Signs, Symptoms, Diagnosis and Treatment For Asymptomatic Inflammatory Prostatitis

The fourth category of prostatitis is Asymptomatic inflammatory prostatitis. It is a symptomless microscopic condition of the prostate gland. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis, acute bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

Signs and Symptoms

These patients have no history of genitourinary pain complaints, but leukocytosis is noted, usually during evaluation for other conditions.

Diagnosis

Diagnosis is through tests of semen, EPS or prostate tissue that reveal inflammation in the absence of symptoms.

Prostate Treatment

No treatment required. It is standard practice for men with infertility and category IV prostatitis to be given a trial of antibiotics and/or anti-inflammatories however evidence for efficacy are weak. Since signs of asymptomatic prostatic inflammation may sometimes be associated with prostate cancer, this can be addressed by tests that assess the ratio of free-to-total PSA. The results of these tests were significantly different in prostate cancer and category IV prostatitis in one study.

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Treatments For Chronic Prostatitis or CPPS

Drs Potts and Payne in the Cleveland Clinic Journal of Medicine states that:

"Indeed, chronic abacterial prostatitis (also known as chronic pelvic pain syndrome) is both the most prevalent form and also the least understood and the most challenging to evaluate and treat. This form of prostatitis may respond to non-prostate-centered treatment strategies such as physical therapy, myofascial trigger point release, and relaxation techniques."

CP/CPPS, which makes up the majority of men diagnosed with "prostatitis", a treatment called the "Wise-Anderson Protocol" (aka the "Stanford Protocol"), has recently been published. This is a combination of:

• medication using tricyclic antidepressants and benzodiazepines
• psychological therapy which uses paradoxical relaxation, an advancement and adaptation, specifically for pelvic pain, of a type of progressive relaxation technique developed by Edmund Jacobson during the early 20th century, and
  
• physical therapy - trigger point release therapy on pelvic floor and abdominal muscles, and also yoga-type exercises with the aim of relaxing pelvic floor and abdominal muscles.

While these studies are encouraging, definitive proof of efficacy would require a randomized, sham controlled study, which is not as easy to do with physical therapy as with drug therapy.

Current protocols largely focus on stretches to release overtensed muscles in the pelvic or anal area (commonly referred to as trigger points), physical therapy to the area, and progressive relaxation therapy to reduce causative stress. Biofeedback physical therapy to relearn how to control pelvic floor muscles may be useful.

Aerobic exercise can help those sufferers who are not also suffering from Chronic Fatigue Syndrome (CFS) or whose symptoms are not exacerbated by exercise. Acupuncture has reportedly benefited some patients.

Pharmacological treatment

There is a substantial list of medications used to treat this disorder.

• The effectiveness of alpha blockers (tamsulosin, alfuzosin) is questionable in men with CPPS. A 2006 meta analysis found that they are moderately beneficial when the duration of therapy was at least 3 months. However a 2004 trial found no benefit from alfuzosin during 6 weeks of treatment and a 2008 clinical trial of alfuzosin found it was no better than placebo for treating CPPS in treatment naive recently diagnosed men.
• Quercetin has shown effective in a randomized, placebo-controlled trial in chronic prostatitis using 500 mg twice a day for 4 weeks. Subsequent studies showed that quercetin, a mast cell inhibitor, reduces inflammation and oxidative stress in the prostate.
• Pollen extract (Cernilton) has also been shown effective in randomized placebo controlled trials.
  
• Commonly used therapies that have not been properly evaluated in clinical trials are dietary modification, gabapentin, and amitriptyline.
• Therapies shown to be ineffective by randomized placebo/sham controlled trials: levaquin (antibiotics), alpha blockers for 6 weeks or less, transurethral needle ablation of the prostate (TUNA).
• At least one study suggests that multi-modal therapy (aimed at different pathways such as inflammation and neuromuscular dysfunction simultaneously) is better long term than monotherapy.
• Antibiotics are generally not recommended. Any improvement on antibiotics is likely to be evanescent, and due to the anti-inflammatory effects of the antibiotic.
  

Surgery

Surgery (including minimally invasive) is recommended only for definitive indications and not generally for CP/CPPS.

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What Are The Common Treatment Of Chronic Bacterial Prostatitis?

Chronic Bactrial Prostatitis treatment requires prolonged courses, usually takes 4–8 weeks, of antibiotics that penetrate the prostate well. Take note that β-lactams and nitrofurantoin are ineffective. These include quinolones (ciprofloxacin, levofloxacin), sulfas (Bactrim, Septra) and macrolides (erythromycin, clarithromycin). Persistent infections may be helped in 80% of patients by the use of alpha blockers (tamsulosin (Flomax), alfuzosin), or long term low dose antibiotic therapy.

Recurrent infections may be caused by inefficient urination, a benign prostatic hypertrophy, neurogenic bladder, prostatic stones or a structural abnormality that acts as a reservoir for infection.

The addition of prostate massage to courses of antibiotics was previously proposed as being beneficial. However, in more recent trials, this was not shown to improve outcome compared to antibiotics alone.

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What Is The Common Treatment Of Acute Prostatitis?

Antibiotics are the first line of treatment in acute prostatitis. Antibiotics usually resolve acute prostatitis infections in a very short time. Appropriate antibiotics should be used, based on the microbe causing the infection.

Some antibiotics have very poor penetration of the prostatic capsule, others, such as Ciprofloxacin, Co-trimoxazole and tetracyclines penetrate well.

In acute prostatitis, penetration of the prostate is not as important as for category II because the intense inflammation disrupts the prostate-blood barrier. It is more important to choose a bacteriocidal antibiotic (kills bacteria, eg quinolone) rather than a bacteriostatic antibiotic (slows bacterial growth, eg. tetracycline) for acute potentially life threatening infections.

Severely ill patients may need hospitalization, while nontoxic patients can be treated at home with bed rest, analgesics, stool softeners, and hydration. Patients in urinary retention are best managed with a suprapubic catheter or intermittent catheterization.

Lack of clinical response to antibiotics should raise the suspicion of an abscess and prompt an imaging study such as a transrectal ultrasound (TRUS). E. coli is able to form a biofilm that may allow the pathogen to persist in the prostate.

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