The patient will complain of perineal and
lower pelvic pain; obstructive, irritative, and painful voiding symptoms; fever;
chills; and perhaps nausea. On examination, the patient will appear ill, perhaps
febrile and dehydrated. If the patient is unable to void properly, he may have a
distended bladder (which may be detected by palpation and/or percussion). The
prostate examination is extremely painful and various authors have described
the prostate as being "boggy" and "hot." A urine culture is mandatory and a
blood culture is suggested if the patient presents with sepsis. A bladder scan
will confirm whether or not the patient is fully emptying his bladder. A prostate
massage for prostatic fluid is extremely painful, usually unhelpful, and might
even be dangerous to the patient. If a patient is not responding to therapy, the
development of a prostatic abscess should be suspected and a transrectal
ultrasound or computed tomography (CT) scan undertaken.
Category II CBP

Patients with this condition present in 1 of 2 ways.[23] The classic presentation is


of a complaint of recurrent UTIs with the same organism at each episode. The
patient will be relatively asymptomatic between treated episodes. The other way
that this condition presents is very similar to the one described later in this
section for category III CP/CPPS. Patients have low-grade obstructive and
irritative voiding symptoms associated with genitourinary and pelvic pain. The
symptoms usually fluctuate with exacerbations and partial remissions. If the
patient presents with a UTI, a focused physical examination including a digital
rectal examination is required. Urine is cultured, and the patient is treated. Once
the patient is either asymptomatic or in partial remission following
antimicrobial therapy, an evaluation of the lower urinary tract is recommended.
In the past, this evaluation involved the 4-glass Meares-Stamey or urinary tract
localization test.[27] This procedure, which is well known to most urologists (at
least the older urologists), includes a collection of initial urine (voided bladder 1
or VB1), a midstream urine (voided bladder 2 or VB2), followed by a careful
digital rectal examination to examine the consistency, size, and tenderness of
the prostate gland. A prostate massage is then undertaken. Prostate massage is
performed by gently but firmly rolling the finger from peripheral to medial on
each side, starting from the base and proceeding to the apex. Prostatic fluid can
usually be produced and is collected as well. The patient then produces another
initial stream of urine after prostate massage (voided bladder 3 or VB3). The 3
urine samples and EPS are sent for quantitative culture, while the sediment of
the 3 urine samples and a wet mount of the EPS are examined under the
microscope for leukocytosis. However, very few urologists still perform this
difficult, time-consuming, and expensive test.[28] A simpler and less costly test
that is almost as accurate as the older method was described several years ago.
[29]
 The new test, which is known as the pre- and postmassage test (PPMT),
compares the bacterial culture results from a midstream urine specimen with
those from a postprostatic massage initial urine specimen. A study reported in
2005 validated the PPMT by comparing it to the older test. Investigators looked
at data from 283 men with CP/CPPS for whom complete VB1, VB2, EPS, and
VB3 samples were available. By examining only the pre- (VB2) and post-
(VB3) massage specimens, they were able to determine that, in over 95% of
cases, PPMT gave the same diagnosis as would be obtained by interpreting the
entire 4-glass Meares-Stamey test.[30] The PPMT is now recommended for
clinical practice in men presenting with chronic prostatitis syndrome.
Category III CP/CPPS
The most common form of prostatitis is nonbacterial chronic pelvic pain
syndrome. Men with this condition present with a long history (by definition,
longer than 3 months) of genitourinary pain with variable obstructive and
irritative voiding symptoms and, perhaps, sexual dysfunction.[25] A complete
history and physical examination including digital rectal examination and
focused neurologic examination are mandatory. Urinalysis and urine culture are
also mandatory. To rule out infection in the prostate gland (which is required to
make this diagnosis), it is strongly suggested that a lower urinary tract
evaluation be undertaken (at least for culture) using the PPMT (test pre-massaggio
e post-massaggio (PPMT).. Microscopic examination of the pre- and postprostatic
massage urine sediment is of academic interest only at this time, because
clinical studies have not been able to find associations between the
inflammatory status of the lower urinary tract and type of prostatitis, severity of
symptoms, and differential response to therapy.[20,21,22] It is also strongly
suggested that patients complete the NIH-CPSI.[2] This symptom index,
validated for symptom assessment in clinical trials,[30,31] has proven invaluable
in clinical practice as well.[32] The questionnaire, which can be completed in 5
minutes by the patient, explores the 3 most important domains of patients'
experience: pain (location, frequency, and severity), voiding symptoms
(obstructive and irritative), and, very important, impact on quality of life
(Figure 2).

(Click to enlarge)
Figure 2. NIH - Chronic Prostatitis Symptom Index. The NIH-CPSI captures
the 3 most important domains of prostatitis experience: pain (location,
frequency, and severity), voiding (irritative and obstructive symptoms), and
quality of life (including impact). This index is useful in research studies and
clinical practice. Reprinted with permission.[2]

This easy-to-administer questionnaire allows the urologist to quickly ascertain


the relative severity of the various domains in the patient's condition and, even
more importantly, it allows the physician to follow the progress of the patient
during and after therapy. It is suggested that a urinary cytology be collected,
particularly in men with microscopic hematuria in the premassage specimen or
those with irritative voiding symptoms. Other optional tests include abdominal
and pelvic ultrasound, transrectal ultrasound, CT scan, and urodynamics
including videourodynamics, and so on. Table 2 outlines the recommendations
for evaluation of a man presenting with category III CP/CPPS. [33]
Table 2. Suggested Evaluation of a Man With CPPS [adapted from reference
33]
Mandatory
History
Physical examination, including digital rectal examination
Urinalysis and urine culture
Recommended
Lower urinary tract localization test
Symptom inventory or index (NIH-CPSI)
Flow rate
Residual urine determination
Urine cytology
Optional
Semen analysis and culture
Urethral swab for culture
Pressure flow studies
Videourodynamics (including flow electromyography)
Cystoscopy
Transrectal ultrasound
Pelvic imaging (ultrasound, computed tomography, magnetic resonance imaging)
Prostate specific antigen
Category IV AIP

Because, by definition, the patient with this condition is asymptomatic, no


diagnostic tests are indicated. This may change in time as we learn more of the
relevance and importance of AIP in related conditions such as benign prostatic
hyperplasia, prostate cancer, and infertility.

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