“I don’t think my husband’s well,” a patient confided to her nurse practitioner. “He took off from work today because of back pain. He hadn’t been sleeping well for the past two weeks and gets up several times every night to urinate. What worries me most is that one night he had pain when he ejaculated and now he seems to have no interest in sex. Is any of this normal for a 35-year-old man?”

These events may seem unrelated to a layperson, but a knowledgeable nurse realizes that they may reflect genitourinary (GU) symptoms involving the prostate.

Prostatitis is inflammation of the prostate gland. Sometimes, infection is present as well. The symptoms may be absent, mild, or severe and life-threatening.¹ The constellation of symptoms associated with this poorly understood condition can be straightforward or obscure, perplexing both providers and patients. The disease is so prevalent that at some time during their lives, 5% to 9% of men will have prostatitis with the risk of repeated attacks and chronicity.^2,3  In addition, in Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS), the main predictor of quality of life is pain, followed by urinary dysfunction and depression.^4,5

The diagnosis of prostatitis can include symptoms ranging from acute to chronic, systemic to localized, with differing values presenting on the urinalysis. In order to describe the known types of prostatitis, subtypes were defined by the NIH to assist the clinician in categorization. The five subtypes of  prostatitis are NIH Category I, ABP; NIH category II, CBP; NIH Category IIIa, ICPPS; NIH Category IIIb, NCPPS; and NIH Category IV, asymptomatic prostatitis.⁶ The classification of prostatitis is based on the existence of prostatic pain, the presence or absence of white blood cells (WBCs) in the urine, and urine culture results.

Looking for Clues

When taking the history of men with GU complaints, clinicians should ask about any history of GU disorders or previous GU surgeries, and any past urinary tract infections (UTIs). A sexual history is also important, including past episodes of sexually transmitted diseases (STDs), new sexual partners, and any of their GU complaints. Finally, the onset and progression of the current problem should be explored. Ask about painful urination, blood or pus in the urine, and frequent urination at night. Urethral discharge or itching, frequency or urgency in urination, low-back or perineal pain, or pain with ejaculation may be present, as well as systemic symptoms of fever, malaise, loss of appetite, and weight loss.⁷ Pain, voiding, and the impact on quality of life may be assessed using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI).⁵

During examination, assess the general appearance of the patient, as well as vital signs to detect systemic illness. A thorough exam of the GU system should include the testicles, scrotum, penis, and inguinal lymph nodes. Examine the prostate by a digital rectal exam. Palpate the inside of the rectum for pain, tenderness, or enlargement of the prostate.⁸ However, avoid vigorous rectal examination or palpation of the prostate, which could cause bacteria to enter the bloodstream and produce sepsis.⁷ Additionally, examine and palpate the abdomen and flank for mass or renal tenderness, the bladder for distention, and the low back for strain or neurological or disc disease.

Both the patient’s history and physical exam findings can narrow the differential diagnosis. Other diagnoses to be considered besides prostatitis are UTI, pyelonephritis, urethritis, cystitis, detrusor muscle impairment, and infection; neurogenic conditions, such as neurogenic bladder and sciatica; and prostate cancer, benign prostatic hypertrophy, and prostatic stones.^5,9

NIH Category I, Acute Bacterial Prostatitis (ABP)

ABP is an infection usually associated with gram-negative bacilli, such as E. Coli, Klebsiella, Pseudomonas, Proteus, Gonorrhea, and Enterobacter. Clinicians theorize that ABP comes from either an ascending urethral infection, reflux of infected urine, or an extension of an infection from the rectum, lymphatic system, or bloodstream.⁹

ABP usually affects young adult men who are at risk due to unsafe sexual practices and elderly men as structural changes in their prostates occur. Patients experience generalized illness with chills, fever, and/or malaise. Other symptoms include dysuria; frequency; difficulty initiating urination; mild to complete obstructive urinary symptoms; hematuria; suprapubic, perineal, and/or low-back pain radiating to the kidneys; and painful defecation and/or ejaculation. Pain is sometimes referred to the tip of the penis.⁷

The pain with ABP is severe and patients may not tolerate prostate examination. The prostate will feel warm, enlarged, very tender, and either firm or boggy (which may differentiate between isolated ABP and an acute flare of CBP). Rectal exams should not be performed because of the risk of spreading bacteria to the systemic bloodstream through the prostatic blood supply.¹

NIH Category II, Chronic Bacterial Prostatitis (CBP)

CBP, which usually occurs in men older than 50 years, is associated with risk factors, such as multiple urinary tract infections and prostatic calculi.¹⁰ Pathogens include both aerobic gram-negative and gram-positive bacteria, which can lead to recurrent UTI or prostatic abscess in older men. Whenever an adult man presents with UTI, CBP should be considered in the diagnosis.

CBP usually has milder symptoms than ABP. However, if fever occurs, an acute recurrence of chronic prostatitis should be considered.⁹ Symptoms include urinary complaints, such as hesitancy, urgency, dysuria, difficulty initiating and terminating urine flow, and a decrease in the strength and volume of the urinary stream. Other symptoms may include hematuria, hematospermia, and painful ejaculations.² Chronic low-back pain or discomfort in the perineal, scrotal, or penile areas may be present. Examination of the prostate may reveal a normal or boggy and mildly tender prostate. WBCs and bacteria will be found in the urinalysis.

NIH Category III, Chronic Prostatitis/ Chronic Pelvic Pain Syndrome (CP/CPPS)

This category was created to include the variant symptoms frequently presented by men with GU complaints. It replaces the traditional classes of nonbacterial prostatitis and prostatodynia respectively. Category III is further subdivided into categories IIIa, inflammatory CPPS (ICPPS) and IIIb, noninflammatory CPPS (NCPPS), and is characterized by the absence of cultured bacteria. These categories are differentiated from each other by the presence or absence of leukocytes in expressed prostate secretions; ICPPS demonstrates leukocytes, while NCPPS does not.

Although the cause is elusive, some authorities believe organisms, such as Gardnerella, Chlamydia, Ureaplasma, and Trichomonas may play a role in its genesis even though these organisms are absent in the urine and prostatic secretions in Category III.^3,9 Autoimmune disorders; cytokines; neuromuscular etiologies, such as pelvic wall muscle tension and neuropathic pain syndrome; allergy-mediated reactions; and psychological stressors are other possible causative factors.^5,6,7 Undiagnosed CBP, occult bacterial prostatitis, elevated uric-acid levels in prostatic secretions, and bladder outflow disorders are also believed to be associated with NIH Category III.²

ICPPS and NCPPS are the most common and most poorly understood forms of prostatitis. The presence of pelvic pain is a requirement for diagnosis.⁶ Generalized illness is absent, and patients may describe urinary complaints of frequency, urgency, dysuria, as well as rectal, perineal, and ejaculatory pain.⁹ Patients may experience changes in sexual function that range from decreased libido to impotence.²

The clinical presentation of I/NCPPS reveals negative cultures. WBCs will be found in prostatic secretions and terminal urine samples with ICPPS (IIIa), but will be absent in NCPPS (IIIb).³

NIH Category IV, Asymptomatic Prostatitis

Asymptomatic prostatitis is often found incidentally in patients who are not experiencing pelvic or prostatic complaints, but who are being evaluated for other urinary issues. The etiology is uncertain. With this type of prostatitis, WBCs are only found concomitantly in prostatic secretions when they are elevated for an unrelated cause.³

Diagnosing Through Glasses, Massage, and Other Methods

Analysis and culture of a divided urine sample can establish a diagnosis of prostatitis. Two methods for obtaining the urine specimens are the Stamey-Meares four-glass localization method and the pre- and postmassage test. With ABP, a complete urinalysis and culture is used instead of a divided urine test.

The Stamey-Meares four-glass localization method (also known as sequential or segmented voided urine culture) is the gold standard in obtaining specimens for urinalysis and culture when prostatitis is suspected.⁵ After two initial urine specimens, clinicians collect prostatic secretions for culture, followed by a final urine specimen. A subsequent urinalysis includes quantitative colony counts.¹

The steps for collecting the specimens are —

1. After cleansing the external urinary meatus with an antiseptic towelette containing povidone iodine or benzalkonium chloride, the patient voids 10 mL of urine into a sterile container, which is labeled VB1 (first voided bladder specimen).
2. As the patient continues to void, 50 mL of midstream urine are collected in a sterile container, which is labeled VB2 (second voided bladder specimen).
3. The clinician then performs prostate massage, using a sweeping motion beginning at the outer edges of the prostate towards the median sulcus, six to seven times on each side. This is followed with posterior to anterior prostate massage. The urethra is milked to express any prostatic secretions, which are collected in a sterile container or on a swab for culture and labeled EPS (expressed prostatic secretions).
4. Finally, the patient voids 10 mL of urine into a sterile container, which is labeled VB3 (third voided bladder specimen).⁹

Urethritis can be diagnosed by examining the VB1, which reflects the urethral environment. The specimen will have 10 or more WBCs/high-power field (HPF), in addition to bacteria and/or red blood cells (RBCs). Bacteria will be greater in the VB1 than in both the VB2, which reflects the bladder, and the VB3 obtained after prostatic massage.¹

With cystitis, there is a greater concentration of WBCs and bacteria in VB2 than in either the urethral or postprostate urine specimens. Bacterial growth and RBCs may be present in greater concentration in both the VB1 and VB2 than in the other samples.¹

Finally, prostatitis is identified by the presence of 10 or more WBCs/HPF in the EPS and VB3 specimens or by a greater number of WBCs present in the EPS and VB3 than in the VB1 and VB2. Another diagnostic clue to prostatitis is bacteria in the EPS and VB3 without bacterial presence in the VB1 or VB2. RBCs may or may not be present. In CPPS, IIIa and IIIb, examination of the EPS and VB3 will reveal no bacterial growth on culture in either specimen. However, WBCs will be present in ICPPS (IIIa).³

