Chronic bacterial prostatitis

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Chronic bacterial prostatitis
Other namesCBP
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Specialty Urology   OOjs UI icon edit-ltr-progressive.svg

Chronic bacterial prostatitis (CBP) is a bacterial infection of the prostate gland and a form of prostatitis (prostate inflammation). It should be distinguished from other forms of prostatitis such as acute bacterial prostatitis (ABP) and chronic pelvic pain syndrome (CPPS). [1]

Contents

Signs and symptoms

Chronic bacterial prostatitis is a relatively rare condition that usually presents with an intermittent UTI-type picture. It is defined as recurrent urinary tract infections in men originating from a chronic infection in the prostate. Symptoms may be completely absent until there is also bladder infection, and the most troublesome problem is usually recurrent cystitis. [2] It has been said that recurrent and relapsing UTIs (i.e., UTIs due to the same pathogen) are a hallmark of chronic bacterial prostatitis. [3] [4] [5]

Chronic bacterial prostatitis occurs in less than 5% of patients with prostate-related non-BPH lower urinary tract symptoms (LUTS).[ citation needed ]

Dr. Weidner, Professor of Medicine, Department of Urology, University of Gießen, has stated: "In studies of 656 men, we seldom found chronic bacterial prostatitis. It is truly a rare disease. Most of those were E-coli." [6]

Causes

Chronic bacterial prostatitis is thought to be caused by ascending urethral infection and by reflux into the ejaculatory duct or prostatic ducts. [7] Risk factors for chronic bacterial prostatitis include functional or anatomic abnormalities, catheterization, prostate biopsy or urethritis (due to sexually transmitted infections), and unprotected penetrative anal sex. [7] In theory, the ability of some strains of bacteria to form biofilms might be one of the factors that facilitate the development of chronic bacterial prostatitis. [8] Recurrent infections may be caused by inefficient urination (benign prostatic hyperplasia, neurogenic bladder), prostatic stones, or a structural abnormality that acts as a reservoir for infection.[ citation needed ]

Diagnosis

In chronic bacterial prostatitis, there are bacteria in the prostate, but there may be no symptoms or milder symptoms than occur with acute prostatitis. [9] The prostate infection is diagnosed by culturing urine as well as prostate fluid (expressed prostatic secretions or EPS) which are obtained by the doctor performing a rectal exam and putting pressure on the prostate. If no fluid is recovered after this prostatic massage, a post massage urine should also contain any prostatic bacteria.[ citation needed ]

Prostate specific antigen levels may be elevated, although there is no malignancy. Semen analysis is a useful diagnostic tool. [10] Semen cultures are also performed. Antibiotic sensitivity testing is also done to select the appropriate antibiotic. Other useful markers of infection are seminal elastase and seminal cytokines.[ citation needed ]

Treatment

Curative therapy

Antibiotics

Antibiotics are effective in the treatment of chronic bacterial prostatitis and are a first-line therapy for the condition. [11] A blood–prostate barrier exists that prevents many antibiotics from penetrating the prostate and achieving adequate antibacterial concentrations. [12] [13] [14] As such, only certain classes of antibiotics are effective and recommended for treatment of chronic bacterial prostatitis. [11] [15] These include fluoroquinolones like ciprofloxacin and levofloxacin; trimethoprim; tetracyclines like doxycycline; and macrolides like azithromycin and clarithromycin. [11] [15] [16] Fluoroquinolones are the first-line antibiotics for chronic bacterial prostatitis, whereas trimethoprim and tetracyclines are second-line antibiotics and azithromycin is reserved for special situations. [11] [15] Fosfomycin has also been repurposed for chronic bacterial prostatitis and is increasingly being employed in its treatment. [15] [17] [16] Antibiotic therapy of chronic bacterial prostatitis requires prolonged antibiotic courses of generally 4 to 6 weeks of treatment, but up to 12 weeks of treatment. [11] [15] [7] Microbiological eradication rates have ranged from 40 to 77% for ciprofloxacin, 75 to 86% for levofloxacin, 77% for doxycycline, 80% for azithromycin, 80% for clarithromycin, and 62 to 77% for a combination of ciprofloxacin and azithromycin. [11] [18] Although antibiotics are effective in the curative treatment of chronic bacterial prostatitis, recurrence rates are high and range from 25 to 50%. [19]

