Diagnostic ultrasound ( PDFDrive )

CHAPTER 10 The Prostate and Transrectal Ultrasound 389
Chronic Prostatitis/Chronic Pelvic
Pain Syndrome
Understanding of the condition called “prostatitis” has changed
over the years. It is not merely “infection in the prostate.” Rather,
prostatitis refers to a chronic pain syndrome in which, surprisingly,
infection, inlammation, and even involvement of the
prostate are not always present. It is commonly termed chronic
prostatitis/chronic pelvic pain syndrome (CP/CPPS). 37,38
Prostatitis and pelvic pain complaints encompass many clinical
syndromes and can severely afect the quality of life of many
men who have chronic pain, sexual dysfunction, and LUTS.
Patients and physicians are oten frustrated because diagnosis
and treatments can be time-consuming and inefective. he impact
of prostatitis on quality of life has been likened to the morbidity
of myocardial infarction, angina, or Crohn disease. Interestingly,
men with CP/CPPS also have an increased incidence of cardiovascular
disease, neurologic disease, sinusitis, anxiety or depression,
and sexual dysfunction. Prostatitis can elevate PSA and on
mpMRI can mimic cancer, leading to potential unneeded cancer
investigations. 32 An estimated 9% to 13% of all men in the 40- to
50-year-old age group are afected. About 25% of visits to urologists
are related to prostatitis symptoms. In men younger than
50 years, CP/CPPS is the leading cause of visits to a urologist,
and in men older than 50, it is the third most common cause,
ater BPH and cancer. he lack of public awareness of this condition
likely relates to men’s general reluctance to discuss “personal”
concerns. 37,39
A consensus group at the National Institutes of Health produced
a Chronic Prostatitis Symptom Index (NIH-CPSI) and
diagnostic lowcharts to help in diagnosis and characterization
of symptom severity. 38,39
I. Acute bacterial prostatitis
II. Chronic bacterial prostatitis
III. CP/CPPS
A. Inlammatory
B. Noninlammatory
IV. Asymptomatic inlammatory prostatitis
Acute bacterial prostatitis is the least common form of
prostatitis, seen in about 2 of 10,000 oice visits, and 5% to 10%
of cases become chronic. Patients have symptoms of acute urinary
or systemic infection usually caused by infection with gramnegative
organisms such as Escherichia coli. TRUS is generally
of little use in acute prostatitis and can be very painful. About
half of these men have indings including edema, prostate
enlargement, increased blood low, venous engorgement,
hypoechoic peripheral halo, and altered patchy echo changes
that can be decreased, increased, or both. TRUS and mpMRI
indings can mimic neoplasia 40 (Fig. 10.8). he diagnosis is mainly
clinical. Symptoms should subside promptly with antibiotic
therapy, but treatment is continued for 4 to 6 weeks. If symptoms
do not subside quickly, abscess formation should be considered.
Abscesses occur in 0.5% to 2.5% of patients with acute bacterial
prostatitis and are more common in those with underlying
diabetes mellitus or immunosuppression (including human
immunodeiciency virus [HIV] infection) and ater catheterization
or instrumentation (see Fig. 10.8E). In such patients, TRUS should
be promptly performed for diagnosis. Small abscesses may not
need drainage, but larger abscesses over about 1.5 cm in diameter
can be easily drained transrectally or transperineally using TRUS
guidance, or they can be unroofed at cystoscopy. Experience has
shown that simple transrectal aspiration can be efective without
need for a drainage catheter. Abscesses have resolved even ater
a single drainage, but repeat aspiration is easily performed if
needed. 40
Chronic bacterial prostatitis is also uncommon. Patients are
typically afebrile but have recurrent episodes of bacterial urinary
infection–like symptoms. Most have no ultrasound indings, but
during acute episodes this condition may appear similar to acute
prostatitis on TRUS and mpMRI. In general, urine cultures are
negative but some have gram-negative organisms, most oten E.
coli. Empirically, about half of patients with chronic bacterial
prostatitis respond to 6- to 12-week courses of antimicrobial
therapy. 40
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
is the most common form of prostatic inlammation. hese men
have lower genitourinary pain with variable voiding and sexual
dysfunction but no evidence of bacterial infection or other cause
of pain. CP/CPPS accounts for about 90% of cases and afects
about 2 per 100 men. It is the most diicult to understand and
treat. CP/CPPS is classiied into two types: inlammatory type
(diagnosed by seeing leukocytes in prostate secretions, urine,
or semen) and noninlammatory type (no evidence of inlammation;
also called prostatodynia). he cause is unknown, and
the CP/CPPS name takes into account that the prostate may not
be the sole source of discomfort. he symptoms, however, are
identical to those of true prostate infection. Neurologic factors,
psychological factors, stress, and genetic predisposition have been
implicated, as well as association with other conditions such
as ibromyalgia, irritable bowel syndrome, and chronic fatigue
syndrome. No cause is identiied in the majority of men with
CP/CPPS. Patients may respond to antibiotics, alpha blockers,
nonsteroidal antiinlammatory drugs (NSAIDs), and analgesics,
which are oten used in multimodal fashion. 38,41 In most cases
the prostate appears normal on ultrasound. Some sonograms
show nonspeciic indings such as peripheral hypoechoic areas,
calciications, venous congestion, increased arterial low, bladder
neck thickening, hypoechoic prostatic rim, and periurethral
hypogenicity, and on TRUS and mpMRI the indings can
mimic neoplasia. 32,38
Asymptomatic inlammatory prostatitis is diagnosed in
men who have no history of genitourinary pain complaints
but who are shown to have inlammatory changes at histology.
Oten biopsy is done because of PSA elevations that are
common with prostate inlammation, even with asymptomatic
inlammation. 40
Diagnostic protocols have attempted to diferentiate among
the various types of prostatitis using history, physical examination,
and urine or other cultures. 38,39 An issue for TRUS and biopsy
is that many of these men have chronically elevated but oten
luctuating PSA levels, even in excess of 10 ng/mL, and the
oten-multiple inlammatory areas can mimic cancer on ultrasound
and mpMRI, leading to biopsy to exclude cancer 32 (see
Fig. 10.8).