FIGURE 13-4

a.magnetic resonance imagine (MRI) for staging.

b.antimicrobial therapy.

c.drainage.

d.retrograde urethrography.

e.transrectal prostate biopsy.

Answers

1.e. unknown. A careful review of the evidence for and against the role of microorganisms—culturable, fastidious, or nonculturable—leaves the reviewer undecided, and etiologic mechanisms other than microorganisms must be considered.

2.d. differentiates CP/CPPS category IIIA patients from category IIIB patients. The differentiation of the two subtypes of category III CPPS is dependent on cytologic examination of the urine and/or EPS.

3.b. a research tool that is useful in clinical practice. The National Institutes of Health Chronic Prostatitis Collaborative Research Network developed a reproducible and valid instrument to measure the symptoms and quality of life/impact of chronic prostatitis for use in research protocols as well as in clinical practice. The symptom index has also proved its usefulness in the evaluation and follow-up of patients in general clinical urologic practice.

4.b. Perform a transrectal ultrasonographic examination. Development of a prostate abscess is best detected with transrectal ultrasonography.

Patients with acute bacterial prostatitis are easily diagnosed and successfully treated with appropriate antibiotic therapy, as long as the clinician keeps a high index of suspicion for prostate abscess in patients who fail to respond quickly to the antibiotics.

5.c. Category IIIA. Diagnosis of category IIIA CP/CPPS, or inflammatory CPPS, is based on the presence of excessive leukocytes in EPS, a postprostatic massage urine sample, or semen.

6.d. Category IIIB. Diagnosis of category IIIB CP/CPPS, or noninflammatory CPPS, rests on no significant leukocytes being found in similar specimens.

7.b. Category II. Category I is identical to the acute bacterial prostatitis category of the traditional classification system. Category II is identical to the traditional chronic bacterial prostatitis classification.

8.e. restart fluoroquinolone antibiotics. The most important clue in the diagnosis of category II, chronic bacterial prostatitis is a history of documented recurrent urinary tract infections. The fluoroquinolone should be continued for a minimum of 4 weeks.

9.c. Video-urodynamics. A wide constellation of irritative and obstructive voiding symptoms is associated with CP/CPPS. Proposed etiologies to account for the persistent irritative and obstructive voiding symptoms include detrusor vesical neck or external sphincter dyssynergia, proximal or distal urethral obstruction, and fibrosis or hypertrophy of the vesical neck. Although flow rate and bladder scan can be done to further delineate these conditions, these abnormalities can be clarified and diagnosed best by urodynamics, particularly video-urodynamics.

.b. Several days of nitrofurantoin therapy followed by a lower urinary tract localization test. In a patient who has acute cystitis, the localization of bacteria in the EPS or VB3 specimen (postprostatic massage sample) is impossible, and, in this case, the patient can be treated with a short course (1 to 3 days) of antibiotics such as nitrofurantoin, which penetrates the prostate poorly but eradicates the bladder bacteriuria. Subsequent localization of bacteria in the postprostatic massage urine sample or EPS sample is then diagnostic of category II prostatitis.

.d. trimethoprim. Studies of animals with and without infection showed that trimethoprim concentrated in prostatic secretion and prostatic interstitial fluid (exceeding plasma levels), whereas sulfamethoxazole and

ampicillin did not. It would be appropriate therefore to not prescribe the combination trimethoprim-sulfamethoxazole in a patient with multiple allergies.

.a. Low-dose prophylactic antibiotics. Prolonged therapy with low-dose prophylactic or suppressive antimicrobials can be considered for recurrent or refractory prostatitis, respectively.

.d. Biofeedback. On the basis of the possibility that the voiding and pain symptoms associated with CPPS may be secondary to some form of pseudodyssynergia during voiding or repetitive perineal muscle spasm, biofeedback has the potential to improve this process. Bladder neck incision in

a young man should be avoided until after he has his family because of the possibility of retrograde ejaculation.

.c. Transurethral drainage. In patients who fail to respond quickly to antibiotics, a prostatic abscess is optimally drained by the transurethral incision route, although ultrasound-guided percutaneous aspiration (via any route) could be attempted first.

.e. May have value in some patients with Category III. Six randomized placebo-controlled trials have shown efficacy for terazosin, alfuzosin, and tamsulosin in patients with CPPS. However, two recent NIH-sponsored large randomized placebo controlled trials have not confirmed its efficacy in heavily pretreated chronic patients, or in recently diagnosed α-blocker naive patients. A number of meta-analyses have confirmed a modest treatment effect, but it appears that the best results are obtained when α- blockers are used as part of a multimodal treatment strategy.

.a. urine analysis, urine culture. Mandatory evaluation of a typical man presenting with CP/CPPS includes history-taking, physical examination, urinalysis, and urine culture.

.a. Observation. Asymptomatic inflammatory prostatitis (Category IV) by definition does not require symptomatic therapy.

