Prostatitis: Characteristics, Diagnosis, and Treatment

Urinary Tract Infections (UTIs)

• UTIs are a clinical and pathological condition involving signs, symptoms, and inflammation.
• Asymptomatic bacteriuria refers to the presence of bacteria in the urine without any signs or symptoms of a UTI.

UTI Classification by Anatomical District

• Lower part of the urinary tract is associated with cystitis.
• The prostate is associated with prostatitis.
• The kidneys are associated with pyelonephritis.

Classification of UTIs by Pathological Conditions

• Uncomplicated UTIs are acute, sporadic, or recurrent lower/upper UTIs, limited to non-pregnant women without anatomical/functional abnormalities or comorbidities.
• Complicated UTIs are UTIs not defined as uncomplicated, indicating an increased chance of a complicated course (e.g., in men, pregnant women, patients with urinary tract abnormalities, catheters, renal diseases, diabetes).
• Recurrent UTIs are recurrences of uncomplicated/complicated UTIs, with a frequency of at least three UTIs per year or two in the last six months.
• Catheter-associated UTIs (CA-UTI) occur in individuals with a current urinary catheter or a catheter in place within the past 48 hours.
• Urosepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection originating in the urinary tract and/or male genital organs.

Risk Factors for UTIs

• Previous UTIs and frequent sexual intercourse.
• Having a new sexual partner and a family history of UTIs.
• Diabetes and neurogenic disorders.
• Incontinence, phimosis, and BPH (Benign Prostatic Hyperplasia).
• For older women, estrogen deficiency and bladder prolapse are major risk factors, while prostatic enlargement is more relevant for men.

Epidemiology of UTIs

• UTIs are a significant health issue, more common in women.
• Up to 60% of women experience at least one uncomplicated UTI.
• Up to 5% of women have recurrent UTIs.
• 1-2% of pregnant women may experience UTIs.
• Of which 0.5-2% may develop pyelonephritis.
• Catheter-associated UTIs occur at a rate of 1.5 per 1,000 catheter days.
• 20% of bacteremias arise from the urinary tract.
• US data from 2007 includes 10.5 million office visits for UTI symptoms, 0.9% of all ambulatory visits, 2-3 million emergency department visits, 400,000 hospitalizations (in 2011), and $2.8 billion in costs.

Pathogenesis of UTIs

• UTIs typically occur through ascending infection, where bacteria colonize the perineal area, ascend the urethra, and reach the bladder (cystitis).
• Bacteria may then ascend to the ureters and kidneys (pyelonephritis).
• Hematogenous or lymphatic pathways are rare.
• Women are more susceptible due to anatomical reasons.
• E. coli colonization in the perineal area, moving to the vagina and then the urethra (shorter in women), ascending to the bladder.
• Bacteria adhere to superficial umbrella cells, colonizing the epithelium.
• The pathogenesis depends on the interaction between the host and the uropathogens.
• Uropathogen virulence-associated factors influence adhesion to the epithelium and cause inflammation.

Virulence-Associated Factors

• Adhesion to the urothelium is a crucial virulence factor.
• Immune evasion and antimicrobial resistance are other important mechanisms.
• Invasion involves bacteria binding to the extracellular membrane and residing within cells, contributing to recurrent infections.

Host Defense

• A non-specific host defense includes urinary flow and the integrity of the urothelial barrier.
• An immune-driven defense activates signaling pathways, triggering inflammation and causing the signs/symptoms of UTIs.
• Asymptomatic bacteriuria may occur when bacteria do not activate inflammation.

Etiology of UTIs

• E. coli accounts for 75-90% of UTI cases.
• Staphylococcus saprophyticus accounts for 5-15%.
• Klebsiella, Proteus, Enterococcus, and Citrobacter species account for 5-10% of the cases.
• Gram-positive bacteria (e.g., enterococci and Staphylococcus aureus) are important pathogens in complicated UTIs, especially prostatitis.

Acute Uncomplicated Cystitis (AUC)

• Most common type of UTI with no fever, chills, rigors, significant fatigue, or flank pain.
• More difficult to identify in men, pregnant women, people with urinary tract abnormalities or catheters, those with renal diseases, or immunocompromised individuals.
• Clinical presentation includes dysuria, urinary frequency/urgency, suprapubic pain, and sometimes hematuria.
• Urine samples are examined for alterations in color, clarity, and odor.

UTI Diagnosis

• Symptoms usually suffice for diagnosis; dipstick and urinalysis can be performed.
• Urine culture is used for suspected complicated UTIs to confirm the diagnosis.
• The dipstick is a cheap and fast diagnostic tool.
• Urinalysis is slower and more expensive, better for evaluating contamination.
• Analyze midstream clean catch urine to avoid contamination, by eliminating the first part of the urine flow for culture.
• For Enterobacteriaceae, a count of ≥10^5 CFU/mL in asymptomatic patients is considered significant (confirm with a second specimen).
• ≥10^2 CFU/mL is significant in symptomatic patients.

UTI Treatment

• EU guidelines indicate that a history of lower urinary tract symptoms is sufficient for diagnosing AUC in women with low risk factors. Dipstick testing can be used for acute uncomplicated cystitis.
• Urine cultures are recommended for suspected acute pyelonephritis, unresolved or recurrent symptoms, atypical symptoms, and in pregnant women. Treatment Considerations:
• Spectrum and susceptibility patterns and tolerance.
• Adverse reactions, costs, and availability.
• Common antibiotic choices, with the exception of quinolones:
• Fosfomycin and Nitrofurantoin
• Co-trimoxazole (TMP/SMX) (only if Escherichia coli resistance rate <20%)

Acute Cystitis in Men

• Less common due to the longer urethral length, which makes ascending mechanism more difficult.
• Prostatic fluid contains antibacterial substances.
• May require quinolones or co-trimoxazole due to prostate involvement.

Recurrent Cystitis

• Defined as >2 UTIs in 6 months or >3 UTIs in 1 year.
• Occurs due to reinfection (different pathogen or strain) or relapse (same pathogen), indicating a possible urinary tract abnormality. Epidemiology and Risk Factors:
• Up to 50% with a recurrent episode within 6 months.
• Incidence is around 100 per 100,000 in the US.
• Risk factors vary by whether a patient is Young/pre-menopausal or post-menopausal/elderly

Pathogenesis treatment for Recurrent UTIs

• Besides the ascending pathway, there is vaginal and periurethral colonization.
• It is managed with behavioral modifications (avoiding diaphragm/spermicides, adequate fluid intake, post-coital urination, wiping from front to back).
• Antimicrobial prophylaxis includes low-dose continuous prophylaxis (3 months), post-coital prophylaxis, or self-treatment.
• Non-antimicrobial approaches include vaginal oestrogen replacement, vaccines, probiotics, cranberry, or D-mannose.

Acute Pyelonephritis

• A complicated, dangerous syndrome with a presence of fever and flank pain.
• May be accompanied by chills, rigors, fatigue, malaise, and costovertebral angle tenderness.
• Managed based on Uncomplicated/complicated case, and whether patient is non-pregnant/pre-menopausal women
• Uropathogens are similar across various pyelonephritis types. Diagnosis:
• Laboratory tests: Urinalysis and blood tests (CBC, creatinine, urea, Na, K, CRP).
• Microbiology tests: Urine culture and blood cultures (at least 2 sets).
• Uultrasound/CT scans are useful for structural/functional abnormalities. Treatment options:
• Beta-lactams (Ceftriaxone/Ceftazidime/Cefepime)
• If these are not effective, the third line of treatment is:
• Carbapenems (Meropenem/Imipenem)
• Fluoroquinolones Non indicated treatment:
• Fosfomycin and nitrofurantoin

Renal and Perinephric Abscesses

• Complications of untreated pyelonephritis, often a result of renal infections. Types:
• perinephric abscess (perinephric area)
• cortical renal abscess (inside the kidney)
• paranephric abscess (outside of the Gerota fascia).
• The clinical presentation is similar to that of pyelonephritis, with fever, pain, fatigue, lumbo-abdominal pain, sweats, and weight loss.
• You should perform a CT scan or ultrasonography.
• Lab tests will always result in leukocytosis and increased CRP.
• A urinalysis will sometimes show pyuria and bacteriuria .
• Perform a blood culture and urine culture. Treatment:
• Use long-term antimicrobial treatment; drainage of the abscess is possible.

Catheter-Associated UTI (CA-UTI)

• Urinary tract infections that affect patients with a urethral (Foley) catheter, suprapubic catheter, or intermittent catheter.
• Urine culture is performed to diagnose.
• Symptoms: fever, suprapubic pain, costo-vertebral angle tenderness, hypotension, altered mental status, and/or sepsis.
• Pathogenesis: catheter is colonized by bacteria, creating biofilms.
• Treatment. catheter-associated bacteriuria. Candida in urine.
• Prevent unnecessary catheterization and remove catheter as soon as possible
• If patient is unable or unwilling to collect urine

Asymptomatic Bacteriuria (ABU)

• Presence of one or more species of bacteria in urine culture, without signs and symptoms of a UTI.
• Mainly caused by Escherichia coli, specifically ABU E.coli, which does not ascend or adhere to the bladder surface.
• Uropathogenic coli (UPEC) do adhere to the bladder, leading to pyelonephritis, abscesses, and sepsis.
• Those that you should Screen and treat are pregnant woman, and patients undergoing endourological procedures: Don't Screen, don't treat:
• women without risk factors Pts undergoing endourological procedures pts/post-menopausal womenpts with renal transplants
• women with diabetes, or other non-typical uropathogenic agents.

Prostatitis

• Not specifically a UTI.
• Classified into acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis.
• Divided into an inflammatory and a non-inflammatory kind.
• Can also be classified into acute bacterial prostatitis, chronic bacterial prostatitis, Pain Syndrome and Asymptomatic inflammatory prostatitis. Prostatitis diagnosis in acute cases:
• You can test for leukocytes and bacteria in urine samples.
• Risk factors: Benign prostatic hypertrophy (BPH), genitourinary and other kinds of infection, high-risk sexual behaviour, history of sexually transmitted diseases.
• You colud also perform semen or ejaculate culture for diagnosis, but they have very low specificity since they are at high risk of contamination.
• Treatments are fluoroquinolones and co-trimoxazole.
• Treatment should last a minimum of 2 weeks, and lasts about 4-6.

Explore the characteristics, diagnosis, and treatment of prostatitis. Differentiate between acute and chronic bacterial prostatitis. Identify key age ranges and treatment strategies for inflammatory and non-inflammatory prostatitis.