Page 2 - Prostatitis

Prostatitis

Evaluation massage test (PPMT) is a simple and reasonably accurate
screen for bacteria. Microscopy is optional. Rationale and
A mandatory history is required for all patients at time of description can be found in reference. 6
evaluation (4:C). The following presenting symptoms should
be elicited: pain location (severity, frequency, and dura- c. Semen cultures
tion), lower urinary tract symptoms (obstructive/voiding and
irritative/storage), associated symptoms (fever, other pain Not recommended (3:D): Based on limited evidence, semen
syndromes) and impact on activities/quality life. A com- cultures have not been shown to be significantly helpful in
prehensive systems review should document past medical identifying men with CBP, unless the same organism causing
and surgical (particularly urologic) history, history of trauma, recurrent UTIs is cultured.
medications and allergies.
d. Transrectal prostatic ultrasonography
1. Acute bacterial prostatitis (NIH category I)
Not recommended (3:B): A TRUS cannot be relied upon for
a. Physical examination differential diagnosis of categories of prostatitis. A TRUS can
be considered optional (4:D) if there is a specific indication.
Mandatory (4:C): The abdomen, external genitalia, perineum
and prostate must be examined. Prostate massage during a e. Urodynamics
digital rectal examination (DRE) is not recommended.
Optional (4:D): Uroflow may be helpful to confirm obstruc-
b. Urine analysis and culture tion. Urodynamics cannot be relied upon for differential
diagnosis of categories of prostatitis, but may help document
Mandatory (2:A) obstruction and/or bladder problems.

c. Imaging 3. Chronic prostatitis/chronic pelvic pain syndrome (NIH category IIIA,
IIIB)
Optional (2:A): A transrectal prostatic ultrasonography
(TRUS) or computed tomography scan is indicated in ABP a. Symptom scoring questionnaire
patients refractory to initial therapy to rule out prostate
abscess/pathology. Pelvic ultrasound (or bladder scan) is Recommended (3:A)- the NIH-CPSI (Fig. 1) has become the
indicated in ABP patients with severe obstructive symptoms, established international standard for symptom evaluation
poor bladder emptying or physical examination findings of (not for diagnosis) of prostatitis. The index has been shown
possible urinary retention. Initial imaging of the prostate is to be reliable and can evaluate the severity of current symp-
not recommended (3:B). toms and be used as an outcome measure to evaluate the
longitudinal course of symptoms with time or treatment.
d. Serum PSA
b. Physical examinations
Not recommended (3:C): Elevated prostate-specific antigen
(PSA) associated with ABP usually leads to confusion and Mandatory (4:C): Examination of abdomen, external geni-
worry. talia, perineum and prostate is mandatory. Exacerbation of
typical pelvic pain with normal DRE pressure is helpful in
2. Chronic bacterial prostatitis (NIH category II) determining prostate centricity, while evaluating myofascial
trigger points and/or possible musculoskeletal dysfunction
a. Physical examination of the pelvis and pelvic floor during DRE is believed to be
helpful in treatment decisions.
Mandatory (4:C): This must include examination of the abdo-
men, external genitalia, perineum, prostate and pelvic floor. c. 4-Glass test and 2-glass pre- and post-massage test (PPMT)

b. Microbiological localization cultures of the lower urinary tract (4-Glass Recommended (3:A): Culture of the lower urinary tract urine
Test or 2-Glass Pre- and Post-Massage Test [PPMT]) specimens is recommended. The 4-glass test is the criterion
standard to rule out CBP. The 2-glass PMT is a simple and
Recommended (3:A): The 4-glass test is the criterion stan- reasonably accurate screen for bacteria. A rationale and
6
dard for the diagnosis of CBP. The 2- glass pre- and post- description for this recommendation are available. At this

CUAJ • October 2011 • Volume 5, Issue 5 307