Prostate Pro Tips

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD

When someone comes in with prostate related symptoms and infection, it's hard to know if we're working with prostatitis vs prostate abscess. How can we improve our prostate game? Tarlan Hedayati, MD schools Matthieu DeClerck, MD, and Neda Frayha, MD with her prostate pro-tips.

Pearls:

• Think about acute bacterial prostatitis when someone presents with symptoms of acute prostatitis AND has the following characteristics: immunocompromised, symptoms > 36 hours, progressive urinary retention, recent antibiotics for prostatitis.
• Avoid prostate exams in people with neutropenia given theoretical risk of seeding bacteria.

• Distinguishing between acute bacterial prostatitis and prostate abscess can be difficult because patients will look sick (fever, tachycardia, abdominal pain) in both cases
  • Suprapubic pain
  • Abdominal pain
  • Urinary retention
  • History of having had prostatitis in the past
  • Pain with defecation or with prolonged sitting
  • Immunocompromised patient
  • Protracted symptoms > 36 hours
  • Progressive urinary retention
  • Patients who have received antibiotics for prostatitis but are getting worse
• • Overlap symptom:
  • Physical exam and CT scan ultimately will help rule out deadly abscess or other
  • Things to make you think more about abscess:
  • Pearl: do not send a PSA during acute prostatitis. Leads to unnecessary worry and future monitoring of PSA levels.
• Prostate exam tips:
• • Start with palpation of the anal-rectal junction to get a sense if discomfort is coming from the exam itself versus the prostate and examine if there a rectal abscess
  • Palpate the prostate last to feel for bogginess, tenderness
  • Prostate massage is supposed to increase the sensitivity of urine culture by squeezing bacteria out of the prostate into the urethra. However given the discomfort, probably not needed in the emergency or even primary care setting → it should be a quick exam
  • Pearl: avoid prostate exam in people with neutropenia given theoretical risk of seeding bacteria
• Categories of prostatitis:
  • A urinalysis, gram stain and culture should not have any bacteria
  • Patients have been dealing with for a longer time and are non-toxic appearing
  • Chronically have WBC's in the urine with no symptoms
  • Diagnosed by biopsy
• • Acute bacterial prostatitis 
  • Chronic bacterial prostatitis
  • Chronic prostatitis or chronic pelvic pain (90% of prostatitis)
  • Asymptomatic inflammatory prostatitis
• Treatment:
• • E-coli is the bacteria you're treating against → check your local antibiogram for resistance patterns
• Prostate abscess 
  • 5th or 6th decade of life
  • Immunosuppression
  • End stage renal disease
  • Indwelling catheter
  • Any recent instrumentation of the prostate
• • Potential complication of inflammatory prostatitis
  • At most 2.5% of patients
  • Risk factors:

REFERENCE:

1. Carroll DE, Marr I, Huang GKL, Holt DC, Tong SYC, Boutlis CS. Staphylococcus aureus Prostatic abscess: a clinical case report and a review of the literature. BMC Infect Dis. 2017 Jul 21;17(1):509.
2. Datillo WR, Shiber J. Prostatitis or prostatic abscess. J of Emerg Med. 2013; 44(1):e121-e122
3. Hsieh MJ, Yen ZS. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Is there a role for serum prostate-specific antigen level in the diagnosis of acute prostatitis? Emerg Med J. 2008 Aug;25(8):522-3.
4. Khan FU, Ihsan AU, Khan HU, Jana R, Wazir J, Khongorzul P, Waqar M, Zhou X. Comprehensive overview of prostatitis. Biomed Pharmacother. 2017 Oct;94:1064-1076.