Prostatitis: Definition, Signs and Symptoms, Risk Factors, Classification and Diagnosis

Human prostate diseases are one of the most common clinical conditions with a strong impact on social, health and individual costs. In particular, inflammatory pathologies of the prostate are increasing sharply in men between the ages of 20 and 40, with a significant impact on the patient's quality of life. In men of all ages and racial origins, the prevalence of prostatitis has been estimated between 10 and 14%, but there are many prejudices in epidemiological studies in patients with prostatitis for several reasons: 

• The lack of a standardized diagnostic tool
• The heterogeneity of clinical presentation
• Heterogeneity of etiology and lack of understanding of pathophysiology

Prostatitis is one of the most common urological disorders and can affect men (Male Reproductive System) of any age, in all its forms. About a third of all men during their life will exhibit symptoms consistent with prostatitis. Although it is often believed to be the result of a bacterial infection, prostatitis can be characterized by inflammation without evidence of infection. In fact, less than 10% of prostatitis cases are caused by bacteria, while the rest which accounts for 90% of cases is Category III prostatitis (CP) or chronic pelvic pain syndrome (CPPS) as is now known but remains the least understood, is the most common manifestation of the disease

Definition of Prostatitis

Prostatitis is an inflammation of the prostate gland that spans a spectrum of clinical diseases. The most common presentation is recurrent dysuria with irritating and obstructive urinary symptoms in the absence of bacterial infection. 
Bacterial prostatitis is an inflammation of the prostate gland and surrounding tissue following an infection. It is classified as acute or chronic. By definition, pathogenic bacteria and significant inflammatory cells must be present in prostate secretions and urine to diagnose bacterial prostatitis

Signs and Symptoms of Prostatitis

Symptoms of acute prostatitis include:

• Fever
• Pain
• Tenderness on digital rectal examination
• Dysuria
• Urgency and pyuria

The prostate is generally enlarged and has a low echogenicity in the TRUS. In some cases, acute prostatitis can progress to prostate formation, particularly in diabetic and immunosuppressed patients

Acute bacterial prostatitis accompaine by symptoms : 

• High fever
• Chills, Malaise 
• Myalgia, localized pain (perineal, rectal, sacrococcygeal), frequency, Urgency
• Dysuria
• Nocturia and retention

Chronic bacterial prostatitis accompaine by symptoms : 

• Difficulty emptying (frequency, urgency, dysuria)
• Low back pain and perineal and suprapubic discomfort

Etiology and Pathogenesis of Prostatitis

The main obstacle to effective management of various prostatitis syndromes lies in our lack of understanding of what is actually causing the symptoms and / or inflammation. Nobody doubts that the acute stage of prostate inflammation is secondary to a generalized infection of the prostate gland by pathogenic bacteria of the prostate. This fulminant infectious disease, generally associated with generalized urosepsis, does not appear to be related to chronic prostatitis syndromes and is probably an independent disease. It is rare, easily diagnosed, almost never occurs twice in the same patient and its management (unless the patient develops a prostate abscess) is standard and generally effective

The exact mechanism of bacterial prostate infection is not well understood. The possible routes of infection are the same as for urinary tract infections. Reflux of infected urine into the prostate gland is believed to play an important role in infection. Intraprostatic urine reflux commonly occurs and causes direct inoculation of infected urine into the prostate. In addition, intraprostatic reflux of sterile urine can cause chemical prostatitis and can be cause of non-bacterial prostatitis

Sexual intercourse can contribute to the infection of the prostate gland because the prostatic secretions of men with chronic prostatitis and vaginal cultures from their sexual partners have developed identical organisms. Other known causes of bacterial prostatitis include permanent catheterization of the urethra and condom, urethral instrumentation and transurethral prostatectomy in patients with infected urine

Many physiological factors are believed to contribute to the development of prostatitis. Functional abnormalities found in bacterial prostatitis include impaired secretory functions of the prostate. Prostate fluid obtained from normal men contains a prostate antibacterial factor (PAF). This low molecular weight thermostable cation is a zinc complex polypeptide that is bactericidal to most urinary tract pathogens. The antibacterial activity of PAF is directly related to the zinc content of the prostate fluid. Zinc levels in the prostate fluid and PAF activity also appear to have decreased in patients with prostatitis and in the elderly. It remains to be determined whether these changes are a cause or an effect of prostatitis

The pH of prostate secretions in prostatitis patients has been reported to have changed. Normal prostate secretions have a pH between 6.6 and 7.6. With over age, the pH  become more alkaline. In patients with prostate inflammation, prostate secretions can have an alkaline pH between 7 and 9. These changes suggest a generalized secretory dysfunction of the prostate that can not only influence the pathogenesis of prostatitis but can also influence the treatment modality

