Prostatitis: etiology and diagnosis - Culture; Identification; Molecular diagnosis (PCR).


Information 15/02/15.


Prostatitis is an inflammation of the prostate gland that occurs as several syndromes with varying clinical signs.


Syndromes can be:


I-bacterial prostatitis acute.

II-Chronic bacterial prostatitis.

III-Chronic prostatitis and chronic pelvic pain syndrome (CPPS: Chronic Pelvic Pain Syndrome), inflammatory and noninflammatory.

IV-Prostatitis asymptomatic inflammatory.


Other terminologies used are "non-bacterial prostatitis" and "Prostatodynia". The first is infectious prostatitis in which there is a common bacteria or other infectious agent causing prostatitis. This usually occurs with agents such as Chlamydia trachomatis, Mycobacterium tuberculosis, Ureaplasma spp., Cytomegalovirus, ... The "prostatodynia", however, is a process characterized by a similar acute or chronic prostatitis symptoms, but there prostatic inflammation or any microbial agent involved, and usually correspond to voiding dysfunction or a psychological component.


In acute bacterial prostatitis patients manifest fever, malaise, arthralgia, myalgia, back pain under (sacral), perineal pain, rectal, which generally increases with bowel, orchialgia, uretralgia, suprapubic pain, spontaneous urethral discharge, accompanied by symptoms urinary tract obstruction. On physical examination, there is fever, and prostate examination is a nodular, swollen, fluctuating hot and prostate. In bacterial prostatitis chronic symptoms are less obvious and exploration is a normal gland with or without calcification. In prostatodynia, during scanning, it is a normal gland.


Acute and chronic bacterial prostatitis are defined by the finding and bacterial infections are treated with antibiotics.


Chronic pelvic pain syndrome (CPPS) is characterized by pain in urological absence of urinary infection, provided that is excluded the active urethritis, urogenital cancer, urinary disease, urethral stricture, bladder or neurologic disease. It is subdivided into two subtypes, inflammatory and noninflammatory, the first one with the presence of leukocytes in semen, prostatic secretions or urine bladder following prostatic massage, whereas in the second, there is no inflammatory cells.


Inflammatory prostatitis Asymptomatic are characterized by the finding of prostate inflammation without clinical manifestations. Usually it found during testing male infertility or during the investigation of the cause of the elevated prostate specific antigen (PSA), found during an analytical control in which this parameter is included. Asymptomatic inflammatory prostatitis These cause elevation of leukocytes in the ejaculate (leukocytospermia) and associated with male infertility but generally untreated.


Bacterial prostatitis, usually caused by sexually transmitted bacteria, but may also occur by hematogenous, lymphatic, or contiguity from surrounding organs extension. Prostatitis exist in inflammatory cells in the glandular epithelium of the prostate gland and the light with inflammatory cells in tissues periglandular. However the presence and amount of inflammatory cells in urine and prostatic secretions not correlate with the intensity of clinical symptoms. Granulomatous prostatitis may be related to HIV infection, which can lead to lack of diagnosis by culture. In these patients may be Cytomegalovirus infections. They can also occur by Mycobacterium tuberculosis infections and Candida albicans, which can be diagnosed as prostatitis culture negative. Another cause granulomatous prostatitis is as of a manifestation of Wegener's granulomatosis, autoimmune nature of a process that affects the blood vessels of various organs (lung, kidney, etc.).


Bacterial prostatitis acute may be caused by ascending infections through the urethra, flow of urine into the prostatic ducts, or lymphatic spread directly or from the rectum. Approximately 80% of cases are gram - negative bacteria (Escherichia coli, Enterobacter spp., Serratia spp., Pseudomonas spp., Enterococcus spp. , And Proteus spp.), There is a finding of Staphylococcus aureus methicillin-resistant. Mixed infections are rare. In young adults should be considered Neisseria gonorrhoeae and Chlamydia trachomatis.


