Mayo Clinic Minute: Steam treatment for enlarged prostate
Acute prostatitis is characterized by a severe urinary tract infection UTIirritative and obstructive voiding symptoms with generalized urosepsis. Acute prostatitis responds promptly to antimicrobial therapy, and is usually self-limiting.
Chronic bacterial prostatitis is usually associated with mild to moderate pelvic pain symptoms and intermittent episodes of acute UTIs. Focused multimodal therapy appears to be more successful than empiric monotherapy. We used search terms and strategies Prostatitis 37 each database. These recommendations are summarized at Prostatitis 37 end of this guideline document.
Within the document, the level of evidence and recommendation grade are included where appropriate and denoted as 3:A which means Level 3 evidence and Grade A recommendation. Prostatitis describes Prostatitis 37 combination of infectious diseases acute and chronic bacterial prostatitisCPPS or asymptomatic prostatitis.
The NIH classification of prostatitis syndromes 12 includes:. Category II: Chronic bacterial prostatitis CBP which is caused by chronic bacterial infection Prostatitis 37 the prostate with or without prostatitis symptoms and usually with recurrent UTIs caused by the same bacterial strain.
Category IV: Asymptomatic inflammatory prostatitis AIP which is characterized by prostate inflammation in the absence of genitourinary tract symptoms.
A mandatory history is required for all patients at time of evaluation 4:C. A comprehensive systems review should document past medical and Prostatitis 37 particularly urologic history, history of trauma, medications and allergies.
Mandatory 4:C Prostatitis 37 The abdomen, external genitalia, perineum and prostate must be examined. Prostate massage Prostatitis 37 a digital rectal examination DRE is not recommended.
Pelvic ultrasound or bladder scan is indicated in ABP patients with severe Prostatitis 37 symptoms, poor bladder emptying or physical examination findings of possible urinary retention. Initial imaging of the prostate is not recommended 3:B.
Mandatory 4:C : This must include examination of the abdomen, external genitalia, perineum, prostate and pelvic floor. The 2- glass pre- and post-massage test PPMT is a simple and reasonably accurate screen for Prostatitis 37. Microscopy is optional. Rationale and description can be found in reference.
Not recommended 3:D : Based on limited evidence, semen cultures have not been shown to be significantly helpful in identifying men with CBP, unless the same organism causing recurrent UTIs is cultured. Optional 4:D : Uroflow may be helpful to confirm obstruction. The index has been shown to be reliable and can evaluate the severity of current symptoms and be used as an outcome measure to evaluate the longitudinal course of symptoms with time or treatment.
The National Institutes of Health Chronic Prostatitis Symptom Prostatitis 37 NIH-CPSI captures the three most important domains of the prostatitis experience: pain location, frequency and severityvoiding irritative and obstructive symptoms and quality of life including impact.
This index is useful in research studies and clinical practice. Adapted from Litwin et al. Mandatory 4:C : Examination of abdomen, external genitalia, perineum Prostatitis 37 prostate is mandatory. Recommended 3:A : Culture of the lower urinary tract urine specimens is recommended. The 4-glass test is the criterion standard to rule out CBP.
The 2-glass PMT is a simple and reasonably accurate screen for bacteria. A rationale and description for this recommendation are available. Not recommended 4:D for routine evaluation.
Optional 4:D : For selected patients. Endoscopy may be indicated in selected patients with obstructive voiding symptoms refractory to medical therapypatients with hematuria or other suspected lower urinary Prostatitis 37 pathology. Not recommended 3:B in routine practice, unless there is a specific indication. Optional 3:C : In selected men with obstructive voiding symptoms, it Prostatitis 37 reasonable to consider urodynamic evaluation e.
Optional 3:B : There is accumulating evidence that psychosocial parameters, such as depression, maladaptive coping mechanisms catastrophizing, resting Prostatitis 37 a coping mechanism and poor social support impact symptoms and results of therapy.
The physician should screen for these psychological problems. Not recommended 3:C Prostatitis 37 While some evidence suggests that this category may have biological relevance, at this time there is no evidence that determination of Prostatitis 37 prostatitis has any clinical relevance.
ABP can be a serious infection with fever, intense local pain and general symptoms. Septicemia and urosepsis are always a potential risk. The following factors must be taken in account when treating ABP: potential urosepsis, choice of antimicrobial agent, urinary drainage, risk Prostatitis 37 justifying hospitalization and auxiliary measures intended to improve treatment outcomes.
The choice and duration of antimicrobial therapy for ABP are based on experience and expert opinion and are supported by many uncontrolled clinical studies. Patients who are Prostatitis 37 severely ill or vomiting may be treated with an oral fluoroquinolone. A single catheterization with trial of voiding or short-term small caliber urethral catheterization is recommended for patients with severe obstructive voiding symptoms or urinary retention.
Suprapubic tube placement is optional for patients who cannot tolerate a urethral catheter. Hospitalization is mandatory in cases Prostatitis 37 hyperpyrexia, prolonged vomiting, severe dehydration, tachycardia, Prostatitis 37, hypotension and other symptoms related to urosepsis.
Hospitalization is recommended in high-risk patients diabetes, immunosuppressed patient, old age or prostatic abscess and those with severe voiding disorders. Incision and drainage of prostate abscess Prostatitis 37 required in selected treatment refractory patients. Transurethral route appears to be modality of choice but abscess may be drained via perineum, rectum or transperineal route.
