Wednesday, 24 May 2017

Prostatitis

There are four main types of prostatitis and each of these is managed differently. In the emergency department, we are most likely to see acute bacterial prostatitis,but might also see chronic infection and pain.



Acute Bacterial Prostatitis
Acute prostatitis is a common disease amongst men over 50 years of age, especially those who are immunocompromised, like in diabetes or HIV/AIDs.  CKD causes immunocompromise - but I couldn't find any obvious links to CKD and prostatitis!

It often presents with frequency, urgency and dysuria. In women, we might attribute these symptoms to a UTI, but UTI is rare in men without anatomical abnormalities, until the prostate starts to get bigger, increasing the frequency again. We should consider doing a scrotal, genital and rectal examination in any man diagnosed with a UTI, to check there isn't something else.

There might be obstructive voiding symptoms in >80% of patients. 38% of people get perineal discomfort which may present as back or rectal pain.
Some people get systemic features. Can get fever in 60% - 86%, maybe with rigors, malaise and myalgias.

Cause - 
Prostate biopsy - happens in 2% of cases - http://www.ncbi.nlm.nih.gov/pubmed/20577611
Resistance to prophylaxis - http://www.ncbi.nlm.nih.gov/pubmed/21782225
E-coli being the most common pathogen.
Can spread by incomplete voiding.

Sneezing whilst voiding - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556327/
Sexually transmitted

What examination--> 

Examination - Look for signs of urinary retention. If in retention, go for an SPA
Classically described as ecquisitely painful and boggy, actually you only get a  painful prostate in 68%. Pain or symptom reproducability is probably the most important symptom.    http://www.ncbi.nlm.nih.gov/pubmed/15822390.


Investigations - 
Urinalysis - send sample off for culture.
               Leucocytes and nitrites have a great positive predictive value, but not a great negative predictive value. http://cid.oxfordjournals.org/content/46/6/951.long


 Do NOT do prostatic massage to get a sample - may make things worse!
 Blood cultures - positive in 8 - 21% of cases http://www.ncbi.nlm.nih.gov/pubmed/20237098  http://www.ncbi.nlm.nih.gov/pubmed/17969797
 CRP raised in most cases
If there's microhaematuria on the dip, make sure it gets repeated as it might be a sign of cancer.
 PSA - not clear role, but has a high negative predictive value - http://bestbets.org/bets/bet.php?id=1585
PR without prostatic massage makes minimal difference to the serum PSA value and generally does not cause a clinically significant increase in PSA levels. However, some studies have found that there may be a minority of men in whom the procedure raises PSA. [ 6 ] For this reason some experts recommend that blood for PSA testing should be taken before DRE.

Urethral catheters are allowed in "experienced" hands but pre-treatment with appropriate antibiotics is mandatory. If the catheter is difficult to pass, a suprapubic is indicated.

So how do you tell if someone has prostatitis, or just a UTI? And like many things, there's no real answer. If they've got a painful or boggy mass on examination, then the answer is easy! If they haven't...could it still be prostatitis? Generally, yes it could be. The patients are normally significantly unwell - the risk of bacteraemia is increased in severe UTIs like pyelonephritis and prostatitis. I think it's reasonable if you have a really really sick ?urinary sepsis, to assume prostatitis until proven otherwise.
Review after 7 days 

Treatment - antibiotics
- Broad spectrum (cephalosporin) plus gentamycin if patient is systemically unwell.
- If oral antibiotics are appropriate, use
o Ciprofloxacin 500mg BD for 28 days or
o Ofloxacin 200mg BD for 28 days
- If patient is allergic to quinolones, consider trimethoprim (200mg BD for 28days) as an alternative. It needs to be for a long time because the prostate has quite a poor blood supply.


Laxatives - if defacation uncomfortable
Rest
NSAIDs
It is possible to add on an alpha blocker such as tamsulosin which has been proven as an beneficial adjunct for symptom relief.
Hydration

A referral to the Urology Team should be made upon discharge.

If fails to respond, arrange trans-rectal USS or CT of the prostate to R/U prostate abscess. Prostatic abscesses are relatively uncommon due to clinical practice due antibiotic therapy. Like prostatitis, common presenting features are dysuria, fever, suprapubic pain +/- urinary retention. Urine examination usually reveals pus cells.  The organisms usually involved include:
Escherichia coli
Staphylococcus spp
Gonococcus spp: rare


You should delay PSA testing for six weeks after treatment for a urinary tract infection.
Ciprofloxacin is the antibiotic which the Prostatitis Expert Reference Group (PERG) recommends as first line treatment for chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome. It has excellent penetration into the prostate, good bioavailability and good activity against typical and atypical pathogens. Treatment should be guided by bacterial cultures and sensitivities once these are known. You should continue treatment for at least four weeks. Options for second line antibiotics include trimethoprim or a tetracycline such as doxycycline.



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The chronic forms of prostatitis are common and debilitating and between 35 to 50% of men report symptoms suggestive of prostatitis at some time in their life.
Prostatitis is a common urological diagnosis in men under 50 years old and is most prevalent in men aged 36 to 50 years.


Four main domains of symptoms of chronic prostatitis/chronic pelvic pain syndrome [ 1 ]
Pain
Lower urinary tract symptoms
Psychological issues
Sexual dysfunction
and these are beyond the remit of this podcast.



http://emedicine.medscape.com/article/2002872-treatment#d10
https://cks.nice.org.uk/prostatitis-acute#!diagnosissub
http://www.racgp.org.au/download/Documents/AFP/2013/April/201304dickson.pdf
http://www.primarycareurologysociety.org/downloads/2015presentations/Jon%20Rees%20Prostatitis.pdf
https://uroweb.org/wp-content/uploads/19-Urological-infections_LR.pdf
http://www.rcemlearning.co.uk/modules/acute-urinary-retention/
http://radiopaedia.org/articles/prostatitis
http://radiopaedia.org/cases/acute-bacterial-prostatitis-and-abscess
http://wikem.org/wiki/Prostatitis

http://learning.bmj.com/learning/modules/flow/ICH.html?execution=e1s1&moduleId=10051979&status=LIVE&action=start&_flowId=ICH&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false

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