Health and Prostate

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The history and physical examination can suggest the diagnosis, but most signs and symptoms of bacterial prostatitis, non-bacterial prostatitis, and even prostatodynia are indistinguishable. The necessary diagnostic routine is difficult and time-consuming, but if it is not initiated at the first presentation (usually by the primary care physician) and if the patient is started on antibiotics for bacterial prostatitis speculatively, it becomes almost impossible to sort out a proper diagnosis and a management plan later.

History and physical examination. A detailed analysis of the type and duration of symptoms, the results of prior investigations, and the response to previous treatments are critical components of the history. Physical examination should not be limited to the external genitalia and the prostate, but should be complete. Sometimes neglected aspects of patient evaluations disclose an alternate explanation for the apparent prostatic symptoms (neurologic, diabetic, malignant, etc).

Patients with acute prostatitis have sudden onset of urinary frequency, urgency, nocturia, and dysuria associated with fever and chills, low back and perineal pain, generalized malaise, and varying degrees of bladder outlet obstruction. On examination the patient usually has an exquisitely tender, boggy, and warm prostate gland.

Chronic bacterial prostatitis can develop from acute bacterial prostatitis, sometimes from inadequately treated acute prostatitis or from subacute prostatitis that did not give rise to acute clinical symptoms. Symptoms are variable and include dysuria, frequency, nocturia, ejaculatory pain, and discomfort in any area of the perineum or external genitalia. The prostate is usually tender to some degree. Patients usually have a history of recurrent urinary tract infections with the same organism.

Non-bacterial prostatitis, perhaps the most common of the prostatitis syndromes, has clinical symptoms and physical findings similar to those of chronic bacterial prostatitis. However, the patient does not have a history of recurrent urinary tract infections.

Patients with prostatodynia usually present with pelvic, perineal, suprapubic, and even penile or urethral pain. These patients do not have a history of recurrent urinary tract infections. Irritative voiding symptoms are uncommon, but many patients with prostatodynia complain of varying degrees of obstructive symptoms, such as hesitancy and a weak or intermittent stream. Palpation of the prostate usually demonstrates a normal gland, although there can be a degree of anal sphincter spasm.

One point that should be made is that palpation of the prostate does not always provide insight into the disease process. The consistency of the prostate and the degree of discomfort accompanying digital rectal examination does not always indicate whether the cause is bacterial.

Perhaps the most important clue to the cause of chronic prostatic symptoms is a history of urinary tract infections. Chronic bacterial prostatitis is the most common cause of recurrent urinary tract infections in males; it follows that a patient with recurrent UTI and inflammation of the prostate is likely to have chronic bacterial prostatitis. Response to antibiotic treatment also provides an important clue. Most men with chronic bacterial prostatitis will achieve some significant symptomatic relief while receiving antimicrobial therapy. This benefit may result from sterilization of the urine and can be independent of the bacteriologic response of the prostatic infection. If the treatment is not curative, the symptoms characteristically recur.

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