Chronic bacterial prostatitis are often caused by Escherichia coli, followed by Enterococcus spp, Pseudomonas aeruginosa, Chlamydia trachomatis, Ureaplasma spp, Trichomonas vaginalis, Candida spp, Mycobacterium tuberculosis, or Cytomegalovirus (the latter two in the context of tuberculosis... systemic or HIV infection).


microbiological diagnosis


Urinalysis and culture can confirm the presence of infection and identify pathogens. Fractionated urine studies (urethral and bladder urine), and cytology expression of prostatic secretion may help differentiate prostatitis urethritis and cystitis. There is no standard diagnostic test for nonbacterial chronic prostatitis.


In urinalysis, are obtained quantitative values of leukocytes and number of bacteria, the presence of fatty substances and macrophages with fat. Urine culture can identify the pathogen, if present.


Fractionated samples of urine, may be useful for the diagnosis of prostatitis. 10 mL of initial urine from the urethra (urine sample removed M1, when detects elevated counts of bacteria suggests urethritis. The next 200 mL of urine is discarded and the mean urine sample (M2) representing the bladder urine is collected . the presence of high bacterial count suggests cystitis without prostatitis then prostatic massage is performed, except when there is an acute prostatitis should not be performed by the risk of causing bacteremia, followed by the expression of prostatic secretion (EPS.: Expressed prostatic secretions) that is collected from the urethral meatus. Finally, 10 mL of urine collected after prostate massage (M3). the bacteria found in the sample of the prostate expression (EPS) and M3 represent the microbiological characteristics of the prostate gland .


Chronic bacterial prostatitis is diagnosed if the cultivation of EPS samples and M3 are the same bacteria as the first voided urine (M1), and counting colonies of the two crops (EPS and M3) is at least 10 times the first voided urine (M1).


therapeutic recommendations


In acute bacterial prostatitis, with signs of severe disease, sepsis evidence, or both, require hospitalization for intravenous antibiotics as broad - spectrum penicillins, third generation cephalosporins, aminoglycosides with or without, or fluoroquinolones. Since 2007, the CDC recommends fluoroquinolones for the treatment of gonococcal but a single dose of ceftriaxone intramuscularly, plus a single oral dose of azithromycin, or oral doxycycline for 7 days. This association prevents the emergence of resistance in gonococci and covers Chlamydia trachomatis.


When no signs of gravity, outpatient therapy can be made 14 to 28 days of oral treatment generally fluoroquinolone or trimethoprim-sulfamethoxazole, for good prostástica diffusion both fluoroquinolones such as trimethoprim or doxycycline or erythromycin for 2 to 3 weeks.


Tests in IVAMI:


  • Microscopic examination, fresh and after Gram staining for observing inflammatory cells and bacteria.
  • Detection by culturing bacteria causing common prostatitis (gram - negative bacteria and gram - positive bacteria) and bacterial sexually transmitted diseases such as Neisseria gonorrhoeae.
  • PCR detection of intracellular bacteria such as Chlamydia trachomatis.
  • PCR detection of Mycobacterium tuberculosis in cases of patients with a history of tuberculosis or HIV infection.
  • Cytomegalovirus PCR detection in cases of patients with HIV infection or immunosuppressed.
  • Testing antimicrobial susceptibility for common bacteria (gram negative and gram) and sexually transmitted bacteria (Neisseria gonorrhoeae), if found.

Recommended sample:


  • Samples of unfractionated urine (M1: first 10 mL of voided urine; M2: urine emitted after having rejected before 200 mL after collection M1; M3: last 10 mL of urine after the massage and prostatic expression, except prostatitis acute where the prostate massage should not be performed.


Sample preservation:


  • Refrigerated (preferred) for less than 2 days.
  • Frozen more than 48 hours.


Shipment to the laboratory:


  • Refrigerated.


Delivery term:


  • Common bacteria and sexually transmitted bacterial cultures (Neisseria gonorrhoeae): 48 hours.
  • PCR Chlamydia trachomatis, Mycobacterium tuberculosis, Cytomegalovirus: 48 to 72 hours.


Cost of testing: