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14 Challenging Concepts in Urological Surgery
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Clinical diagnosis
of prostatic abscess
<1 cm >1 cm
TRUS
Conservative
management
(ABx)
Reassess
Cured No response
Localized
to prostate
TUR drainage
Figure 2.3 Flowchart depicting an algorithm for management of a patient diagnosed with
prostatic abscess. ABx, antibiotics; TRUS, transrectal ultrasound; TUR, transurethral.
Adapted from Abdelmoteleb et al. Management of prostate abscess in absence of guidelines. Int Braz J Urol. 2017;
43:835– 40 under the Attribution 4.0 International (CC by 4.0) (https:// creativecommons.org/ licenses/ by/ 4.0/ ).
US drainage and
ABx
If no improvement
CT scan
Extraprostatic
extension
Open drainage
5
Figure 2.4 Cross- sectional imaging of the pelvis. (a) Coronal section, (b) sagittal section, and (c) transverse
section showing resolution of prostatic abscess following transurethral drainage.
The patient recovered thereafter and a CT scan done by the colorectal team sug-
gested resolution of the prostatic abscess as seen in Figure 2.4.
Learning point Classification of prostatitis
Prostatitis is one of the common urinary tract problems found especially in men younger than 50 years
of age. It is a group of disorders with a wide spectrum of symptoms and ranges from a clinically
straightforward entity to a more complex- to- treat presentation. The disease was traditionally classified into
acute bacterial, chronic bacterial, chronic non- bacterial, and prostatodynia.6 However, in 1995 the National
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Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the US National Institutes of Health
(NIH) adopted a new working definition7 which is currently applied in clinical practice (Table 2.1).
Table 2.1 NIH classification of prostatitis
Category Designation Status of infection
I Acute bacterial prostatitis Acute infection of prostatitis
II Chronic bacterial prostatitis Recurrent infection of prostate
III Chronic non- bacterial prostatitis/
chronic pelvic pain syndrome
IIIA Inflammatory WBC in semen/ EPS/ post- prostatic massage urine
IIIB Non- inflammatory No WBC in semen/ EPS/ post- prostatic massage urine
IV Asymptomatic inflammatory
prostatitis
EPS, expressed prostatic secretion; WBC, white blood cell.
Clinical tip Meares– Stamey test
Stamey et al. described a test in 1965 to help localize UTIs.8 It enables separation of voided
urinary stream into urethral (voided bladder one or VB1), midstream urine (voided bladder two
or VB2), and post- prostatic massage urine (voided bladder three or VB3) in order to distinguish
urethral and prostatic infection in the presence of sterile midstream urine. In 1968, Meares and
Stamey introduced the concept and value of direct culture of expressed prostatic secretions (EPS)
when VB1 and VB3 were equivocal. In simpler terms, the VB1 is the first 10 mL of voided urine
and represents the urethral specimen; the next 150– 200 mL is VB2 and represents the bladder
specimen. EPS is collected while carrying out a vigorous prostatic massage and represents prostatic
fluid. Finally, VB3 is the first 10 mL of urine after prostatic massage and represents EPS trapped in
prostatic urethra. This information continues to be relevant with the new classification system of
prostatitis as shown in Table 2.2 below.
Although the four- glass (specimen) Meares– Stamey test is the standard method of assessing men
with symptoms of chronic pelvic pain syndrome (CPPS) or chronic prostatitis (CP), it can be quite
cumbersome and thus a simplified two- glass pre- and post- massage test is being widely used.
The results from a two- glass test have been shown to have a strong concordance with results
from a four- glass Meares– Stamey test and thus offers a reasonable alternative that is simple and
cost- effective.
Semen culture has also been proposed as a simpler test than the gold standard four- glass test. The
sensitivity of semen cultures for diagnosing CBP is very variable, therefore the diagnostic value remains
controversial and further studies are needed.
9
No demonstrable infection
Asymptomatic
15Case 2 Prostatitis
Table 2.2 Diagnostic criteria used for the classification of prostatitis
Type White blood cell count/
high- power field (400×)
I >10 + + X +
II >10 – – + +
IIIA >10 – – – –
IIIB <10 – – – –
IV >10 – – – –
VBI VB2 EPS VB3
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Expert comment Bacterial prostatitis (types I and II)
Type 1 prostatitis presents acutely either in the outpatient or emergency setting. The diagnosis is
mainly clinical and treatment with antibiotics usually resolves the problem. The symptoms initially
are storage or voiding LUTS associated with suprapubic rectal or perineal pain. If untreated or
inadequately treated, ABP can progress to prostatic abscess and one needs to have an index of
suspicion for prostatic abscess if the patient has systemic symptoms like fever, chills, nausea, vomiting,
and malaise. Some patients may develop urinary retention as a complication of prostatic abscess.
Ten per cent of patients diagnosed with ABP may progress to CBP and this diagnosis is made if the
patient is symptomatic for at least 3 months or has recurrent prostatitis. The aetiology of the bacterial
types of prostatitis has been described earlier and for successful treatment, use of appropriate
antibiotics is important.
Antibiotic penetration into the prostate depends upon their lipid solubility, dissociation constant (pKa),
and protein binding. Beta lactam antibiotics due to their low pKa and low lipid solubility penetrate
poorly into prostate. However good to excellent penetration is seen with quinolones, tetracyclines,
macrolides, sulphonamides, nitrofurantoin, and aminoglycosides like tobramycin and netilmicin.
In CBP, oral antibiotic therapy can achieve cure rates of 70– 90% at 6 months but a systematic review
did not identify any randomized controlled trials to compare it with a placebo or no treatment.11
There are some studies showing the effectiveness of anal submucosal12 or prostatic antimicrobial
injections,13 but the evidence is limited and such treatment is not standard and mostly experimental.
Interventions like transurethral resection of the prostate (TURP) for treatment of CBP have not been
studied in a randomized controlled setting but some retrospective studies have suggested a role for
TURP in patients with CBP and obstructive symptoms.14 There are some reports of surgical options like
TURP and radical prostatectomy performed in extreme cases of CBP.
10
Future directions
Treatment with phage therapy
has been explored recently due
to the role of phage strains in
bacterial elimination and local
immunomodulation.15 However,
further research needs to be done
to establish its effectiveness as a
future tool in treatment of bacterial
prostatitis.
Learning point Aetiology and symptoms in CP/ CPPS
CP/ CPPS is the most common form of prostatitis and also the most poorly understood one. Ten
per cent of patients with CP progress to CP/ CPPS. However, the aetiology is unclear in most of
the cases. Non- infectious factors that have been implicated include inflammation, autoimmunity,
hormonal imbalances, pelvic floor tension myalgia, intraprostatic urinary reflux, and psychological
disturbances.16 A case– control study by Pontari et al. showed that the lifetime prevalence of
non- specific urethritis, cardiovascular disease, neurological disease, psychiatric conditions, and
haematopoietic, lymphatic, and infectious disease was significantly greater in men with CP/
CPPS.17 CP/ CPPS shares multiple demographic, clinical, and psychosocial aspects with chronic pain
conditions like fibromyalgia and chronic fatigue syndrome and thus may have a similar primary
pathophysiology.
18
The patients experience chronic pelvic pain and LUTS but there may also be associated sexual
dysfunction. Some patients may complain of unusual symptoms like the sensation of a foreign body
in the rectum, rectal pain during and after defecation, premature ejaculation, spontaneous sexual
stimulation, or alteration of orgasms.19 Owing to the heterogeneous nature of this condition, the
diagnosis is based on symptoms; absence of any diagnostic biomarkers makes its diagnosis and
treatment approaches variable and thus outcomes relatively poor. As a result of this, there is high
disease burden and patient as well as physician dissatisfaction.
