Center for Disease Control and Prevention.

1998 Guidelines for treatment of sexually transmitted diseases. Morb Mortal Wkly Rep 1998; 47:1 -111.

8. PROSTATITIS, EPIDIDYMITIS AND ORCHITIS

SUMMARY

Prostatitis is a disease entity that is diagnosed by symptoms, the microscopy of expressed prostatic secretion (EPS), and the culture of EPS and segmented urine samples. According to the duration of symptoms, prostatitis is described as either acute or, where symptoms are present for at least 3 months, chronic. We recommend the classification of prostatitis suggested by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK)/National Institutes of Health (NIH), in which bacterial prostatitis (acute and chronic) is distinguished from chronic pelvic pain syndrome (CPPS).

Acute bacterial prostatitis (ABP) can be a serious infection and parenteral administration of high doses of bactericidal antibiotics, such as aminoglycosides and a penicillin derivative or a third-generation cephalosporin, are required until defeverescence and the normalization of infection parameters. In less severe cases, a fluoroquinolone may be given orally for 10 days.

In chronic bacterial prostatitis (СВР) and CPPS, a fluoroquinolone or TMP should be given orally for 2 weeks after the initial diagnosis. The patient should then be re-assessed and antibiotics continued only if pre-treatment cultures were positive or if the patient reports a positive effect of the treatment in terms of pain relief. A total treatment period of 4-6 weeks is then recommended.

Inflammatory processes of the testis (orchitis) and epididymis (epididymitis) have to be classified as acute or chronic processes according to the onset and clinical course. The majority of cases of epididymitis are due to common urinary pathogens. Bladder outlet obstruction and urogenital malformations are risk factors for this type of infection. Orchitis of the child and mumps-orchitis are of haematogenous origin. Epididymo-orchitis is also seen in systemic infections, such as tuberculosis, lues, brucellosis and cryptococcus disease. Antimicrobials should be selected on the empirical basis that in young, sexually active men C. trachomatis is usually the causative agent, and that in older men with BPH or other micturition disturbances, the most common uropathogens are involved.

Prior to antimicrobial therapy, a urethral swab and MSU should be obtained for microbiological investigation. Fluoroquinolones, preferably those with good activity against С trachomatis (e.g. ofloxacin, levofloxacin), should be the drugs of first choice, because of their broad antibacterial spectra and their favourable penetration into the tissues of the urogenital tract. If C. trachomatis has been detected as the aetiological agent, treatment could also be continued with doxycycline, 200 mg/day, for a total treatment period of at least 2 weeks. Macrolides may also be considered. For cases of С trachomatis epididymitis, the sexual partner should also be treated.

8.2 Prostatitis

8.2.1 Background

What was previously denoted 'prostatitis', is today more frequently referred to as 'prostatitis syndrome'. This disease entity is diagnosed and classified by symptoms, microscopy and the culture of EPS and segmented urine samples, according to Meares and Stamey (1). The term 'syndrome' indicates that, in most cases, the aetiology is unknown and the diagnostic criteria are weak. A causative pathogen is detected in only 5-10% of cases (2). For the remaining patients, treatment is given on an empirical basis, and numerous medical and physical forms of treatment have been reported. In recent years, a new classification has been introduced, and hence a better systematization of treatment options may be of benefit for these patients (3,4). This section deals with documented or suspected bacterial infections of the prostate.

8.2.2 Classification systems

The purpose of the four-glass technique, described by Meares and Stamey (1), was to localize the infection to the urethra, the prostate or the bladder. Ten years later, Drach et al. (5) suggested a classification of prostatitis based on the work of Meares and Stamey. In this classification, various types of prostatitis are differentiated according to the findings of WBC or positive cultures in EPS and segmented urine samples (VB1 - first-voided urine; VB2 - mid-stream urine; VB3 - urine following prostatic massage). This has been the most widely used classification of prostatitis for almost three decades (Table 12). The latest World Health Organization (WHO) classification of diseases (International Classification of Diseases, 10th version) is based on this classification (6).

Table 12: Classification of prostatitis according to Drach et al. (5)

Acute bacterial prostatitis

• Clinically significant infection of the prostate with acute symptoms
Chronic bacterial prostatitis

• Significant inflammation of the prostate

• Isolation of an aetiologically recognized organism from the prostatic fluid/urine
Chronic abacterial prostatitis

• Significant prostatic inflammation

• Failure to isolate an organism from the prostatic fluid/urine, or the isolation of an organism the
aetiological significance of which is debatable

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