The pre- and postmassage tests are simpler alternatives for diagnosing prostatitis. After cleansing his penis with an antiseptic towelette, the patient obtains an initial midstream urine sample and then a second sample after prostate massage. Both specimens are sent for microscopy and culture. Findings from the pre- and postmassage test differ with the etiology of the prostatitis. For example, urine micrology with CBP will reveal greater than 13 WBCs/HPF in both pre- and postmassage urine specimens, while urine cultures of both specimens will be negative. With ICPPS (IIIa), fewer than 10 WBCs/HPF will be found in the premassage urine, and as many as 10 WBCs/HPF to 20 WBCs/HPF in the postmassage urine. As with CBP, cultures will be negative.²

Additional laboratory tests can differentiate prostatitis from common conditions, such as diabetes, sexually transmitted infections, and renal calculi, which have similar presenting signs and symptoms. Besides culturing any penile discharge, CBC, BUN, and creatinine will be assessed to evaluate renal function. Electrolytes, glucose, and blood cultures can help differentiate prostatitis from benign prostatic hypertrophy, urinary tract infections, and renal calculi.⁸ Additionally, clinicians may consider an IV pyelogram and a transrectal ultrasound to detect prostatic calculi; a urine cytology to rule out malignancies; and urodynamic testing, depending on the patient’s history and presenting symptoms.⁹

Treatment Modalities

Depending on the severity and classification, prostatitis may be treated on an outpatient basis. On the other hand, if a patient is acutely ill with fever, chills, and severe pain, he may require IV antibiotics and hospitalization. Antibiotic therapy had been initiated with 160 mg/800 mg of trimethoprim/sulfamethoxazole (TMP/SMX) (Bactrim DS) in the past. Now, after cultures are obtained, first line therapy is initiated with a fluoroquinolone, such as ciprofloxacin 500 mg twice a day.¹¹ Other antibiotics that are used for initial treatment are fluoroquinolones and tetracyclines.² While some treatment recommendations have been recommended beyond 90 days, evidence for superiority of this regime over a 28 day regime is lacking. Thus, the current recommendation is for antibiotic therapy for 28 days.¹¹ The prolonged length of antibiotic use is not due to antibiotic resistance, but due to the poor penetration of antibiotics into prostatic tissue.

Providers should not overlook medications necessary for pain control. However, patients can promote comfort just by avoiding alcohol, coffee, tea, and spicy foods that may irritate symptoms. They should not take over-the-counter cold preparations, which may contain decongestants or antihistamines that increase urinary retention and aggravate preexisting prostatic hypertrophy.¹² They should also avoid stress.

ABP may require hospitalization and aggressive IV antibiotics to prevent or treat prostatic abscess. A urinalysis and culture should be repeated one month after the initiation of therapy,¹³ and consideration should be given toward a possible structural cause of the infection.¹¹

CBP can be initially treated with TMP/SMX twice a day.^2,9 Other authorities recommend a fluoroquinolone as first line because they have a higher cure rate.^2,11,14 It is important to understand the cure rates for antibiotics so that the nurse is astute to patients who may not be improving. A urinalysis and culture is recommended one month after therapy is started and then every month. Sequential urine samples and EPS cultures should be repeated at four weeks to six weeks.⁹ CBP may also be treated with intraprostatic injections of antibiotics to achieve higher prostatic concentrations or transurethral resection of the prostate, though results are individualized.⁶ Long term administration of antibiotics may be the recourse.⁶

NIH Category III CP/CPPS is the most difficult prostatitis to treat because the cause is unknown; there are no cultured bacteria to guide treatment protocol.  However, it is still debated whether bacteria play a role in the cause of CP/CPPS. Current research is using the polymerase chain reaction (PCR) to identify bacterial gene products in prostate biopsy specimens.⁶ Empirically, many patients have experienced some relief of symptoms with a course of long term administration of antibiotics. Alpha-adrenergic blockers, such as terazosin (Hytrin) and prazosin (Minipress), tamsulosin (Flomax), and also finasteride (Proscar), may improve urinary flow and reduce obstructive symptoms in CP/CPPS.^5,15 These medications have a lowering effect on blood pressure, so the patient must be educated on potential orthostatic changes. Non-steroidal anti-inflammatories (NSAIDs) can be effective in pain control. Phytotherapies include saw palmetto, Quercetin, and Cernilton.^15,16 Some successful nonpharmacologic therapies to aid with voiding dysfunction include biofeedback and pelvic floor training.⁵ Pilot studies and clinical trials are currently investigating the promising uses of botulinum toxin injections to the urethral sphincter, oral electroacupuncture, and microwave/thermal modalities.^15,17,18

Adjunctive measures may be added to enhance comfort and reduce future exacerbations. In addition to pain medication and Sitz baths, relief of discomfort may be obtained with bedrest, donut-shaped cushions, and stool softeners. Antispasmodics, such as oxybutynin (Ditropan), alone or in conjunction with diazepam (Valium), may control bladder spasms.² Frequent ejaculations may be beneficial in promoting prostate contraction.

Nurses need to communicate to patients that prostatitis is not infectious, contagious, or a precursor to cancer.² Patients and partners also need to know that sexual activity may continue.