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Chronic bacterial prostatitis

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Updated 2024 EAU guidelines for the diagnosis and management of chronic bacterial prostatitis.

Background

Overview

Definition
CBP is caused by a chronic bacterial infection of the prostate gland characterized by recurrent UTIs caused by the same bacterial strain, pelvic pain, and LUTS.
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Pathophysiology
CBP is caused by a chronic bacterial infection commonly involving E. coli and enterococci.
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Disease course
Clinical manifestations include pain, which may be poorly localized (pelvis, genitalia, lower back, or hypogastrium), and LUTS (weak stream, straining, hesitancy, urgency, frequency, dysuria).
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Prognosis and risk of recurrence
CBP is not associated with increased mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic bacterial prostatitis are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the Prostatitis Expert Reference Group (PERG 2015), and the Canadian Urological Association (CUA 2011). ...
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Classification and risk stratification

Staging: as per PERG 2015 guidelines, classify patients as being:
in the early stages of the disease, if they have experienced persistent, recurrent symptoms for < 6 months and are antibiotic-naïve
in the later stages of the disease, if they have experienced persistent, recurrent symptoms for > 6 months and are refractory to initial pharmacotherapy.
B
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  • Severity assessment

Diagnostic investigations

Physical examination: as per CUA 2011 guidelines, perform a physical examination (including the abdomen, external genitalia, perineum, prostate, and pelvic floor) in patients with suspected CBP or chronic prostatitis/chronic pelvic pain syndrome.
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  • Microbiologic testing

  • PSA

  • Transrectal ultrasound

  • Cystoscopy

  • Pelvic imaging

  • Urodynamic testing

  • Psychosocial assessment

Medical management

General principles: as per PERG 2015 guidelines, ensure a multidisciplinary team care including urologists, pain specialists, nurse specialists, physiotherapist, general physicians, cognitive behavioral/psychological therapists and sexual health specialists.
B
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  • Antibiotic therapy

  • Analgesic therapy

  • Alpha-blockers

  • 5-ARIs

  • Pentosan polysulfate

Nonpharmacologic interventions

CBT: as per PERG 2015 guidelines, consider offering CBT in conjunction with other treatments to improve pain and QoL in later-stages of CBP or chronic prostatitis/chronic pelvic pain syndrome.
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  • Physiotherapy

  • Alternative medicine

Surgical interventions

Drainage of prostatic abscess: as per CUA 2011 guidelines, perform incision and drainage of the prostatic abscess, preferably via transurethral route.
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  • Prostatectomy

Specific circumstances

Patients with asymptomatic prostatitis
As per CUA 2011 guidelines:
Do not screen or evaluate for asymptomatic prostatitis.
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Do not treat patients with asymptomatic prostatitis.
D
Consider initiating antimicrobial therapy in selected patients with asymptomatic prostatitis with elevated ptostate-specific antigen, infertility, and in patients scheduled to undergo prostate biopsy.
D

Patient education

General counseling: as per PERG 2015 guidelines, discuss differential diagnoses (including urological cancers) and other concerns (such as infertility) at first presentation to establish a full patient history and help inform future investigations.
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Follow-up and surveillance

Management of refractory disease: as per PERG 2015 guidelines, switch to an alternative treatment method or refer to specialist care if a bacterial cause is excluded and no symptom improvement is observed after antibiotic therapy.
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