Nonsteroidal anti-inflammatory agents have been suggested for reducing symptoms including fever. Because of their unique and favourable pharmacokinetic properties, their broad antibacterial spectra and comparative clinical trial evidence, the fluoroquinolones are the recommended agents of choice for the antimicrobial treatment of CBP.
CBP due to P. CBP Prostatitis 37 with a confirmed uropathogen that is resistant to the fluoroquinolones can be considered for treatment with trimethoprim-sulfamethoxazole or other antimicrobialsbut the treatment duration should be 8 to12 weeks. The combination of antimicrobials and alpha-blockers Prostatitis 37 been suggested to reduce the high recurrence rate 28 and this combination of two therapeutic regimens is considered optional for in-patients with obstructive voiding symptoms.
For treatment refractory patients with confirmed uropathogen localized to the prostate, the following are optional treatment strategies:.
The introduction of an internationally accepted classification system, 12 a validated outcome index, the NIH-CPSI, 7 and the significant number of randomized placebo controlled clinical trials published over the last decade and a half 11 has permitted best-evidence based guideline recommendations. Twenty-three clinical trials 29 — 54 were available at time of this guideline development.
These English-language trials evaluated medical therapies using a prospective, randomized controlled design; these trials were used to support these recommendations. These have been recently reviewed and analyzed. Alpha-blockers cannot be recommended as a first line monotherapy 1:A. Alpha-blocker therapy appears to provide benefit in a multimodal therapeutic algorithm for men with voiding symptoms 2:C.
Prostatitis 37 must be continued for over 6 weeks likely Prostatitis 37 12 weeks. Anti-inflammatory therapy is helpful for some patients, but is not recommended as a primary treatment 1:B ; however, it may be useful in an adjunctive role in a multimodal therapeutic Prostatitis 37 2:C.
Phytotherapies specifically quercetin and the pollen extract, cernilton are optional recommendations for first line 2:B Prostatitis 37 combination multimodal therapy 3:C. Other medical therapies, such Prostatitis 37 5-alpha-reductase inhibitor therapy, pentosanpolysulfate and pregabalin, while not recommended as primary monotherapy 1:Amay provide benefit in Prostatitis 37 patients older men with LUTS for 5-ARI therapy, men with associated pain perceived bladder pain and irritative voiding symptoms for pentosanpolysulfate and neuropathic type pain for pregabalin.
Muscle relaxants, saw palmetto, corticosteroids, and tricyclic antidepressants have all been suggested 6 and used, but recommendations Prostatitis 37 have to wait for results from properly designed randomized placebo controlled trials 4:D.
A number of physical therapies have been recommended, 6 but they also suffer from a lack of prospective controlled data obtained from properly designed controlled studies. Prostatic massage, perineal or pelvic floor massage and myofascial trigger point release has also been suggested as a beneficial treatment modality for patients, Prostatitis 37 focused pelvic physiotherapy has yet to be shown to provide more benefit compared to SHAM physiotherapy.
Biofeedback, acupuncture and electromagnetic therapy also show promise, but like all the other physical therapeutic modalities, require sham controlled trials before recommendations can be made 3:C.
Psychological support and therapy has been advocated based on new psycho-social modelling of this syndrome. The evidence for surgical therapies has been reviewed.
Further assessment of heat therapy employing sham controls, Prostatitis 37 inclusion exclusion criteria and validated symptom outcome measures are recommended. Pudendal nerve blocks or neurolysis surgery have been suggested for CPP that can be shown to be secondary to pudendal nerve entrapment 3:C.
A number of uncontrolled clinical studies have strongly suggested Prostatitis 37 multimodal therapy is more effective than monotherapy in patients with long-term symptoms. Therapy is not indicated 3:A since these patients by definition are asymptomatic. However, antimicrobial therapy for selected patients with category IV prostatitis associated with elevated PSA, infertility and those planned for prostate biopsy may warrant consideration 3:C.
Initial imaging of the prostate not recommended 3:B Ultrasound optional 2:A if suspicion for prostatic abscess is entertained. Imaging of the prostate Not recommended 3:B ; optional 4:D only in highly selected patients.
No evaluation unless considering Prostatitis 37 therapy for elevated PSA or infertility. Recommended 3:C. Antimicrobials: Patients with severe symptomatic febrile acute bacterial Prostatitis 37 Aminoglycosides in combination with ampicillin, broad spectrum penicillin in combination with a beta-lactamase inhibitor, a 3rd generation cephalosporin or a fluoroquinolone is required until defeverescence and normalization of Prostatitis 37 urosepsis.
Recommended 2:A. Following resolution of severe infection and for less severely ill patients, outpatient oral fluoroquinolones for weeks are appropriate.
Recommendation 4:B. Oral fluoroquinolone therapy for susceptible bacteria for weeks. Trimethoprim-sulfamethoxazole or other antimicrobials for fluoroquinolone resistant bacteria. Recommended 3:B. Recommended 4:C. Anti-inflammatory monotherapy Not-recommended 1:B ; Anti-inflammatory therapy as part of a multimodal treatment strategy Optional 2:C. The phytotherapies quercetin and pollen Prostatitis 37 recommended 2:B but are likely most effective as a part of a multimodal treatment strategy 3:C.
Five alpha-reductase inhibitor Prostatitis 37. Individualized multimodal therapy directed towards to defined clinical phenotype. Minimally invasive therapies such as TUNA, laser therapies, etc.
Not recommended 2:A. Invasive surgical therapies such as TURP and radical prostatectomy. Not recommended 4:D. The following potentially effective therapies can be considered in selected patients Optional 4:D.