 The prostate is a walnut sized gland that is located beneath the urinary bladder (see picture below). The prostate surrounds the urethra (urine, channel) like a donut. When the prostate becomes inflammed it can impinge on urine flow and cause symptoms. The function of the prostate is to produce fluid and enzymes that contribute to the semen and are needed for male fertility. Prostatitis was categorized into four forms:
Form of Prostatitis |
Symptoms |
Prostatic Secretions |
Culture Results |
Acute Bacterial |
Fever,chills, burning, back, lower abdominal, testicular or groin pain, general malaise or weakness, difficulty with urination |
Increased number of white blood cells |
Bacterial growth |
Acute Bacterial |
Same as above without fever or chills |
Increased number of white blood cells |
Bacterial growth |
Non Bacterial |
Same as above |
Increased number of white blood cells |
No bacterial growth |
Prostatodynia |
Same as above |
No white blood cells |
No bacterial growth |
Culture diagnosis of acute bacterial prostatitis is straightforward and easily accomplished in the laboratory. On the other hand, microbiologic diagnosis of chronic prostatitis and prostatodynia represents a particular challenge. Chronic prostatitis has a poor record of treatment success. Recent literature suggests that the condition referred to as chronic non-bacterial prostatitis (prostatodynia) may actually have an infectious etiology (cause). Some patients relate the onset of their symptoms to sexual activity- sometimes associated with acute urethritis, while others have indicated no relationship to sexual activity.
Figure 6.1 |
The use of antimicrobial therapy may or may not elicit a transient relief of symptoms. A number of organisms have been reported to possibly cause this syndrome. Trichomonas vaginalis, Chlamydia trachomatis, mycoplasma,
staphylococci, coryneforms and viruses. These data are controversial since other researchers have failed to demonstrate the presence of these microorganisms in culture or have found them in rare circumstances. The microbiological work up is further complicated by the presence of inhibitory substances known to exist in prostatic secretions and the history of multiple previous courses of antibiotics.
Bacterial infection of the prostrate gland, may occur as a result of urethal infection or by reflux of infected urine into prostatic ducks emptying into the urethra. Other possible routes of infection included invasion of rectal bacteria. There is an association between bacteria prostatitis and urinary tract infection. When the patient has acute bacteria prostatitis, there is an abrupt onset of fever and genitourinary and constitutional signs and symptoms. Chronic bacterial prostatiis is a more subtle illness which is characterized by relapsing, recurrent urinary tract infections and persistence of bacteria in the prostatitis glands despite multiple courses of antibiotics. A third syndrome, chronic idiopathic prostatitis, (sometimes called a bacterial prostatitis, or non bacterial prostatitis and prostatodynia), may or may not be associated with excessive numbers of inflammatory cells in the prostatic secretions and with lack of bacteria in culture. The prostaic secretions from many patients appear normal. The recent literature suggests there is no clear reason to distinguish prostatodynia from non-bacterial prostatitis. Since subjects with prostatodynia may at times have excessive numbers of inflammatory cells in there express prostatic secretions. During the past few years, molecular data and cultures perform with special media strongly suggested that chronic idiopathic prostatitis may actually be a cryptic bacterial infection of the prostate gland that is usually missed or undetected by routine conventional cultures in clinical micro-biology laboratories. The definition of non bacterial prostatitis and prostatodynia are still controversial.
Specimen Collection and Bacteriologic Culture
Quantitative bacteriologic cultures confirm the diagnosis of bacterial prostatitis when the infectious agent is localize to the prostate gland. The technique for obtaining segment cultures of the male lower urinary tract was first described in 1968. This method (although rarely used today in clinical practice) is still considered by many to be the "Gold Standard" for localizing infections to the prostate gland. The sampling conditions would require a full bladder and the samples must be collected by using aseptic techniques. The patient is asked to urinate the first few drops into a sterile container. The mid stream urine is then collected into another container. A prostate examination and a massage is perform and the prostate fluid is collected, cultured and examined under the microscope and examine for the present of inflammatory cells. The patient is then asked to urinate into a third container. The traditional criteria for diagnosis chronic bacteria prostatitis is a 10- fold increase in the concentration of micro organism when the bacteria count of the post massage urine sample or expressed prostatic secretion sample is compared with that of the first urine samples.
Most of the urinary pathogens are also the causative agents of acute and chronic prostatitis. E. coli predimanates as a cause of prostatitis. Other organisms such as Klebsiella, Enterobacteria, Proteus, Serratia, and Pseudomonas, can also be isolated from patients with prostatitis. Gram-positive bacteria particularly the cocci remain controversial as possible causative agents. Recently, coagulase-negative, staphylococcal species and coryneforms have been found to play a role in chronic idiopathic prostatitis.
Difficult to culture coryneforms where missed by routine culture but careful microscopic observation and culture on enriched media reveal the present of these bacteria. Other organisms such as Chlamydia and Ureoplasma which are difficult to culture on routine media are known to cause prostatitis. Herpes simplex virus and cytomegalovirus have been found in the male genital tract. Fungal prostatitis can be caused by Candida, Cryptococcus and Aspergilla.
Treatment failures are not uncommon in prostatitis. Altered pharmacokinetics in the inflamed prostate might account for the treatment failure of clinically diagnosed chronic bacterial prostatitis. It may also be difficult to irradicate bacteria within prostate stones or protected within infection induced microcolonies and biofilms.
Is Nonbacterial Prostatitis Caused By A Chemical Inflammatory Reaction In The Prostate Or Is It An Autoimmune Disease?
Reflux of urine and other chemicals may serve as an underlying mechanism initiating a chemical inflammatory reaction in the prostate. Researchers have recently developed a mouse model of autoimmune induced prostatitis which may occur in humans. It is postulated that an initial bacterial infection sets off an immune/inflammatory response in the prostate that continues long after the bacteria have been killed by antibiotics.
Our approach to treating prostatitis takes into account all of these above mentioned aspects of prostatitis. We begin with an initial consultation (lasting 1 to 1 1/2 hours) including a detailed treatment history and review of records as many of our patients have been to multiple doctors in the past. A physical examination is performed and urine and prostate fluid are obtained for microscopic examination and culture. The specimens are cultured on special media to allow for the growth of rare and hard to culture organisms. These are left for 7 days where most labs discard the specimens after 48 hours if there is no growth. We are currently investigating new and improved growth and culture media to better diagnose the problem.
Based on the patients symptoms and test results, a urine flow test and measurement of bladder residual urine may be recommended. On occasion the prostate and bladder may need to be examined by ultrasound or cystoscopy. A treatment regimen including prostate massage, antibiotic therapy, diet modification and anti-inflammatory/immune modulation medications is undertaken. We believe in a natural and holistic approach to the problem and are advocates of natural, herbal and bioflavinoid therapies as well as conventional treatments. Surgical therapy is rarely needed to treat prostatitis. Occasionally a blockage of the ejaculatory duct or seminal vesicle prevents the infection from draining and resolving even with the help of the most powerful antibiotics. In these cases the blockage may need to be removed. The same techniques are used in the treatment of certain causes of male infertility. Male infertility specialists therefore have an increased familiarity and experience with these procedures and can recognize when they need to be used to treat prostatitis. Therapy is custom tailored to the individual patient's needs.
|
