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

UTIs

UTIs are the fourth highest indication for antibiotic prescribing in primary care. They account for approximately 5% of GP consultations. Around a quarter of people will get better whether they take antibiotics or not.

StatisticsMen: incidence <1% between 20 and 60 years of age
Women: 1 in 2 will be treated during their lifetime
 1 in 3 will be treated by 24 years of age

PathophysiologyCommon organisms:
E. coli = 70%
Staph saprophyticus = 15%
Proteus mirabilus = 10%

Proteus, klebsiella, enterobacter and enterococcus are rare.
Pseudomonas and candida are hospital acquired.

Clinical Features
It is important to make sure you ask about all the history features:
-    Frequency
-    Urgency
-    Dysuria - In patients who can explain their symptoms, dysuria is the most diagnostic symptom in older and younger women.
-    Nocturia
-    Haematuria
-    Suprapubic pain
-    Fever

In male patients ask about:
-    Poor stream
-    Terminal dribbling
-    Incomplete voiding
-    Overflow incontinence

Investigations
The role of urinalysis is controversial. Most sources recommend not using urinalysis in patients under 65 years of age, with three or more classic features. 90% of these patients are likely to have a positive urine culture.

For women under 65 years with mild or up to two symptoms, a urine sample is required to:
    Assess its cloudiness
    Consider urinalysis
    Consider a urine culture
Remember that urinalysis requires the sample having enough time to contact the bladder - frequency may affect quality of results.

False-negative nitrite tests are common, but false positives are uncommon
Leukocyte esterase detects the presence of pyuria which can be a non-specific finding.
The absence of both nitrites and leukocyte esterase reliably excludes UTI.
Blood and/or protein in urine are consistent with UTI, but are often non-specific findings

Diagnosis
Most laboratories take 105 colony-forming units per millilitre (cfu/ml) as the threshold for diagnosing significant bacteriuria.

Lower counts such as 103 or 104 of a pure growth of Escherichia coli (E. coli) or Staphylococcus saprophyticus may be significant if women have definitive symptoms of a urinary tract infection and there are white cells present on microscopy.

Epithelial cells with mixed growth may suggest contamination of the specimen.

Sterile pyuria may be due to Chlamydia. Tuberculosis is less likely but still recognised as an important cause of sterile pyuria. Other causes include STIs, renal tumour or calculus, genitourinary tuberculosis, and antibiotic therapy prior to collecting an MSU

No white cells indicates a lack of an immune reaction. This could indicate that bacteriuria is contamination but it also occurs in the immunosuppressed.

Management
Patients with visible haematuria and those over forty years old with microscopic haematuria should be referred for a 2 week wait urology appointment to exclude malignancy.

Antibiotics:
3 days for women, 7 days for men.
In nitrofurantoin, nausea is less likely if you use the modified release formulation (100mg twice daily).
One study suggests that NSAIDs are as effective as antibiotics!

Do not treat asymptomatic bacteriuria, even if catheter associated, which occurs in 25% of women >65years, and 10% of men >65years. A positive urine culture or dipstick test will not differentiate between a urinary tract infection or asymptomatic bacteriuria. Pregnant people should be treated for asymptomatic bacturia, and then have regular urine cultures at each antenatal visit.

Dietary Advice
Cranberry juice might interfere with the attachment of bacterial to uroepithelial cells. It is not useful acutely as treatment of UTIs. Increased oral hydration has little benefit in the acute management of an established UTI and reduced the concentration of antibiotics in the urine. Tea, coffee (caffeine-containing drinks), and alcoholic and citrus drinks should be avoided until symptoms have resolved as they can cause bladder irritation. These drinks should be replaced by water.

Recurrent UTI
- diabetes mellitus
- obesity
- chronic constipation
- poor fluid intake and infrequent voiding of urine
- atrophic vaginitis
- use of tampons

Differential Diagnoses
Atrophic Vaginitis
Presents with superficial stinging and burning on urination and watery non-odourous vaginal discharge. Examination is likely to show mild atrophic vaginal changes only. This is likely due to menopausal changes, and might respond to vaginal oestrogen from cream, pessarys or rings.

Acute ProstatitisCan present similarly to UTIs, but is more likely to also have systemic symptoms such as lower back pain, genital pain and a fever.

Interstitial CystitisOccurs in young people with suprapubic pain and fullness and frequency especially after consuming alcohol. Advise patients to keep a urinary symptom diary, monitor fluid intake and avoid irritants such as caffeine and alcohol.
Need urology follow up.

Purple Bag SyndromeThis is a rare sign of UTI, caused by gram negative bacteria. Treatment is directed towards the underlying bacterial infection and changing the catheter.

DeleriumAcute delirium in elderly patients is a common clinical scenario with protean aetiology, including UTI. Do not treat a positive dipstick in a delirious patient unless there are other indicators of a UTI.

References
http://academiclifeinem.com/paucis-verbis-card-urinary-tract-infection/http://academiclifeinem.com/uncomplicated-urinary-tract-infection-older-adults-diagnosis-treatment-1/
https://jama.jamanetwork.com/article.aspx?articleid=1832516
http://bestbets.org/bets/bet.php?id=1324
http://bestbets.org/bets/bet.php?id=2422http://www.enlightenme.org/learning-zone/spot-diagnosis
http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1529
http://www.enlightenme.org/learning-zone/have-you-ever-seen
http://elearning.rcgp.org.uk/course/info.php?id=117
http://www.npc.nhs.uk/therapeutics/common_infections/uti/quiz.php