Prostatitis is one the most frustrating and challenging diagnoses in urology. Much confusion exists about the cause of symptoms often attributed to prostatitis. By using a broader diagnostic acumen, physicians can better differentiate various forms of prostatitis or genital/pelvic pain syndromes.
The NIH established a classification system that can help both doctors and researchers who are trying to find causes as well as treatments for prostatitis.
Category I prostatitis includes patients with acute bacterial prostatitis. Patients present with fever, and symptoms of the lower urinary tract such as burning, frequency and/ or difficulty urinating. Some may even notice blood in their urine. This rare type of infection can occur suddenly, without risk factors, or in men who have had recent instrumentation of the urinary tract, such as catheterization. The urinalysis is usually abnormal and subsequent culture typically grows the culpable bacteria. Antibiotic therapy is highly effective in this setting.
Category II prostatitis or chronic bacterial prostatitis, is a diagnosis usually given to men with recurrent urinary tract infections, who grow the same organism in the urine, over and over again when they are symptomatic. After excluding sources of reinfection, like abnormal urinary tract anatomy or a stone within the ureters or bladder, the organism can usually be localized to the prostate gland, by means of a special culture technique which involves urine specimens taken before and after a prostate massage. These men are usually symptom-free when microscopic analysis of their urine is normal. Sometimes it is impossible to eradicate the organism from the prostate gland despite prolonged antibiotic therapy. Depending upon the frequency or severity of re-infection, your doctor may suggest daily low dose antibiotic therapy to prevent recurrent bouts.
Category III prostatitis refers to a form of chronic abacterial prostatitis and represents the most common form of the diagnosis- most men who present to their doctor with burning or pain in the pelvis or urinary tract, and lower urinary tract symptoms do not have bacteria in their urine nor prostate massage specimen. Fortunately, this observation was taken into account during the classification process, and includes a broader and more accurate diagnosis: Chronic Pelvic Pain Syndrome. Some men only experience pain, while some may experience urinary problems as well as changes in their sexual function. Many patients receive antibiotics or other medications which afford them no relief of their symptoms. Often, an abnormality of the pelvic floor musculature is identified, which can also explain certain urinary symptoms such as inability to start a urinary stream or weaker flow, and certain components of sexual dysfunction, such as pain or spasm after ejaculation. Certainly, there are other causes for one or all of these symptoms, therefore, a physician must exclude the other possibilities prior to making a diagnosis of chronic pelvic pain syndrome. Besides muscular tension and myofascial trigger points, some men also have symptoms consistent with irritable bowel syndrome, Fibromyalgia or disorders of defecation. For this reason, a multidisciplinary treatment plan is often necessary, incorporating the expertise of urologists, physical therapists, psychologists and colorectal specialists.
Category IV prostatitis refers to a form of asymptomatic prostatitis which is identified, incidentally, in semen specimens or prostate biopsies. This type of prostatitis may not require treatment since it is not a clinical diagnosis, which means it was not identified by the patient’s symptoms nor the findings on clinical exam. On the other hand, treatment may be warranted if an asymptomatic man is being evaluated for infertility, since the inflammation noted in his semen may be a sign of reproductive tract infection, and in some instances, when a man has an elevated PSA without evidence of prostate cancer.
The diagnosis of prostatitis must be interpreted with caution, as rarer bacterial forms require methodical culturing and more aggressive antibiotic therapy. The more common, abacterial form requires a broader, multidisciplinary approach which will usually confirm a diagnosis which ironically, excludes the prostate as the culprit. Patients are strongly cautions against the empiric use or overuse of antibiotics, especially when appropriate cultures have not been obtained.