Terms about LUTI Anatomy of prostate Definition of prostatitis Epidemiology of prostatitis Etiology of prostatitis Classification of prostatitis Clinical presentation of prostatitis Evaluation of prostatitis Treatment of prostatitis

1. Prepare by:
Dr. Lutfi Ahmed Al-Bawri

2. Subjects
 Terms about LUTI
 Anatomy of prostate
 Definition of prostatitis
 Epidemiology of prostatitis
 Etiology of prostatitis
 Classification of prostatitis
 Clinical presentation of prostatitis
 Evaluation of prostatitis
 Treatment of prostatitis

3.  Bacteriuria : indicates the presence of bacteria in
the urine
 Pyuria: is the presence of white blood cells in the
urine and, when seen in conjunction with bacteriuria,
is indicative of a true infection
 Asymptomatic bacteriuria (ASB):is the isolation
of bacteria from the urine in significant quantities
consistent with infection, but without the local or
systemic genitourinary signs or symptoms.

4.  UNRESOLVED BACTERIURIA: occurs when the
urine cannot be sterilized despite antibiotic treatment
 RECURRENT BACTERIAL :infections that occur after
successful antimicrobial eradication (negative culture)

5. Anatomy

6. Prostate

8. classification of Lowsley

9. Other classification of prostate
according to zones( McNeal)
Video
T.Z
C.Z
P.Z
A.S

13. Definition
prostatitis is defined as an increased
number of inflammatory cells within the
prostatic parenchyma

14. Epidemiology
 Prostatitis is the most common urologic
diagnosis in men younger than 50 years and
the third most common urologic diagnosis in
men older than 50 years after benign prostatic
hyperplasia (BPH) and prostate cancer of men
older than 18 years.
 The prevalence of prostatitis-like symptoms
ranges from 2.2% to 16%, with a median
prevalence rate approximating 7% for chronic
prostatitis and CPPS.
 Prostatitis accounts for 6% to 8% of outpatient
visits from men to urologists.

15. Etiology
 Microbiology
 Altered prostate host defense
 Dysfunctional voiding
 Intraprostatic ductal reflux
 Immunological alterations
 achemically induce inflammation
 Pelvic floor muscle abnormalities
 Neural sensitization
 Psychosocial assosiation
 Interstitial cystitis or bladder pain syndrom

16. Etiology
 Microbiology
 Altered prostate host defense
 Dysfunctional voiding
 Intraprostatic ductal reflux
 Immunological alterations
 chemically induce inflammation
 Pelvic floor muscle abnormalities
 Neural sensitization
 Psychosocial assosiation
 Interstitial cystitis or bladder pain syndrom

17. Microbiology
 Gram –ve enterobacteria account for 90% of acute
bacterial prostatitis. (E. coli, Klebsiella, Serratia,
Pseudomonas)
 Enterococcus (gram +ve) 5 – 10%, and Staphs.
 Role of anaerobes are unknown.
 Anti-Chlamydial antibodies in 30% of chronic
prostatitis, but < 1% culture organism.
 Corynebacterium Infection.
 Ureaplasma Infection.
 Other Microorganisms. Candida and other
mycotic infections such as aspergillosis and
coccidioidomycosis

18. Etiology
 Microbiology
 Altered prostate host defense
 Dysfunctional voiding
 Intraprostatic ductal reflux
 Immunological alterations
 chemically induce inflammation
 Pelvic floor muscle abnormalities
 Neural sensitization
 Psychosocial assosiation
 Interstitial cystitis or bladder pain syndrom

19. Altered prostate host defense
 Phimosis
 unprotected penetrative anal rectal intercourse
 acute epididymitis
 indwelling urethral catheters and condom catheter
drainage.

20. Etiology
 Microbiology
 Altered prostate host defense
 Dysfunctional voiding
 Intraprostatic ductal reflux
 Immunological alterations
 chemically induce inflammation
 Pelvic floor muscle abnormalities
 Neural sensitization
 Psychosocial assosiation
 Interstitial cystitis or bladder pain syndrom

21. Dysfunctional voiding
 Anatomic or neurophysiologic obstruction
resulting in high pressure dysfunctional
flow patterns demonstrated that bladder
neck, prostatic, and urethral anatomic
abnormalities predisposed some men to
developing prostatitis.

