General symptoms are the sense of malaise with high fever of intermittent type
and diffuse arthromies. Locally, perineal pain is present, accompanied by
extreme polio, dysuria, stranguria, bladder tenesmus, symptoms sustained by both
bladder irritability and frequent incomplete urinary retention caused by the
sudden obstacle at the prostate level. There is a live pain of defecation, for
which the patient tends to reduce the frequency of evacuations causing
constipation. Acute catarrhal inflammation can regress spontaneously or
following appropriate therapy; in some cases there is instead the evolution
towards the ascissualization with exacerbation of the described symptomatic
symptomatology. If untreated, the abscess tends spontaneously to the formation
of a fistulosis which usually opens in the urethra and, more rarely, in the
rectum, bladder or perineum.
Besides being a sequel to an acute episode, this form can manifest itself as a
chronic process from the beginning.
The generic diagnosis of prostatitis is easily suspected already on the basis of the symptomatic picture. The differentiation between the various forms of prostatitis and prostatosis requires careful clinical examination.
In acute prostatitis, prostate exploration reveals an increased volume gland, of
softness, pasty due to edema, very hot and above all painful to pressure. In the
ascissualized forms there is the distinct sensation of fluctuation in the
context of a tense-elastic, very painful swelling. In chronic bacterial
prostatitis the prostate is of normal or slightly increased volume with an
irregular surface due to the presence of protruding nodules which are very
painful to palpation. The objective picture is very similar to that of the
carcinoma, so much so that in many cases it is only the biopsy study that
settles the legitimate doubts. In abacterial prostatitis the findings are not
always uniform: sometimes the objective picture does not differ from that of the
chronic bacterial form; other times (and they are the most frequent) the
prostate appears instead increased in volume but of pasty consistency due to
edema and congestion. Finally, prostatodynia, a typical affection of juvenile or
adult age, almost always shows a completely normal gland.
Together with the microscopic examination of the prostatic secret, it represents
one of the cornerstones of differential diagnostics.
The exact execution of the sample is fundamental for its reliability: when the
bladder is full, the patient is bitten and the first 10 ml of urine indicated as
VB 1 are collected in a sterile test tube; in a second test tube, after having
made urinate about 200 ml, another 10 ml are collected which represent the
intermediate flow or VB 2; subsequently the patient is invited to stop the
urination and a prostatic massage is performed by collecting the obtained
secretion, EPS, in a third tube; after the massage the urination is resumed
collecting, always in sterile collector, the first 10 ml emitted indicated as
VB3. The data obtained are interpreted as follows: in an infection of the
urethra the bacterial count in the sample VB 1 (initial jet of washing of the
urethra) significantly overlaps that of the samples EPS and VB 3; on the
contrary, in the case of bacterial prostatitis, EPS and VB 3 above VB 1. In the
cases of bladder infection all the samples show a superimposable bacterial count.
Acute prostatitis is characterized by a purulent secretion that produces a
confluent growth of the pathogen in the culture, with a strongly alkaline pH. In
chronic prostatitis the prostatic secretion is equally alkaline but the
microscopic finding is characterized by exfoliation and inflammatory cells,
leukocytes and macrophages. Finally, the chronic abacterial prostatitis gives
rise to a secretion that contains, in addition to exfoliation cells and few
macrophages, also obligatorily a number of leucocytes not less than 10 per field;
below this number the secretion is considered normal and the diagnosis is
oriented towards prostatodynia. In the field of diagnostic imaging, a prominent
role is played by transrectal ultrasound, which allows a reliable differential
diagnosis with other prostatic diseases. Ultrasound images of acute prostatitis
are characterized by anechoic areas due to inflammatory edema or to the
ascission of the outbreak. Hyperechogenic areas that remain confined within the
capsule are instead characteristics of chronic bacterial prostatitis. In
granulomatous prostatitis, the presence of focal dense asymmetric nodules is
noted. Such findings, such as those of chronic prostatitis, almost always
require a targeted biopsy for the differential diagnosis with prostate cancer.
Among the radiological investigations, it still retains its precise role the
urinary and retrograde cysto-urethrography which highlights any urethral
narrowings caused by prostatitis and the presence of the fistulosis and abscess
cavities. Finally, as a supplement to the morphological data, the urodynamics
offers us the evaluation of the functional damage linked to prostatitis.
Uroflowmetry is generally shown to be impaired due to the obstruction caused by
the volumetric increase in the gland. The repetition of the examination during
the treatment allows to evaluate over time the evolution of prostatitis and
consequently the correctness of the established therapy.
The observation of a high level of male infertility linked to infection of the
genital tract and low urinary has stimulated a growing interest in the possible
etiological role played by prostatitis and almost always associated bladder
cells. Numerous in vitro studies have shown that the addition of live
microorganisms, in quantities greater than 10 colonies per ml of normal seed,
decreases the sperm motility and agglutination capacity while this does not
occur for more modest concentrations of bacteria. From this it emerges that, in
acute prostatitis, in which the bacterial concentration is very high, direct
damage may occur on the seed, while in chronic prostatitis, in which the
quantity of microorganisms is decidedly inferior, infertility is produced not on
the basis of a direct effect of pathogens on spermatozoa, but for alteration of
the prostatic secretion. In fact it is well known that the composition and
physical characteristics of the fluids of the accessory genital glands play a
decisive role for the vitality of nemasperms and therefore for the fertility of
the individual.
Bacterial acute prostatitis: the treatment is based on the administration of analgesics, antipyretics and antibiotics at bactericidal doses, following the indications of the culture and of the relative antibiogram. The intense and widespread inflammatory reaction favors the passage of antibacterial substances from the plasma to the prostatic ducts, otherwise considerably difficult, thus allowing the drugs to carry out their action completely. Clinical experience shows instead that chronic bacterial prostatitis poses significant treatment problems, given the considerable refractory nature of the antibacterial medical therapy due to the difficulty of spreading drugs inside the prostate bone, therefore it also necessitates physical maneuvers (massage ) or, more rarely, surgical (endoscopic resection).