.c. a phenotype categorization. UPOINT is a classification system that categorizes CP/CPPS patients into one or more of six distinct clinical phenotypes.

.d. is a reasonable choice for selected patients. In a number of shamcontrolled trials, acupuncture was shown to be effective in some patients.

.a. rest. Studies show that the maladaptive pain coping technique of using "pain contingent resting" (the use of rest rather than more active behaviors to control pain) is not beneficial.

1.e. Ask the pathologist if the diagnosis could be corpora amylacea. Corpora amylacea are most often associated with BPH. Amyloid of the prostate does not look like this; moreover, if there is concern for amyloid, a Congo Red stain should be obtained. Asking the pathologist to clarify the diagnosis, which would be unusual given the circumstances, is most appropriate.

2.d. observe the patient. The pathology shows multinucleated giant cells, which are not uncommonly seen after chronic irritation. There is no evidence of caseating necrosis and, in this patient with a cause for the giant cells, observation is the correct course.

Imaging

1.d. epididymo-orchitis. The image demonstrates skin thickening in the scrotum, hydrocele, and a complex hypoechoic mass in the enlarged epididymis that has no flow; color flow Doppler images demonstrate increased flow in the testis and in the remainder of the epididymis, consistent with epididymo-orchitis complicated by an epididymal abscess. These composite findings make the other listed possibilities less likely.

2.c. drainage. The CT image demonstrates low-attenuation areas in the prostate, primarily the left posterolateral aspect, with extension into the left periprostatic region. The appearance is most compatible with an abscess. This could be confirmed with transrectal ultrasonography. These findings on CT along with the clinical history and a rectal examination, which would reveal extreme tenderness, are sufficient to suggest a prostate abscess. Urgent drainage is prudent in such patients. Although urethral strictures and upper tract abnormalities may be the cause of recurrent urinary tract infections in a male, neither study is required urgently in a patient with a prostatic abscess. Antimicrobial therapy alone is not sufficient treatment at this stage of the infection. MRI may help in delineating the extent of involvement in equivocal cases but is unlikely to add more useful information when the results of CT and the physical examination are flagrantly abnormal. The appearance of the prostate on the CT image is not consistent with prostate cancer.

Chapter review

1.Granulomatous prostatic inflammation is a common occurrence following surgery or BCG treatment.

2.The most common cause of acute bacterial prostatitis is the

Enterobacteriaceae family of gram-negative bacteria.

3.Bacteria reside deep in the ducts of the prostate gland and form aggregates called biofilms that allow the bacteria to persist in the presence of antibiotics.

4.Factors that increase the risk of bacterial colonization of the prostate include (1) intraprostatic ductal reflux, (2) phimosis, (3) specific blood groups, (4) unprotected anal intercourse, (5) urinary tract infections, (6) acute epididymitis, (7) indwelling urethral catheters, (8) condom catheter drainage, and (9) transurethral surgery.

5.Prostate-specific antigen levels can be markedly elevated during an episode of prostatitis.

6.Cytokines appear to play an important role in the development of prostatitis.

7.There is no validated level of WBCs in prostatic fluid that differentiates noninflammatory from inflammatory conditions; however, a finding of 5 to 10 WBCs/HPF is considered by many to be the upper limit of normal for prostatic fluid.

8.Patients with prostatitis-like symptoms who have no evidence of infection and complain of irritative voiding symptoms should have urine cytology performed.

9.It may not be the specific type of bacteria that causes CPPS but rather the individual's response to the infection being greater in those prone to get CPPS. The symptoms may continue chronically because of persistent immunologic mechanisms long after the bacterial infection has been eradicated.

10.Dysfunctional voiding may be a cause of CPPS.

11.Altered autonomic function may be responsible for the pain.

12.The NIH Chronic Prostatitis Symptom Index has three domains: pain, urinary function, and quality of life.

13.UPOINT is a 6-point clinical classification that includes the following categories: urinary, psychosocial, organ specific, infection, neurologic/systemic, and tenderness.

14.Orchitis is rare and usually viral in origin; most cases of bacterial orchitis are secondary to local spread from the epididymis.

15.Epididymitis usually results from spread of infection from bladder, urethra, or prostate via the vas deferens.

16.Development of a prostate abscess is best detected with transrectal

ultrasonography. A prostatic abscess is optimally drained by the transurethral incision route,

17.The classification of prostatitis is as follows: Category I is identical to the acute bacterial prostatitis category of the traditional classification system. Category II is identical to the traditional chronic bacterial prostatitis classification. Category IIIA CP/CPPS, or inflammatory CPPS, is based on the presence of excessive leukocytes in EPS, a postprostatic massage urine sample, or semen. Category IIIB CP/CPPS, or noninflammatory CPPS, rests on no significant leukocytes being found in similar specimens.