To test or not to test (for bacterium in prostatitis), that is the question!

Does testing for bacterium in prostatitis feature in your practice? Once considered the ‘gold standard’ of testing for bacterial prostatitis, the four-glass Stamey test has fallen out of favour in recent years, yet patients are still prescribed antibiotics for symptoms of prostatitis as par for the course. With less than 5% of all cases presenting as bacterial, the pendulum appears to have swung too far in the wrong direction. Quinolone antibiotics still remain the drug of choice in combating the effects of prostatitis (bacterial or not) with limited results at best. So what, if anything has replaced the Stamey glass test? The two-glass or pre-post-massage test (PPMT) has shown 96% accuracy in identifying the presence of bacterium when compared with the four-glass test, yet patients do not receive either.

Patients at The Pelvic Pain Clinic, London (dedicated to treating male pelvic pain, including chronic pelvic pain syndrome and nonbacterial prostatitis), are rarely, if ever, given four- or two-glass tests to confirm the presence of bacteria. They are more likely to be given a semen and/or urine test, yet used alone these tests are not accurate enough to give a clear diagnosis of bacterial prostatitis. On average these patients have had their symptoms for 12 months, seen at least one urologist and had multiple rounds of antibiotics at varying lengths and dosages with little, if any, symptom relief.

Successful treatment of prostatitis has remained elusive to healthcare providers since the earliest recordings of treatment in the 19th Century. Clear and accurate diagnosis of the presence of bacterium is imperative to ensure appropriately tailored care for this group of patients.

Does testing for bacterium feature in your practice? If you do not test, what are the barriers you face in using the tests? Would a UK-wide directory of urologists who carry out these tests be useful?

Your thoughts and wisdom would be appreciated.

Read the article here. 

Comments (6) Add yours ↓
  1. Declan Cahill Mr

    National database unlikely to be useful since this is such a multitude of clinical scenarios.
    Testing never beneficial unless clinically obvious and then culture sensitivity very comforting.
    Contamination with strep very common. Contamination suggested more likely in absence of white cells.
    Ibuprofen my first line but suspect I need to use a more potent antiinflammatory.
    Very unlikley to be infective unless obvious from the history. Men don’t have quiet urinary infections.
    The majority of this group are inflammatory prostatitis. Theoretically urinary reflux into the prostate from outflow dysfunction. A chemical prostatitis.
    Injudicious use of ciprofloxacin is weak, uninformed and a danger for the future.
    Hope that is off the fence!

    June 6, 2017 Reply
  2. Frank Chinegwundoh consultant urologist

    I don’t do PPMT. I give the man the option of ciproxin but make them aware of the lack of evidence. Some wish for that, others happy with a NSAID.
    The important thing is making a clinical diagnosis, giving dietary and lifestyle advice. Taking it seriously. Reviewing the man. Explaining the up and down nature of the ailment and that it eventually ‘burns itself out’.
    I agree that the majority of this group is inflammatory. I think pelvic & genital pain syndrome is a better term as I often doubt if the prostate is the source of the problem. The prostate is more often than not not tender on rectal examination.
    I’m not sure that the management is any better now than 25 years ago when I first saw men with ‘prostatitis’.

    June 6, 2017 Reply
  3. Christian Brown Urologist

    I dont call it prostatitis as it’s unhelpful and inaccurate. Chronic Pelvic Pain Syndrome (CPPS) is a much better term, it implies an unknown cause and deflects from the knee jerk reaction to give more antibiotics. It’s essential to test the urine and semen as the patients always assume it’s infection and then perform some form of outflow assessment. This is usually all normal. Then the symptom treatment starts.

    Anti inflammatories and alpha blockers can work as can alternative drugs such as gabapentin and amytryptilline. Also consider techniques such as massage therapy, acupuncture and hypnosis, all used in managing chronic pain and can be useful in this area.

    June 7, 2017 Reply
  4. Karl Monahan Therapist

    Thank you so much for your valuable comments and input, it is greatly appreciated.

    It is such a tricky and delicate ground to tread on. How do we move away from the overuse and repeated prescription of antibiotic on this population? What will it take for this culture to change? By carrying out regular PPMT could it not change this focus? Used in conjunction with UPOINT(S) this information could prove to be very valuable for more accurate patient diagnosis (through more accurate phenotyping) and subsequent treatment

    The term prostatitis in itself is particularly misleading and only fuels the notion that a patient might have a bacterial infection or inflammatory process specific to the prostate. I do believe accurate and clear education is paramount here and this ultimately takes time. I prefer the term CPPS but still feel there are greater subdivisions that could be used for more patient focused treatment

    Research indicates that the prostate is so rarely implicated in the majority of prostatitis cases. I agree that there will be inflammatory processes involved but whether they are more centrally driven (central sensitisation) remains to be investigated further.

    Prostate exams have been found to be painful on non-symptomatic men and the levels of WBC do not correlate with patient symptoms scores. It seems to me there is so much more at play here. Treating the whole person and not just symptoms – using a biopsychosocial model lends to greater patient outcomes?!

    It appears that not much has changed since the mid 20th century in terms of appropriate, patient focused treatment. Sadly the patients are the ones who are suffering here. Prostate cancer and BPH have certainly moved head over heals in the right direction, I only wish the same could be applied to Prostatitis/CPPS/Male Pelvic Pain

    June 26, 2017 Reply
  5. Why are we not testing for bacteria in Prostatitis? | The Pelvic Pain Clinic

    […] Why are we not testing for bacteria in Prostatitis? I wrote a blog post on this very matter on the “Trends in Urology and Mens Health” website. I asked the urologists on there if they thought the testing for bacteria in Prostatitis was relevant in todays age and if they did or didn’t carry out these tests. I also asked if a national directory of specialists who carried out these tests was necessary. You can read the blog and the replies here  […]

    July 31, 2017 Reply
  6. Diarmuid McCarthy GP

    The four-glass test was described by Meares and Stamey as a ‘localization’ test for detectable infection (urethritis vs prostatitis) rather than as a sensitive ‘detection’ test (PMID: 4870505). To have ever been considered as the gold standard of “testing for” bacterial prostatitis is probably due to prostatitis ‘research guidelines’ and the NIH classification being misinterpreted as actual clinical guidelines.

    It’s worth noting that a four-glass test wouldn’t exclude bacterial seminal vesiculitis, so withholding antibiotics based on a negative four-glass test could be totally inappropriate.

    August 1, 2017 Reply

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