Chronic bacterial prostatitis (CBP)

Chronic bacterial prostatitis (CBP)

• is characterised by recurrent infections with documented positive cultures of expressed prostatic secretions (1)
  • identified via the four or two glass test
    • tests compare urine samples before and after prostatic massage in an attempt to isolate bacteria or leucocytes in either expressed prostatic secretions or in urine following prostatic massage
      
      
• chronic bacterial prostatitis is usually associated with mild to moderate pelvic pain symptoms and intermittent episodes of acute urinary tract infections (2)
  
  
• is caused by chronic bacterial infection of the prostate with or without prostatitis symptoms and usually with recurrent UTIs caused by the same bacterial strain (2)
  
  
• organisms commonly implicated in bacterial prostatitis include Escherichia coli, other gram-negative enterobacteriaceae, occasionally Pseudomonas species, and, rarely, gram-positive enterococci (1)
  
  
• risk factors for chronic bacterial prostatitis include (1):
  • urethral catheterisation or instrumentation,
  • condom drainage,
  • dysfunctional voiding (high-pressure urination), and
  • unprotected anal intercourse
    
    
• is asymptomatic until the patient has a urinary tract infection with associated symptoms such as suprapubic, lower back, or perineal pain, with or without mild urgency and increased frequency of urination and dysuria
  • pain may be exacerbated by sitting on a hard chair
  • rectal examination usually reveals an enlarged, firm, and irregular prostate. Massage may result in the exudation of a purulent urethral discharge
    
    
• it will be asymptomatic between acute infective episodes (1)

Treatment chronic bacterial prostatits is with the use of an appropriate antibiotic, generally a fluroquinolone such as ciprofloxacin

• seek expert advice
• fluoroquinolone treatment trials with a follow-up of at least 6 months support the use of flouroquinolones as first-line therapy (2)
  • recommended 4- to 6-week duration of antimicrobial treatment is based on experience and expert opinion and is supported by many clinical studies
  • success rates with oral antimicrobials have reached about 70% to 90% at 6 months in studies comparing different regimens (1)

Serum glucose should be checked to exclude diabetes mellitus.

Notes:

• a systematic review found "found low- to very low-quality evidence that alpha blockers, antibiotics, 5-ARI, anti-inflammatories, phytotherapy, intraprostatic BTA injection, and traditional Chinese medicine may cause a reduction in prostatitis symptoms without an increased incidence of adverse events in the short term, except for alpha blockers which may be associated with an increase in mild adverse events (3)"
• chronic prostatitis (also known as chronic pelvic pain syndrome (CPPS) or primary prostate pain syndrome) should be considered separate from acute and chronic bacterial prostatitis and is not associated with active infection (4)
  • CPPS
    • is characterised by pelvic or perineal pain in the absence of pathogenic bacteria in expressed prostatic secretions
    • is often associated with irritative and obstructive voiding symptoms including urgency, frequency, hesitancy, and poor interrupted flow
    • symptoms can also include pain in the suprapubic region, lower back, penis, testes, or scrotum and painful ejaculation
    • CPPS may be inflammatory (white cells present in prostatic secretions) or non-inflammatory (white cells absent in prostatic secretions) (1)

Reference:

1. Bowen DK, Dielubanza E, Schaeffer AJ. Chronic bacterial prostatitis and chronic pelvic pain syndrome. BMJ Clin Evid. 2015 Aug 27;2015:1802. PMID: 26313612; PMCID: PMC4551133
2. Nickel JC. Prostatitis. Can Urol Assoc J. 2011 Oct;5(5):306-15. doi: 10.5489/cuaj.11211. PMID: 22031609; PMCID: PMC3202001.
3. Franco JVA et al. Pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database Syst Reviews 08 October 2019
4. Healy R, Thorne C, Manjunath A. Chronic prostatitis (chronic pelvic pain syndrome) BMJ 2023; 383 :e073908 doi:10.1136/bmj-2023-073908