Diagnostic Workup of Chronic Prostatitis - EXPIRED
Program year 2001
Focus of Measure:
To ensure that all eligible members, who are newly diagnosed with chronic prostatitis receive the appropriate follow-up tests within a clinical appropriate timeframe
- Prostatitis accounts for almost two million office visits per year in the United States. (1)
- Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common problem affecting 10% to 14% of all men, regardless of age or ethnicity. (2)
- As many as 50% of men are affected by this condition at some point in their life. (3)
- Chronic prostatitis is associated with substantial costs and lower quality-of-life scores. (4)
Reason for indicated intervention or treatment
- The classification of chronic prostatitis is based on microscopic and culture examination of prostate-specific specimens such as expressed prostatic fluid, ejaculate and postprostate massage. (5)
- Although prostatic massage usually produces purulent secretions with a large number of bacteria on culture, bacteremia may result from manipulation of the inflamed gland. For this reason and because the etiologic agent can usually be identified by Gram's staining and culture of urine, vigorous prostatic massage should be avoided in acute cases. The expression of prostatic fluid is believed to be totally unnecessary and perhaps even harmful in cases of suspected acute prostatitis. (6)
Evidence supporting intervention or treatment
- No well-designed trials have specifically evaluated the validity or diagnostic accuracy of laboratory testing in diagnosing chronic prostatitis (7), and there has been considerable debate about the usefulness of some of these examinations.
- The traditional Stamey-Meares four-glass localization method, which includes bacterial cultures of the initial voided urine, midstream urine, prostatic secretions, and a postprostatic massage urine specimen (8), is considered to be the gold standard for evaluating prostatitis. However, since the test is cumbersome and expensive, it is infrequently performed by primary care physicians and urologists (9-11) and its use does not dramatically change management strategies. (11) Furthermore, its usefulness in diagnosing or treating prostatic disease has never been validated.
- An alternative pre- and postmassage two-glass test has been proposed (12), but has also not been validated. A prospective study of 143 patients diagnosed with chronic prostatitis showed that the two-glass and four- glass tests gave very similar results. (13) A retrospective review of 112 patients using the four-glass test as the gold standard showed sensitivity and specificity rates of 91% for the two -glass test. (11)
- A large case - control study of 463 men enrolled in the National Institutes of Health Chronic Prostatitis Cohort study and 121 age-matched men without urinary symptoms showed that men with CP/CPPS had significantly higher leukocyte counts in all segmented urine samples and expressed prostate secretions, but not in semen, as compared to controls. However, since the control population also had a high prevalence of leukocytes, the differences were clinically insignificant. There was no difference in rates of localization of bacterial cultures. The high prevalence of leukocytes and positive bacterial cultures in the control population raises questions about the usefulness of the standard four-glass test as a diagnostic tool. (14)
- Another large cohort study of 488 men in the National Institutes of Health Chronic Prostatitis Cohort study questioned the relevance of determining the bacterial and inflammatory status of the lower urinary tract, because the parameters do not correlate well with duration, frequency or severity of symptoms. (15)
- The 2000 Washington meeting of the International Prostatitis Collaborative Network and a consensus symposium of the NIH Chronic Prostatis Collaborative Research Network held in 2002 developed guidelines for evaluating patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). (16, 17)
- Mandatory investigations for patients presenting with CP/CPPS include history and physical examination, including digital rectal exam (DRE), urinalysis and urine culture.
- Recommended evaluations include some form of lower urinary tract localization study (such as the traditional Meares-Stamey four-glass test or the pre- and postmassage two-glass test), a flow rate, residual urine volume determination and urine cytology.
- Optional evaluations include semen analysis and culture, urethral swab, pressure-flow studies, cystoscopy, transrectal ultrasound of the prostate, and pelvic imaging studies.
- The International Consensus Conference on Advances in the Diagnosis and Treatment of Prostatitis in Giessen, Germany in 2002 came to the consensus that the diagnosis of CP/CPPS was one of exclusion. (17)
- Basic evaluations for patients presenting with CP/CPPS include history and physical examination, including DRE, along with urinalysis and midstream urine culture.
- Further evaluations include lower urinary tract localization tests (microscopic and culture), flow rate, and residual urine determination.
- Selected patients should get other laboratory evaluations such as urine cytology, urethral evaluation, semen analysis and culture, and prostate-specific antigen.
