for
PROSTATITIS
Developed for
the
Aerospace
Medical Association
by their
constituent organization
American
Society of Aerospace Medicine Specialists
Overview: Prostatitis
is the most common urologic diagnosis in men younger than 50 years of age and
is the 3rd most common diagnosis in men greater than 50 years of
age. It is defined as an increased number of inflammatory cells in the
prostatic parenchyma. The National Institute’s of Health (NIH) classification
for prostatitis is recognized as the best clinical classification system.
1. Acute
bacterial prostatitis (NIH category I) – This category is relatively uncommon.
Findings may include fever, genitourinary pain, obstructive voiding symptoms,
dysuria, urgency and frequency. Patients may also present with malaise, nausea,
vomiting and can progress to frank septicemia. The most common organisms are
gram negative enterobacteriaceae such as E. coli from gastrointestinal sources
and less commonly gram positive enterococci. Initial diagnosis is made by
history, physical, urinalysis and culture. A digital rectal exam may be
performed with gentle prostatic palpation but prostatic massage is NOT
performed as it can lead to bacteremia. The PSA may be acutely elevated but
will subside over the ensuing weeks and should be followed toward normal particularly
in the older population. Midstream urine will show significant WBCs and may
show bacteruria with a positive culture. In a military field setting, the lab
may be a simple dip stick type urinalysis with no culture available. Treatment
for uncomplicated cases requires 2 – 4 weeks of oral antibiotics. For those
significantly ill or who fail to respond to oral treatment rapidly, consider an
abscess and treat with intravenous antibiotics and urologic referral. Consult a current pocket antibiotic reference
book for the most appropriate agent based on patient age, potential pathogens and
resistance patterns as recommendations change with time.
2. Chronic
bacterial prostatitis (NIH category II) – NIH II typically affects men aged 40
-70 years of age. The patient usually has a history of recurring lower urinary
tract infections (UTIs). The bacteria
reside in aggregates or biofilms found in ducts and acini of the prostate
gland. The risk for recurrence is greater in those with functional voiding
abnormalities or inadequate initial treatment of acute prostatitis. Organisms
such as Chlamydia trachomatis may also play a role in some patients. For diagnosis of NIH category II or higher,
examination of urine and urine culture before and after prostatic massage is
needed. A digital rectal exam with gentle prostatic massage should be performed
after the patient has produced the first urine specimen followed by a
post-massage urine sample. The massage is not done on a patient with a
significant acute illness to prevent inducing a bacteremia. The post-massage
urine sample has increased WBCs and may reveal pathogens but cultures may be
sterile unless an acute UTI is also present.
Antibiotic treatment may range from 1 – 3 months depending on the medication
chosen and the severity of illness. This
category requires a urologic evaluation to eliminate a functional abnormality.
3. Chronic Pelvic Pain Syndrome or CPPS
(NIH category III) – This category is composed of two sub-types and accounts
for the majority of all prostatitis cases. NIH III type A and B CPPS have
persistent chronic genitourinary pain without uropathogenic bacteria. The
syndrome becomes chronic after three months of duration and quality of life is
significantly affected. Examination of urine and culture before and after
prostatic massage is required. Treatment may involve anti-inflammatory
treatment and/or alpha-adrenergic blockers to improve urine outflow. Empiric
antibiotic therapy may be useful but it is not understood if improvement
results from an antimicrobial action on uncultured organisms or from an
anti-inflammatory affect. Urologic
consultation is required.
Nonbacterial prostatitis or
inflammatory CPPS (NIH category IIIA) – Patients may complain of traditional
symptoms of prostatitis but report increased pain localized to the perineum,
suprapubic area, penis, groin or lower back. Additionally, they may report pain
during or after ejaculation. Increased numbers of WBCs are found in expressed
prostatic secretions and may also be found in the post-prostatic massage urine
or semen. All cultures are negative. Flight surgeons should be aware there may
be an association between this syndrome and an increased incidence of depression
or psychological disturbances.
Prostatodynia or noninflammatory CPPS
(NIH category IIIB) – The symptoms are similar to IIIA. All cultures are
sterile and there are insignificant or no WBCs found in expressed prostatic
secretions, post-prostatic massage urine or semen. This syndrome may result
from smooth muscle tone abnormalities in the prostatic urethra.
4. Asymptomatic inflammatory prostatitis
or AIP (NIH category IV) – WBCs are expressed in prostatic secretions,
post-prostatic massage urine sediment, semen or histological specimens of the
prostate gland but the patient has absolutely NO symptoms. No infection is
present, cultures are negative and patients frequently have benign prostatic
hypertrophy and/or an elevated PSA. A noninfectious etiology may be present
such as prostate cancer. Urologic consult is required.
Aeromedical Concerns: In general, return to flying status is dependent on the NIH
classification, side effects of the antibiotic selected, time to clinical
resolution and applicable policy from the designated regulating authority.
Environment:
Vibration in the cockpit may traumatize the perineal area and aggravate prostatitis
so a temporary grounding can assist in recovery. Those assigned to high G-force
aircraft may also exacerbate the condition secondary to the G load in the
perineal area.