22. Classification

24. Prostatitis under microscope

25. Clinical presentation

26. Category I – Acute Bacterial
Not common
The patient typically complains of :
 Urinary frequency, urgency, and dysuria.
 Obstructive voiding complaints including hesitancy,
poor interrupted stream, strangury, and even acute
urinary retention are common.Vesical Tenesmus.
 Perineal and suprapubic pain
 Associated pain or discomfort of the external genitalia.
 Significant systemic symptoms including fever, chills,
malaise, nausea and vomiting, and even frank
septicemia with hypotension
Approximately 5% of patients with acute bacterial
prostatitis may progress to chronic bacterial
prostatitis

27. Category I – Acute Bacterial
 Send MSSU (Mid Stream Specimen of Urine) / blood
cultures.
 Antibiotics
 i.v. if evidence of sepsis
 Aminoglycoside, cephalosporins, or fluoroquinolones.
 2 – 4 weeks treatment.
 Surgery
 SP catheter
 TRUS or CT to exclude abscess.
 Abscess best drained by TUR.

28. Category II – Chronic Bacterial Prostatitis.
 5 – 15% of Prostatitis
 Recurrent UTI’s in 25 – 40%
 May be asymptomatic between episodes or have a
long history of CPPS.
 Treat with Antibiotics
 Fluoroquinolones (Cipro- Levo- and Ofloxacine) most effective.
 12 weeks of treatment.
 60 – 85% bacteriological cure.
 40% symptom cure.

29. Category IIIa – Chronic Pelvic Pain Syndrom
(CPPS Inflammatory)
 Symptoms present for > 3 months.
 Pain – Perineum, suprapubic and penile but can be
testes, groin or lower back.
 Pain during or after ejaculation.
 LUTS (storage and voiding symptoms)
 Erectile dysfunction is increased.

30. Category IIIb – Chronic Pelvic Pain Syndrom
(CPPS non-bacterial)
 Same presenting features as IIIa, but < 10 WBC per HP
Field on Expressed Prostatic Secretion and VB3.
 NIH – Chronic Prostatitis Symptom Index.

32. Category IV – Asymptomatic Inflammatory
Prostatitis
 As name suggests!!
 WBC’s or bacteria in EPS or VB3 or histological
examination of gland.
 Present with obstruction, raised PSA, infertility.

33. Subjects
 Definition
 Epidemiology
 Etiology
 Classification
 Clinical presentation
 Evaluation
 Treatment

34. Evaluation
 History
 physical Examination
 Condition Specific Questionnaires
 Urinalysis and Culture
 Semen culture
 Optional: PSA, Urinary Cytology, US,
Cystoscopy, Urodynamics , Psychosocial
evaluation

35. Evaluation
 History
 physical Examination
 Condition Specific Questionnaires
 Urinalysis and Culture
 Semen culture
 Optional: PSA, Urinary Cytology, US,
Cystoscopy, Urodynamics, Psychosocial
evaluation

36. History

38. Evaluation
 History
 physical Examination
 Condition Specific Questionnaires
 Urinalysis and Culture
 Semen culture
 Optional: PSA, Urinary Cytology, US,
Cystoscopy, Urodynamics, Psychosocial
evaluation

40. Evaluation
 History
 physical Examination
 Condition Specific Questionnaires
 Urinalysis and Culture
 Semen culture
 Optional: PSA, Urinary Cytology, US,
Cystoscopy, Urodynamics, Psychosocial
evaluation

41. Urinalysis and Culture

42. Urinalysis and Culture

44. • UPOINT classification of chronic prostatitis and chronic
pelvic pain syndrome patients allows better descriptions of
individual phenotypes

46. Treatment

47. Treatment
 Antimicrobials
 α-Adrenergic Blocker Therapy
 Anti-Inflammatory Agents and Immune
Modulators
 Muscle Relaxants
 Hormone Therapy
 Phytotherapeutic Agents
 Neuromodulator Therapy
 Prostatic Massage , Pelvic Floor Physiotherapy ,
Pudendal Nerve Entrapment Therapy ,
Acupuncture, Psychological Support, Lifestyle
Modification and Other Conservative Therapies

48. Treatment
 Antimicrobials
 α-Adrenergic Blocker Therapy
 Anti-Inflammatory Agents and Immune Modulators
 Muscle Relaxants
 Hormone Therapy
 Phytotherapeutic Agents
 Neuromodulator Therapy
 Allopurinol
 Prostatic Massage , Pelvic Floor Physiotherapy ,
Pudendal Nerve Entrapment Therapy , Biofeedback,
Acupuncture, Psychological Support, Lifestyle
Modification and Other Conservative Therapies

50. Minimally Invasive
Therapies
 Balloon Dilatation.
 Transurethral Needle Ablation.
 Extracorporeal Shockwave Therapy.
 Minimally Invasive Neuromodulation
Therapies.
 Microwave Hyperthermia and
Thermotherapy.