The medians for HMSA in 2007 were as follows:
- For practitioners with a minimum of 5 eligible members in the denominator: 42.6%
- For practitioners with a minimum of 15 eligible members in the denominator: 38.45%
January 1, 2006 - December 31, 2006
Continuously enrolled males with one diagnosis of chronic prostatitis in the inpatient setting or two diagnoses of chronic prostatitis in the outpatient setting during the period from one month after the beginning of the measurement year through two months prior to the end of the measurement year (i.e., nine months total)
Males who were diagnosed with chronic prostatitis within one year (365 days) prior to the index diagnosis of chronic prostatitis
Males who had a either a microscopic urinalysis, urine culture, or evidence of evaluation of prostate-specific specimens, from one month prior through two months after the index diagnosis of chronic prostatitis
Interpretation of Score:
High score implies better performance
Adapted from Health Plan Employer Data Information Set (HEDIS) technical specifications
Effectiveness of Care:
This measure is classified as a disease management measure. Disease management measures are those that are applicable to individuals who have been diagnosed with a condition and that are part of the treatment or management of the condition (e.g., cholesterol reduction in patients with diabetes; radiation therapy following breast conserving surgery; appropriate follow-up after an acute event).
Strength of Recommendation:
See Strength of Recommendation Based on a Body of Evidence - EXPIRED for the algorithm used to determine the strength of a recommendation. While this algorithm provides a general guideline, authors and editors of the PQSR clinical measures may adjust the strength of recommendation based on the benefits, harms and costs of the intervention being recommended.
The abbreviation USPSTF shown in the algorithm stands for United States Preventive Services Task Force.
- Collins MM, et al. How common is prostatitis? A national survey of physician visits. J Urol, 1998. 159(4): p. 1224-8.
- Mehik A, et al. Epidemiology of prostatitis in Finnish men: a population-based cross-sectional study. BJU Int, 2000. 86(4): p. 443-8.
- Stamey T. Urinary tract infections in males., in Pathogenesis and treatment of urinary tract infections., T. Stamey, Editor. 1980, Williams and Wilkins: Baltimore. p. 342-429.
- Calhoun EA, et al. The economic impact of chronic prostatitis. Arch Intern Med, 2004. 164(11): p. 1231-6.
- Nickel JC, LM Nyberg and M Hennenfent. Research guidelines for chronic prostatitis: consensus report from the first National Institutes of Health International Prostatitis Collaborative Network. Urology, 1999. 54(2): p. 229-33.
- Dennis L Kasper, EB Anthony Fauci, Stephen Hauser, Dan Longo, J Larry Jameson. Harrison's Principles of Internal Medicine. 16th.
- McNaughton Collins M, R MacDonald and TJ Wilt. Diagnosis and treatment of chronic abacterial prostatitis: a systematic review. Ann Intern Med, 2000. 133(5): p. 367-81.
- Meares EM and TA Stamey. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol, 1968. 5(5): p. 492-518.
- Roberts RO, et al. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology, 1998. 51(4): p. 578-84.
- Moon TD. Questionnaire survey of urologists and primary care physicians' diagnostic and treatment practices for prostatitis. Urology, 1997. 50(4): p. 543-7.
- McNaughton Collins M, et al. Diagnosing and treating chronic prostatitis: do urologists use the four-glass test? Urology, 2000. 55(3): p. 403-7.
- Nickel JC. The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol, 1997. 3(1): p. 38-43.
- Seiler D, et al. [Four-glass or two glass test for chronic prostatitis]. Urologe A, 2003. 42(2): p. 238-42.
- Nickel JC, et al. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol, 2003. 170(3): p. 818-22.
- Schaeffer AJ, et al. Leukocyte and bacterial counts do not correlate with severity of symptoms in men with chronic prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study. J Urol, 2002. 168(3): p. 1048-53.
- Nickel J. Special report on prostatitis: state of the art. Rev Urol, 2001. 3: p. 94-98.
- Nickel JC. Clinical evaluation of the man with chronic prostatitis/chronic pelvic pain syndrome. Urology, 2002. 60(6 Suppl): p. 20-2; discussion 22-3.
- Nickel J. Clinical evaluation of the patient presenting with prostatitis. Eur Urol, 2003. 68 (Suppl): p. 1-4.
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