PROSTATITIS In both acute and chronic prostatitis, the seminal vesicles and posterior urethra are usually also involved. Acute prostatitis Aetiology Acute prostatitis is common, but underdiagnosed. The usual organism responsible is Escherichia coli, but Staphylococcus aureus, Staphylococcus albus, Streptococcus faecalis, Neisseria gonorrhoeae or Chlamydia may be responsible. The infection may be haematogenous from a distant focus or it may be secondary to acute urinary infectionClinical features General manifestations overshadow the local: the patient feels ill, shivers, may have a rigor, has 'aches' all over, especially in the back, and may easily be diagnosed as having influenza. The temperature may be up to 39degC. Pain on micturition is usual, but not invariable. The urine contains threads in the initial voided sample, which should be cultured. Perineal heaviness, rectal irritation and pain on defaecation can occur; a urethral discharge is rare. Frequency occurs when the infection involves the bladder. Rectal examination reveals a tender prostate; one lobe may be swollen more than the other, and the seminal vesicles may be involved. A frankly fluctuant hygiene abscess is uncommon. Treatment Treatment must be rigorous and prolonged or the infection will not be eradicated and recurrent attacks may ensue. Spread of infection to the epididymides and testes may occur. Prolonged treatment with an antibiotic that penetrates the prostate well is indicated (trimethoprim or ciprofloxacin) Chronic prostatitis Many urologists find the diagnosis of chronic prostatitis and 'prostatodynia' very difficult, for many men present with perigenital pain, testicular pain, prostatic pain exacerbated by sexual intercourse or pain that apparently renders sexual intercourse out of the question. Psychosexual dysfunction in such patients may be the underlying problem. The diagnosis of chronic prostatitis has to be based on: * persistent threads in voided urine; * prostatic massage showing pus cells with or without bacteria in the absence of urinary infection. Aetiology This is thought to be the sequela of inadequately treated acute prostatitis. While pus is present in the prostatic secretion, the responsible organism is often difficult to find. Other organisms such as Chlamydia species may be responsible for chronic abacterial prostatitis. Clinical features The clinical features are extremely varied. Only men with symptoms of posterior urethritis, prostatic pain and perigenital pain accompanied by intermittent fever and pus cells or bacteria in the post-prostatic massage specimen should be diagnosed as having chronic prostatitis. Diagnosis The three-glass urine test is valuable. If the first glass with the initial voided sample shows urine containing prostatic threads, prostatitis is present. Rectal examination of the prostate may be normal or may show a soft, boggy and tender prostate. Examination of the prostatic fluid obtained by prostatic massage should show pus cells and bacteria. Urethroscopy may reveal inflammation of the prostatic urethra, and pus may be seen exuding from the prostatic ducts. The verumontanum is likely to be enlarged and oedematous. In many men with the symptoms described above, all investigations are normal. Treatment Antibiotic therapy should be administered only in accordance with bacteriological sensitivity tests. Trimethoprim or ciprofloxacin penetrate well into the prostate. If Trichomonas or anaerobes are the responsible agent, a rapid response is obtained from administration of metronidazole (200mg t.d.s. for 7 days to both paners). If Chlamydia is suspected, doxycycline is the antibiotic treatment of choice. There is little evidence that prostatic massage helps in eradicating the infection. Ref: Bailey and love 27th edition Pgno : 1475