The tissues surrounding the prostate berries are infected with inflammatory inflammatory cells (lymphocytes). The most common infectious agents are Enterobacteriaceae gram-negative (Escherichia coli, Pseudomonas aeruginosa, Klebsiella, Serratia, Enterobacter aerogenes). 5% to 10% of infections are caused by gram-positive bacteria (Staphylococcus aureus and saprophyticus, Streptococcus faecalis)

E. coli most often causes chronic bacterial prostatitis, with other gram-negative organisms isolated less frequently. The controversy remains around the importance of gram-positive organisms in chronic bacterial prostatitis. in some studies, aureus and diphtheroids have been isolated

Classification of Prostatitis

I Acute Bacterial Prostatitis (ABP)

Acute bacterial prostatitis is the least common of the four types, while, both the diagnose and treatment is easy and effective. Men with this disease often have chills, fever, pain in the lumbar and genital area, urinary frequency and urgency often at night, burning or pain when urinating, body pain and demonstrable urinary tract infection. , as evidenced by white blood cells and bacteria in the urine. It is treated with an appropriate antibiotic

II Chronic Bacterial Prostatitis (CBP)

Chronic bacterial prostatitis is also relatively rare. It is acute prostatitis associated with a defect at the base of the prostate, a focal point for bacterial persistence in the urinary tract. Effective treatment generally requires identification and removal of the defect and therefore treatment of infection with antibiotics. However, antibiotics often don't cure it

III Chronic Pelvic Pain Syndrome (CPPS)

Chronic prostatitis / chronic pelvic pain syndrome is the most common but lesser known form of the disease. It is found in men of any age; the symptoms disappear and then return without warning. Chronic prostatitis / chronic pelvic pain syndrome can be inflammatory or Non-inflammatory In the inflammatory form, urine, semen and other prostate fluids show no evidence of a known infectious organism, but contain cells that the body generally produces to fight infections. In the non-inflammatory form, there is no evidence of inflammation, including cells that fight infections

• IIIA Inflammatory CPPS  (chronic non-bacterial prostatitis): white blood cells in expressed prostate secretions (EPS), VB3 or semen, but without optical bacteria in specific prostate samples

• IIIB Non-inflammatory CPPS (prostatodynia): no WBC in EPS, VB3 or semen, no bacteria

IV Asymptomatic Inflammatory Prostatitis (Histological Prostatitis)

Asymptomatic inflammatory prostatitis is the diagnosis when the patient has infection-fighting cells in his semen but, does not complain of pain or discomfort. Doctors generally find this form of prostatitis when looking for causes of infertility or evidence of prostate cancer

Risk Factors for Prostatitis

• Incomplete emptying of the urinary bladder caused by mechanical obstruction (stenosis, stones) and neurological defects (diabetic neuropathy, paralysis, spinal cord injury)
• Injury to a recent bladder infection 

• Benign prostatic hyperplasia(BPH)

• Advanced age (obstructive uropathy, reduction of the prostate antibacterial factor, reduction of the uromucoid)

• The incidence of gonorrhea, chlamydia, or other sexually transmitted disease

• Permanent urethral catheter (decomposition of the mucous layer, facilitated bacterial ascension)
• Diabetes mellitus (bacterial multiplication favored by high glucose levels, reduced function of granulocytes)
• Excessive alcohol consumption

Diagnosis of Prostatitis

Differential diagnosis for prostatitis includes sexually transmitted diseases (STDs), urinary tract infections, genitourinary malignancy, urolithiasis, urethral stenosis and neurogenic bladder. 

The study for all prostatitis cases starts with a focused history and physical exam, including sexual history, urinalysis and urine culture. Depending on a patient's risk factors, further studies may include urethral cultures of gonorrhea and chlamydia, herpes and HIV tests, serum creatinine, prostate specific antigen (PSA), post-residual registry, zero urinary cytology, computed tomography, cystoscopy, transrectal ultrasound of the prostate (TRUS) and urodynamics

On examination, the prostate is tender and swampy with suprapubic tenderness during acute episodes of prostatitis. The most common causative organism is E. coli; Other organisms include Enterobacteriaceae, Enterococci and Pseudomonas aeruginosa. Empirical treatment begins with 8-16 weeks of trimethoprim / sulfamethoxazole (TMP) or quinolone antibiotics. Symptomatic control can be achieved with alpha-blockers, anticholinergics, NSAIDs and sitz baths. Consider surgical treatment with transurethral resection of the prostate (TURP) in men with prostate stones, prostate abscess or persistent prostatitis after extensive medical treatment