Blog entry by Rcgp Learning
Prostatitis is a very common condition in men. According to a systematic review, 8.2% of men had prostatitis symptoms out of a selection of over 10,600 participants. (1). It is particularly prevalent in those aged 35-50 (2). Prostatitis covers a range of conditions such as acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
Although the symptoms of prostatitis present regularly in primary care, it can be a challenge for GPs to make a correct diagnosis due to the broad spectrum of causative triggers.
To establish a diagnosis of CBP or CP/CPPS, the patient should have a history of persistent or recurrent symptoms for a minimum of three out of the past six months, though often suspicion is raised after a shorter duration of symptoms. For CP/CPPS there is no ‘gold standard’ for definitive diagnosis, so it is typically based on the patient’s history and excluding other possible causes (1).
A definitive diagnosis of CBP relies on the presence of a recurrent urinary tract infection (UTI) and isolation of an aetiologically recognised organism from prostatic fluid or urine, though often treatment is commenced before an aetiologically recognised organism is cultured.
The four main categories of symptoms are as follows:
Pain could be from physical dysfunction, neuropathy and/or inflammation, with the most common sites being the prostate or pelvic floor muscles. A retrospective study showed that patients most commonly complained about pain in the perineal, testicular, pubic and penile areas.
There is growing evidence that depression, anxiety and panic disorders are more common in men with chronic pelvic symptoms, compared to other men.
Lower Urinary Tract Symptoms (LUTS)
These include voiding symptoms such as weak stream, straining and hesitancy or storage symptoms such as urgency, incontinence, frequency, nocturia and dysuria.
Symptoms include problems with ejaculation, erectile dysfunction or decreased libido.
Examination of patients with the symptoms of CP/CPPS should include the abdomen, external genitalia, bladder, perineum and a digital rectal examination. To rule out CBP and ABP, a urine dipstick and/or MSU for culture and microscopy should be arranged as well as sexually transmitted diseases screening. If appropriate, a prostate specific antigen test should be arranged, though levels can be elevated with prostate enlargement, infection, inflammation, so it might need to be postponed during the acute flare.
To assess severity and improvement of symptoms, the international prostate symptom score can be used.
Management is unsurprisingly varied and multi-modal and often based on expert or consensus opinion, as there is still lack of gold standard evidence. It ranges from antibiotics and alpha blockers to physiotherapy and CBT. The EKU module on ‘Chronic Prostatitis and Chronic Pelvic Pain Syndrome’ has a detailed work-up on treatment and management in primary care.
Patients should be reviewed 4-6 weeks after the initial presentation, with no further action required if the symptoms have resolved, but referral to specialist care should be considered at initial presentation if there is diagnostic uncertainty or symptoms are severe and require immediate specialist attention.
These patients require a holistic approach to their symptoms, and a good social, psychological and sexual history are important in their management.
For further and in-depth advice on diagnosis and management of chronic prostatitis and chronic pelvic pain syndrome, refer to EKU 15’s module on the topic.
(1) BJU International. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline.  Available from: http://onlinelibrary.wiley.com/doi/10.1111/bju.13101/pdf
(2) Prostate Cancer UK. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. [September 2014] Available from: https://prostatecanceruk.org/media/2491363/pcuk-chronic-prostatitis-guideline-full-sept-2015.pdf