Levofloxacin (the levorotatory enantiomer of ofloxacin) has been found to reach prostatic fluid concentrations that are 5.5 times higher than those of the same dose of ciprofloxacin. [20] [21] [22] These findings indicate that levofloxacin has a greater ability to penetrate the prostate than ciprofloxacin and suggest that it might be comparatively more effective in the treatment of chronic bacterial prostatitis. [20] [21] [22] However, clinical findings have been mixed, with one large clinical trial finding that levofloxacin was more effective than ciprofloxacin (bacterial eradication rate = 86% vs. 60%; clinical cure/improvement = 93% vs. 72%; bacterial recurrence rate = 4% vs. 19%) and another similarly large trial finding that they were equivalent (bacterial eradication rate = 75% vs. 77%; clinical cure/improvement = 75% vs. 73%). [11] [20] [18] [23] Moxifloxacin shows even greater prostatic penetration than levofloxacin as well as a broader spectrum of antibacterial activity, with improved activity against Gram-positive bacteria and anaerobic pathogens. [16] [19] It may be the only fluoroquinolone able to obtain prostatic concentrations that are 10-fold above the minimum inhibitory concentration (MIC) against Enterococcus faecalis . [19] However, limited experience with and data on moxifloxacin for chronic bacterial prostatitis are available as of 2022. [19] [16] Another limitation of moxifloxacin for such purposes is that it may have greater safety concerns than other fluoroquinolones, for instance higher cardiovascular risks. [16] Other fluoroquinolones that have also been used and found effective in the treatment of chronic bacterial prostatitis include norfloxacin, lomefloxacin, ofloxacin, and prulifloxacin. [24] [16]

Aside from fluoroquinolones, certain other antibiotics with the potential for improved activity, including minocycline, tigecycline, linezolid, daptomycin, clindamycin, and vancomycin, have also been used limitedly off-label in the treatment of chronic bacterial prostatitis with reported success. [16] [15] [24] However, the safety of novel antibiotics for treatment of chronic bacterial prostatitis is understudied and significant toxicities are known for many of them, which is especially of concern due to the long treatment courses required. [16] Antibiotics with poor prostatic penetration that may not be suitable for curative treatment of chronic bacterial prostatitis include nitrofurantoin, [25] [26] [17] [12] [27] sulfamethoxazole, most penicillins (e.g., ampicillin, penicillin G), aminoglycosides, most cephalosporins, other β-lactams, and the tetracycline oxytetracycline, among others. [7] [12] [16] [27] Findings on the penetration of amoxicillin into the prostate are inconsistent, with prostate tissue levels of 0.77 and 26.4 μg/mL reported in two different studies. [12] [28] Clinical findings of amoxicillin/clavulanic acid for treatment of chronic bacterial prostatitis are also mixed, with reports of high rates of both success [26] [29] [30] and failure. [31] [32] The more lipophilic tetracyclines minocycline and doxycycline show good or excellent prostate penetration like ciprofloxacin. [27] [12] [33]

Prostatectomy

In some men, chronic bacterial prostatitis can be severe and highly refractory to treatment or relapsing. [34] [35] In addition, it can be life-threatening due to urinary tract infections (UTIs). [35] Prostatectomy, or prostate removal surgery, has been used rarely and in well-selected patients to treat these kinds of cases. [34] [35] A 2017 systematic review evaluated prostatectomy for chronic prostatitis. [34] Transurethral resection of the prostate (TURP) by electrocautery was done in 110 patients, and in these individuals, symptoms were cured in 70%, improved in 15%, and unchanged in 15%. [34] Radical prostatectomy was done in 21 patients and resulted in symptoms being cured in 95%. [34] There are significant rates of erectile dysfunction and urinary incontinence with prostatectomy. [34] [35] These complications can be reduced with minimally invasive and nerve-sparing surgical techniques, such as robotically assisted radical prostatectomy or laparoscopic prostatectomy. [34] [35] However, significant rates of complications still occur even with minimally invasive forms of prostatectomy. [34] [35] All of the studies in the 2017 systematic review were prospective or retrospective case series and there were no randomized controlled trials. [34] As such, little evidence is available to inform clinical decision-making in terms of prostatectomy for chronic prostatitis. [34]