Medication
selection: The more common civilian
choices include quinolones (like ciprofloxacin),
doxycycline, macrolides,
and Trimethoprim-Sulfamethoxazole (TMX/SMX). The service branches have
individual medication
lists vetted for flight approval but these lists are not identical. Quinolones
can
shorten the course of
treatment but have the increased risk for central nervous system side effects
compared to other
antibiotics. Ciprofloxacin and levofloxacin have been waived in some service
branches. There is no FAA restriction on quinolone use.
For acute prostatitis, once an idiosyncratic
medication reaction
is ruled out and symptoms have resolved, the airman can return to flying
status. This
assumes the
medication was chosen from the vetted list for the Air Force, Army, Navy or
FAA. Use good
operational risk
management for drug selection and reference your antibiotic pocket guide as
recommendations change
with time. For aviators requiring prolonged antibiotics in areas with
significant
increased sun
exposure, be cognizant of the drugs with increased risk for photo dermatitis
(like
doxycycline) and
adjust treatment or sun exposure warnings accordingly.
Consultation:
Aviators with NIH category II-III may have reasons for recurring infections
such as dysfunctional voiding, intraprostatic ductal reflux, pelvic floor
musculature abnormalities, neural dysregulation or prostatic calculi requiring
special urologic studies. Consultation is generally required to rule out other
pathology. NIH IV has special risks for prostatic cancer and requires
consultation.
Medical Workup:
The workup should include: a thorough history, complete examination,
urinalysis, cultures and discussion of all associated symptoms and medication
side effects. Labs such as CBC and PSA should be submitted if performed. If obtained, the urologist’s diagnosis,
prognosis, reports and tests results are to be included. For those with CPPS,
psychological status should be addressed.
Aeromedical Disposition (military): Please refer
to service specific guidance as there is some variation.
NIH I: No waiver
required. Treat the aviator with empiric antibiotics for 2-4 weeks (duration
based on
antibiotic chosen) or
based on cultures if available. Ground the aviator during the acute illness. If
an
antibiotic is
selected from an approved aircrew list, the aviator can be returned to flying
status when
symptoms have
resolved and no adverse medication reaction has been demonstrated.
NIH II: A waiver is
required. Chronic bacterial prostatitis is often asymptomatic between episodes
of
acute exacerbation.
For all three services, the risk of recurrent exacerbations with rapid onset of
symptoms require
grounding unless the infection is cured or suppressed with antibiotics. Urologist
consultation is
generally required to rule out other voiding abnormalities and a waiver is
required for the
condition and
continued antibiotic use.
NIH IIIA and IIIB:
Nonbacterial prostatitis and prostatodynia will require urologic consultation
and waiver
approval for all
three services. Psychological factors may also need consideration.
NIH IV: This
diagnosis requires urologic evaluation and a waiver for all three services.
Aeromedical Disposition (civilian): For
antibiotic use, once the idiosyncratic reaction to the drug is ruled out and
the symptoms have resolved the airman can return to flying status. The presence of chronic pain, the use of a
disqualifying medication, the finding of cancer or the demonstration of a
psychological disorder would require a special issuance.
Waiver Experience (military): There are 31
aviators in the USAF electronic waiver file approved for flight with the
diagnosis of prostatitis. Fourteen of
these were approved for flight while on antibiotics. 43% of those on
antibiotics were approved for ciprofloxacin or levofloxacin, 36% for TMX/SMX
and 21% for doxycycline. Three aviators were disqualified. One of 31 was
diagnosed with CPPS.
Waiver Experience (civilian): Special
issuance is not required for this condition.
References:
Air Force Instruction 48-123V, A4.21.10
Chronic Prostatitis, prostatic hypertrophy with urinary retention or abscess of
the prostate; 5 June 2006.
David RD. Rational antibiotic treatment of
outpatient genitourinary infections in a changing environment. Am J Med July
2005; 118 (7A): p 7S – 13S.
Dehart RL, Davis JR, et al. Selected
Medical and surgical Conditions of Aeromedical Concern, Prostatitis. In: Dehart
RL eds. Fundamentals of Aerospace Medicine, 3rd Ed. Philadelphia: Lippincott
Williams and Wilkins; 2002: p451.
Federal Aviation Administration. Aviation Medical Examiner (AME)
Information. http://www.faa.gov/about/ office_org/
headquarters_offices/avs/offices/aam/; cited 11 Sept 2007.
Hua VN. Acute and chronic prostatitis. The
Med Clin N Am. 2004; 88: 483-494.
Kim ED. Bacterial prostatitis. E Medicine.
14 June 2005: p 1-15; http://www.emedicine.com; cited 21 August
2007.
Nickel JC. Chronic bacterial prostatitis:
An evolving clinical enigma. Urology. 2005; 66 (1): p 2-8.
Nickel JC. Prostatitis and related
conditions. In: Walsh PC eds. Campbell-Walsh Urology, 9th Ed.
Philadelphia: Saunders; 2007: 1-31; http://www.mdconsult.com; cited 21 August
2007.
NOMI
Aeromedical Waiver Guide. 16.3, Prostatitis. http://www.nomi.med.navy.mil/NAMI/
WaiverGuideTopics/index.htm; cited 21 August 2007.
Rayman RB, Hastings JD, Kruyer WB, Levy RA,
Pickard JS.
US
Army Waiver Guide. Prostatitis. https://aamaweb.usaama.rucker.amedd.army.mil/
AAMAWeb/policyltrs/Army_APLs_Mar06_v3.pdf; cited 21 August 2007.
2/15/08