Chronic prostatitis is a common condition occurring in younger men which presents problems of diagnosis and treatment. In some patients a bacterial population of known pathogens can be identified in the prostatic fluid. In many others proof of bacterial etiology is lacking. There has therefore been an acceptance of two common forms of the disease, namely chronic bacterial prostatitis and a condition that has been variously termed chronic abacterial prostatitis, nonspecific prostatitis, prostatosis and prostatic neurosis. Despite the refinements of methods of collection and bacteriologic processing of prostatic fluid, certainty of bacterial recovery cannot be assumed. The sample obtained may fail to include fluid from all parts of the gland or, in particular, from the inflamed parts of the gland. The inconsistency of recovery of bacteria from known cases of bacterial prostatitis lends support to this thesis and suggests that the segregation of chronic prostatitis into bacterial and nonbacterial groups is by no means certain. Where episodes of recurrent genitourinary infection such as cystitis, epididymitis and, less commonly, pyelonephritis occur, bacterial etiology is more likely to be established but otherwise the distinction between differing clinical entities is not obvious.
Diagnosis
The common clinical features of chronic prostatitis are summarized in Table 1. A variety of complaints, singly or in various combinations, may be elicited, the most common being urinary symptoms and discomfort and pain in various sites. Less common symptoms include hemospermia, perineal discomfort or pain after ejaculation. Others relating to sexual function are sometimes emphasized but are probably coincidental. There is considerable variation between patients in severity of symptoms but the clinical pattern appears to be consistent for individual patients.
| Table 1 — Signs and symptoms of chronic prostatitis |
1. Urinary
- Irritative: dysuria, frequency, urgency
- Obstructive: slowness, dribbling
- Urethral discharge
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| 2. Pain at various sites (see Table 2) |
3. Prostatic changes
- Changes in consistence
- Irregularity
- Tenderness
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Changes are commonly detectable on rectal examination of the prostate although normal palpatory findings may be encountered. These changes include variations in:
(1) size;
(2) consistence, such as areas of softening or bogginess with or without areas of induration;
(3) contour, with irregularity of the surface; and
(4) amount of discomfort or pain on palpation.
Assessment of these changes lacks the precision of bacteriologic quantitation but, provided the limitations are recognized, may still be valuable in diagnosis and assessment of therapy in chronic prostatitis.
The number of pus cells in prostatic fluid shows such variation from day to day in individual patients, unrelated to clinical course, that this feature lacks value in diagnosis or review.
Cystourethroscopy may show typical changes in the prostatic urethra but the importance of these has been largely discounted because to a minor degree they may be seen in asymptomatic patients. Apart from illustrating some typical prostatic changes, this examination is useful in excluding other pathologic conditions of the prostate and bladder. Trabeculation of the bladder in young men with prostatitis is seen frequently enough to suggest a relationship with dysfunctional voiding.
Radiologic studies including intravenous urograms serve to exclude other causes of urinary tract infection. Prostatic calculi may be demonstrated.
Needle biopsy of the prostate has been generally unrewarding either in demonstrating pathological changes or in isolating bacteria.
Bacteriologic diagnosis in chronic prostatitis was considerably advanced by the refined techniques introduced by Meares and Stamey. Their studies indicated the value of taking samples of urine from the first voided specimen (VB1), from a midstream specimen (VB2) and a voided specimen immediately after prostatic massage (VB3). Prostatic massage usually produces a specimen of prostatic fluid (EPS) for bacteriologic examination. Localization of the source of the infection may therefore be possible, although it must be remembered that all urine sampled passes through the prostatic urethra. In using these methods very sensitive bacteriologic culture techniques must be used to ensure counting of as few as 10 organisms per ml, because in chronic prostatitis there are often only small numbers of bacteria in the prostatic secretion (EPS) or urine after massage (VB3). This is the reason that routine bacteriologic studies of prostatic fluid or postmassage urine rarely show positive results.
Etiologic factors in chronic prostatitis are rarely obvious but include urethral stricture, previous urethritis (gonococcal or nonspecific), previous instrumentation or catheterization and previous episodes of acute prostatitis.
