Review Question - QID 107337

This patient presents with a somewhat prolonged prodrome of symptoms suggestive of chronic prostatitis. The mainstay of treatment for this condition is alpha blockers and antibiotics.

Chronic prostatitis is a syndrome consisting of lower urinary tract symptoms and pelvic pain. It is a distinct entity from chronic bacterial prostatitis. Prominent symptoms include pain that can involve the lower abdomen, penis, testicles, or prostate area. There is often concurrent bladder irritation or obstruction that leads to voiding difficulty. Urinalysis can reveal pyuria, but not always. It can be associated with irritable bowel syndrome and fibromyalgia. Front-line treatment for chronic prostatitis includes alpha blockers and fluoroquinolone antibiotics.

The clinical syndrome described can overlap with other conditions such as benign prostatic hypertrophy (BPH), prostate cancer, and chronic bacterial prostatitis. BPH typically has a predominance of voiding symptoms rather than dysuria. Prostate cancer could potentially present in this way; however, none of the given answer choices would be appropriate for the treatment of prostate cancer. Finally, chronic bacterial prostatitis is a similar condition, but the question stem should emphasize bacteruria or even prostatic fluid bacterial positivity, which is the best diagnostic method for this. After diagnosing chronic prostatitis, one must know that the initial therapy is BOTH alpha blockers and antibiotics, and that finasteride and antidepressants can be adjunctive therapies.

Incorrect Answers:
Answers 1 and 2: As stated above, the treatment of chronic prostatitis consists of combination therapy with alpha blockers and antibiotics. Antibiotics alone would be indicated for a urinary tract infection or chronic bacterial prostatitis. Alpha blockers alone are indicated for uncomplicated BPH.
Answers 4 and 5: Although finasteride (a 5-alpha reductase inhibitor) and duloxetine (a serotonin-norepinephrine reuptake inhibitor) can be used as adjunctive agents for patients refractory to the initial therapies, they should not be used first-line.

Prostatitis is a common condition in general medical practice, occurring in roughly eight percent of men. It is divided into acute bacterial, chronic bacterial, chronic - pelvic pain syndrome, and asymptomatic (typically found on biopsy done for a different reason); these are distinguished primarily by history and lab studies. One should also consider bladder cancer, nephrolithiasis, and enteroviscular fistula on the differential with these conditions (1).