Other treatments

The addition of prostate massage to courses of antibiotics was previously proposed as being beneficial and prostate massage may mechanically break up the biofilm and enhance the drainage of the prostate gland. [36] [37] However, in more recent trials, this was not shown to improve outcome compared to antibiotics alone. [38]

Bacteriophages hold promise as another potential treatment for chronic bacterial prostatitis. [7] [39]

Symptomatic and suppressive therapy

Persistent infections may be helped in 80% of patients by the use of alpha blockers (α1-adrenergic receptor antagonists) or by long-term low-dose antibiotic therapy. [11] [25] [40] Alpha blockers, including tamsulosin, alfuzosin, and doxazosin among others, are used specifically in the management of voiding lower urinary tract symptoms (LUTS) like slow urinary flow or urinary hesitancy, although they might also help with pain and other symptoms. [11] However, their effectiveness is modest and the clinical significance has been questioned. [11] Possibilities for low-dose suppressive antibiotic therapy include nitrofurantoin, trimethoprim/sulfamethoxazole, fluoroquinolones, cephalosporins, and tetracyclines. [25] [40] Prostate-penetrant nonsteroidal anti-inflammatory drugs (NSAIDs), like celecoxib and rofecoxib, as well as possibly ibuprofen, naproxen, and diclofenac, can also be used as analgesics to treat pain and inflammation in chronic bacterial prostatitis. [7] [41]

Methenamine is a urinary antiseptic and antibacterial agent which is used in the prevention of recurrent urinary tract infections (UTIs). [42] It is non-inferior to low-dose prophylactic antibiotics for this purpose. [43] [44] [45] In contrast however, methenamine itself is not an antibiotic and does not promote antibiotic resistance. [42] [43] The drug works by being selectively and pH-dependently decomposed in acidic environments like the bladder into the active form formaldehyde, which is potently bactericidal. [42] Since formaldehyde is only formed from methenamine in acidic environments, it is not expected to be effective in the curative treatment of chronic bacterial prostatitis, and hence is not recommended for such purposes. [42] Methenamine decomposes into formaldehyde at a pH of below 6, [42] whereas the normal pH of prostatic fluid is 6.5 to 6.7 and in chronic prostatitis the pH is 7.0 to 8.3. [12] However, in persistent chronic bacterial prostatitis, prophylactic methenamine may be useful as an alternative to low-dose prophylactic antibiotics in preventing prostatitis-derived UTIs and managing associated symptoms. [25] Prophylactic low-dose methenamine combined with an ascorbic acid (vitamin C) supplement, which is theorized to enhance its activity by making the urine more acidic, has been reported to be effective for this purpose based on clinical experience. [25] In any case, supporting clinical data for this use are lacking as of 2020. [25]

Androgen deprivation therapy with surgical castration, estrogens, and the 5α-reductase inhibitor finasteride have shown beneficial effects on chronic bacterial prostatitis in terms of bacterial growth and inflammation in animal models, but clinical studies in humans have not been performed. [19] [46] [47]

Prognosis

Over time, the relapse rate is high, exceeding 50%. However, recent research indicates that combination therapies offer a better prognosis than antibiotics alone.

A 2007 study showed that repeated combination pharmacological therapy with antibacterial agents (ciprofloxacin/azithromycin), alpha-blockers (alfuzosin) and Serenoa repens extracts may eradicate infection in 83.9% of patients with clinical remission extending throughout a follow-up period of 30 months for 94% of these patients. [48]

A 2014 study of 210 patients randomized into two treatment groups found that recurrence occurred within 2 months in 27.6% of the group using antibiotics alone (prulifloxacin 600 mg), but in only 7.8% of the group taking prulifloxacin in combination with Serenoa repens extract, Lactobacillus sporogens (now Heyndrickxia coagulans), and arbutin (a combination referred to by the name "Lactorepens"). [49]

Large prostatic stones was shown to be related with the presence of bacteria, [50] a higher urinary symptoms and pain score, a higher IL-1β and IL-8 concentration in seminal plasma, a greater prostatic inflammation and a lower response to antibiotic treatment. [51]

Epidemiology

In a 2008 systematic review of 10,617 men, 8.2% had experienced prostatitis symptoms. [11] [52] It has been estimated that 35 to 50% of men may be affected by prostatitis symptoms during their lifetime. [11]

Additional images

Related Research Articles

<span class="mw-page-title-main">Ciprofloxacin</span> Fluoroquinolone antibiotic

Ciprofloxacin is a fluoroquinolone antibiotic used to treat a number of bacterial infections. This includes bone and joint infections, intra-abdominal infections, certain types of infectious diarrhea, respiratory tract infections, skin infections, typhoid fever, and urinary tract infections, among others. For some infections it is used in addition to other antibiotics. It can be taken by mouth, as eye drops, as ear drops, or intravenously.

<span class="mw-page-title-main">Urinary tract infection</span> Infection that affects part of the urinary tract

A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyelonephritis). Symptoms from a lower urinary tract infection include suprapubic pain, painful urination (dysuria), frequency and urgency of urination despite having an empty bladder. Symptoms of a kidney infection, on the other hand, are more systemic and include fever or flank pain usually in addition to the symptoms of a lower UTI. Rarely, the urine may appear bloody. Symptoms may be vague or non-specific at the extremities of age.

<span class="mw-page-title-main">Epididymitis</span> Inflammation of the epididymis, part of the testicle

Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. Onset of pain is typically over a day or two. The pain may improve with raising the testicle. Other symptoms may include swelling of the testicle, burning with urination, or frequent urination. Inflammation of the testicle is commonly also present.

<span class="mw-page-title-main">Levofloxacin</span> Antibiotic

Levofloxacin, sold under the brand name Levaquin among others, is a broad-spectrum antibiotic of the fluoroquinolone drug class. It is the left-handed isomer of the medication ofloxacin. It is used to treat a number of bacterial infections including acute bacterial sinusitis, pneumonia, H. pylori, urinary tract infections, Legionnaires' disease, chronic bacterial prostatitis, and some types of gastroenteritis. Along with other antibiotics it may be used to treat tuberculosis, meningitis, or pelvic inflammatory disease. It is available by mouth, intravenously, and in eye drop form.

<span class="mw-page-title-main">Nitrofurantoin</span> Antibacterial drug

Nitrofurantoin, sold under the brand name Macrobid among others, is an antibacterial medication of the nitrofuran class used to treat urinary tract infections (UTIs), although it is not as effective for kidney infections. It is taken by mouth.

<span class="mw-page-title-main">Amoxicillin/clavulanic acid</span> Combination antibiotic medication

Amoxicillin/clavulanic acid, also known as co-amoxiclav or amox-clav, sold under the brand name Augmentin, among others, is an antibiotic medication used for the treatment of a number of bacterial infections. It is a combination consisting of amoxicillin, a β-lactam antibiotic, and potassium clavulanate, a β-lactamase inhibitor. It is specifically used for otitis media, streptococcal pharyngitis, pneumonia, cellulitis, urinary tract infections, and animal bites. It is taken by mouth or by injection into a vein.

<span class="mw-page-title-main">Ofloxacin</span> Antibiotic to treat bacterial infections

Ofloxacin is a quinolone antibiotic useful for the treatment of a number of bacterial infections. When taken by mouth or injection into a vein, these include pneumonia, cellulitis, urinary tract infections, prostatitis, plague, and certain types of infectious diarrhea. Other uses, along with other medications, include treating multidrug resistant tuberculosis. An eye drop may be used for a superficial bacterial infection of the eye and an ear drop may be used for otitis media when a hole in the ear drum is present.

<span class="mw-page-title-main">Pyelonephritis</span> Inflammation of the kidney

Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness. Other symptoms may include nausea, burning with urination, and frequent urination. Complications may include pus around the kidney, sepsis, or kidney failure.

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<span class="mw-page-title-main">Norfloxacin</span> Chemical compound, antibiotic

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Prostatic congestion is a medical condition of the prostate gland that happens when the prostate becomes swollen by excess fluid and can be caused by prostatitis. The condition often results in a person with prostatic congestion feeling the urge to urinate frequently. Prostatic congestion has been associated with prostate disease, which can progress due to age. Oftentimes, the prostate will grow in size which can lead to further problems, such as prostatitis, enlarged prostate, or prostate cancer.

<span class="mw-page-title-main">Acute prostatitis</span> Serious bacterial infection of the prostate gland

Acute prostatitis is a serious bacterial infection of the prostate gland. This infection is a medical emergency. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

Odynorgasmia, or painful ejaculation, also referred to as dysejaculation, dysorgasmia, and orgasmalgia, is a physical syndrome described by pain or burning sensation of the urethra or perineum during or following ejaculation. Causes include: infections associated with urethritis, prostatitis, epididymitis; use of anti-depressants; cancer of the prostate or of other related structures; calculi or cysts obstructing related structures; trauma to the region.

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men – over 40% of older men are affected – but lower urinary tract symptoms also affect women. The condition is also termed prostatism in men, but LUTS is preferred.

<span class="mw-page-title-main">Chronic prostatitis/chronic pelvic pain syndrome</span> Medical condition

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), previously known as chronic nonbacterial prostatitis, is long-term pelvic pain and lower urinary tract symptoms (LUTS) without evidence of a bacterial infection. It affects about 2–6% of men. Together with IC/BPS, it makes up urologic chronic pelvic pain syndrome (UCPPS).

<span class="mw-page-title-main">Acute exacerbation of chronic obstructive pulmonary disease</span> Medical condition

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<span class="mw-page-title-main">Quinolone antibiotic</span> Class of antibacterial drugs, subgroup of quinolones

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<span class="mw-page-title-main">Urinary anti-infective agent</span> Medication for urinary tract infections

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References

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  29. ↑ Bowen DK, Dielubanza E, Schaeffer AJ (August 2015). "Chronic bacterial prostatitis and chronic pelvic pain syndrome". BMJ Clin Evid. 2015. PMID   26313612. Amoxicillin-clavulanic acid (co-amoxiclav) and clindamycin. One case series included 50 men resistant to empirical treatment with quinolones. The expressed prostatic secretions from 24 of these men exhibited high colony counts of gram-positive and gram-negative anaerobic bacteria, either alone (18 men) or in combination with aerobic bacteria (6 men). After treatment with either amoxicillin-clavulanic acid or clindamycin for 3 to 6 weeks, all men had a decrease or total elimination of symptoms, and no anaerobic bacteria were detected in prostatic secretions.
  30. ↑ Szöke I, Török L, Dósa E, Nagy E, Scultéty S (June 1998). "The possible role of anaerobic bacteria in chronic prostatitis". Int J Androl. 21 (3): 163–168. doi:10.1111/j.1365-2605.1998.00110.x. PMID   9669200. Patients with chronic prostatitis who gave positive culture results for anaerobes were treated with amoxicillin/clavulanic acid or clindamycin for 3-6 weeks. After treatment, samples were again taken and cultured for all pathogens known to cause prostatitis. These post-therapeutic samples revealed a decrease or total elimination of the symptoms, and no anaerobic bacteria could be detected.
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  42. 1 2 3 4 5 Lo TS, Hammer KD, Zegarra M, Cho WC (May 2014). "Methenamine: a forgotten drug for preventing recurrent urinary tract infection in a multidrug resistance era". Expert Rev Anti Infect Ther. 12 (5): 549–554. doi:10.1586/14787210.2014.904202. PMID   24689705.
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  50. ↑ Mazzoli, Sandra (August 2010). "Biofilms in chronic bacterial prostatitis (NIH-II) and in prostatic calcifications". FEMS Immunology and Medical Microbiology. 59 (3): 337–344. doi: 10.1111/j.1574-695X.2010.00659.x . ISSN   1574-695X. PMID   20298500.
  51. ↑ Soric, Tomislav; Selimovic, Mirnes; Bakovic, Lada; Šimurina, Tatjana; Selthofer, Robert; Dumic, Jerka (2017). "Clinical and Biochemical Influence of Prostatic Stones". Urologia Internationalis. 98 (4): 449–455. doi:10.1159/000455161. ISSN   1423-0399. PMID   28052296. S2CID   4927272.
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