Clinical tip Clinical evaluation of CP/ CPPS
Clinical evaluation to assess the severity of CP/ CPPS can be carried out using the 13- point validated
National Institute of Health Chronic Prostatitis Symptoms Index (NIH- CPSI) (Figure 2.5).20 An
alternative classification system using the UPOINT system categorizes the severity of patients’
symptoms based on the predominant symptom group.21 This UPOINT system in CP/ CPPS originally
encompassed Urinary, Psychosocial, Organ specific, Infective, Neurological, and Tenderness as
different symptom phenotypes but the aspect of Sexual dysfunction was added later on (Table 2.3).
22
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Figure 2.5 The NIH- CPSI.
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Table 2.3 UPOINT classification phenotypes in CP/ CPPS
U Urinary NIH- CPSI score >4, obstructive and storage LUTS, high post- void residuals
P Psychosocial Clinical depression, anxiety, stress, maladaptive coping, etc.
O Organ specific Prostate tenderness, leucocytes in prostatic fluid, haematospermia,
prostatic calcification
I Infective Gram- negative bacilli or enterococci in prostatic fluid, documented
successful response to antimicrobial therapy
N Neurological Clinical evidence of central neuropathy, pain beyond pelvis, irritable bowel
syndrome, fibromyalgia, chronic fatigue syndrome, etc.
T Tenderness Painful tenderness and/ or painful muscle spasm or trigger points in
abdomen and/ or pelvic floor
S Sexual Sexual and ejaculatory dysfunction
Treatment is aimed to alleviate symptoms using strategies targeting the predominant phenotype of
symptom. Interventions include identification and avoidance of risk factors23 which include aspects
of lifestyle (sedentary, fatigue, high stress), diet (alcohol, coffee, pepper, spicy foods, excessive dieting),
sexual habits (delaying ejaculation, extremes in frequency of sexual activity, coitus interruptus), and
perineal trauma (sitting position, sports, tight clothing). Education and clear communication with the
patient and his sexual partner providing information about the nature of disorder, chronic pain cycle,
treatment options, and clinical outcomes is important.
24
Expert comment Patients with CP/ CPPS
CP/ CPPS is a complex and poorly understood condition with a huge impact on the quality
of life of the affected person and treating the condition needs effective communication with
the patient and a shift away from a traditional approach to management towards a more
pragmatic multimodal approach. Communication not only between the physician and the
patient but also between the multidisciplinary team looking after the patient, including their
general practitioner, is the key element of this. Education of patients and their sexual partners
to understand the current concepts, the chronic pain cycles, and the challenging nature of this
disease can level expectations and help focus on achievable objectives. Social support helps gain
the much- needed adjustments that might need to be made at work or elsewhere to help the
patient manage his condition.
Learning point Therapeutic and evidence base in CP/ CPPS
A combined approach addressing risk factors, promoting a healthy lifestyle and diet, and
pharmacological, psychological, and neuromodulatory interventions improve outcomes.
Pharmacological interventions include the use of alpha blockers, antimicrobials, antiinflammatory and other pain medications, antidepressants, and neuroleptics. By reducing voiding
pressures and improving voiding flow patterns, alpha blockers alleviate discomfort. A randomized
placebo- controlled study, however, did not show any benefit and hence these are reserved for
the subset of patients with voiding symptoms. There is no clear- cut role for 5- alpha reductase
inhibitors but they reduce NIH- CPSI scores; the same is true for phosphodiesterase type 5
inhibitors.
There is only moderate to low- quality evidence for benefit from short- term use of antiinflammatory medications (non- steroidal anti- inflammatory drugs and steroids), antibiotics, and
phytotherapy (quercetin, pollen extract (Cernilton®), cranberry, etc.). Intraprostatic botulinum toxin
A has been shown to have benefit in improving NIH- CPSI scores and pain scores but the benefit
is short term and treatment may need to be repeated. Pelvic floor botulinum toxin A did not show
much benefit. In a recent Cochrane review, allopurinol, anticholinergics, antidepressants, pentosan
polysulfate, pregabalin, and mepartricin were ineffective.
25
25
There is moderate quality evidence for non- pharmacological interventions like acupuncture,
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extracorporeal shockwave therapy, circumcision, and tibial nerve stimulation in improving
prostatitis symptoms, but the quality of evidence is weak for other interventions like lifestyle
modifications, physical activity, prostatic massage, electromagnetic chair, thermotherapy,
sonoelectromagnetic therapy, ultrasound therapy, biofeedback, external radiofrequency,
laser therapy, myofascial trigger point release, osteopathy, trans- electrical nerve stimulation,
transurethral needle ablation, and so on.26 However, lifestyle modifications and physical activity
have an overall benefit on health and are frequently recommended.
Future directions
Further research to study the effect of various proven and unproven interventions on various different
parameters of this symptom complex is needed as most studies have so far focused on urinary
and pain symptoms. Cannabinoids such as N- palmitoylethanolamide and flavonoid polydatin are
currently being studied.
Psychological distress evaluation should be carried out by a dedicated psychologist or mental health
practitioner such that at- risk patients can be identified and interventions introduced as an integrative
therapy and as part of a multimodal approach.28 Such evaluation would provide an insight into
patients’ internal beliefs, perception of chronic pain, social support and interactions, relationships, and
so on. This would not only help understand possible psychological causes of physical manifestations
but also help plan adjustment and coping strategies.
Expert comment Asymptomatic inflammatory prostatitis
Asymptomatic inflammatory prostatitis is usually a histological diagnosis and is frequently an
incidental finding in men undergoing investigations for prostate cancer or in men undergoing infertility
investigations. Its prevalence ranges between 11% and 42%.29 As the name suggests, it is asymptomatic
and only presents clinical issues in the context of unnecessary biopsies for raised prostate- specific
antigen or abnormal findings on MRI related to it. There are suggestions of a role in development of
benign prostate hyperplasia and prostate cancer30 but this unproven. It is usually left untreated but
when seen in conjunction with leucocytospermia, it can be associated with male infertility.
27
19Case 2 Prostatitis
A final word from the expert
Inflammation of the prostate gland has been recognized as an entity for around two centuries
but remains essentially a clinical diagnosis with the use of other investigations primarily to
provide supportive evidence of either inflammation or infection localized to the prostate. The
term ‘prostatitis’ itself can cover a wide range of clinical conditions and it is therefore important
that, whenever possible, this is also qualified with type and the 1995 NIDDK/ NIH classification is
useful for this purpose.
Acute prostatitis (category I) has the clearest treatment pathway, and the majority of patients
have infection from Gram- negative bacteria which usually responds well to antibiotic treatment
with only a small proportion developing an abscess which can be readily identified on imaging
and drained via the transrectal or transurethral route. As for any acute infection, a high index of
suspicion and early diagnosis is critical to avoid systemic involvement and improve outcomes.
Unfortunately, CP (categories II and III) is an altogether more difficult entity both to
characterize and treat. The role of the Meares–Stamey test and/ or semen culture should not be
underestimated as it is important to establish early on in the management whether bacteria are
involved in causing symptoms. Where this is the case, that is, CBP (category II), treatment with
extended courses of antibiotics can lead to a satisfactory resolution in much the same manner
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as acute prostatitis. However, it is more commonly the case that bacteria are not detected and
chronic non- bacterial CP/ CPPS (category III) is therefore the most common form of prostatitis.
The treatment of CP/ CPPS is difficult, often unsatisfactory for patients, and should not be
regarded as the purview of the urologist alone. Its effective management frequently requires
the use of multiple modalities and multiple clinical disciplines with the primary focus being
on symptomatic management. Early recognition of the need for a multimodality approach is
perhaps the most important aspect of the modern- day management of this still very poorly
understood condition.
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21Case 2 Prostatitis
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SECTION 2
Urinary tract stones
Case 3 Renal stones
Case 4 Ureteric stones
Case 5 Bladder stone management
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