Prostatitis Secondary to Trichomoniasis

Authors:
John Pennington, MD, and Charlotte Coggins, MD, MBA
Mayo Clinic Health Systems Waycross

Citation:
Pennington J, Coggins C. Prostatitis secondary to trichomoniasis [published online May 16, 2017]. Infectious Diseases Consultant.

A 33-year-old man presented to the emergency department (ED) with left flank pain, fever, nausea, and vomiting. The patient appeared acutely ill but in no distress. He also was complaining of difficulty with urinating and requested a urinary catheter. He stated that he had had a similar problem in the past while he had been incarcerated. He recalled having taken a medication for this issue, and the problem had resolved; however, he did not remember the name of the medication. At the same time, he also had been given a prescription for lisinopril for hypertension.

Physical examination. Initial laboratory test results upon admission showed an elevated creatinine level of 2.5 mg/dL (reference range, 0.1-0.4 mg/dL), and a computed tomography scan of the abdomen and pelvis showed no hydronephrosis. Costovertebral angle tenderness was noted on the left greater than the right; however, bilateral perinephric stranding was noted, slightly more prominent on the right. His blood pressure was also elevated at 141/101 mmHg.

Diagnostic tests. The results of an initial urinalysis showed the following values: protein, 3+ positive; glucose, 1+ positive; ketones, trace positive; occult blood, 1+ positive; nitrite, negative; leukocyte esterase, negative; red blood cell (RBC) count, 19/high-power field (HPF); white blood cell (WBC) count, 4/HPF; and Trichomonas vaginalis, moderately positive. We interpreted these results as a possible indication of an active infection due to his physical examination findings as well as the urinalysis results showing evidence of trichomoniasis, despite being negative for WBCs.

Treatment. Treatment with metronidazole was started in the ED as well as single doses of azithromycin and ceftriaxone for possible gonorrhea and chlamydia coinfection. A Foley catheter was placed as requested by the patient, and oral tamsulosin, 0.4 mg twice daily, was also started to help with urination when the catheter would eventually be removed 1 day later.

The following day, the Foley catheter was removed, and a prostate massage was attempted but did not yield an adequate specimen for further analysis. The prostate was enlarged and tender upon digital rectal examination.

A repeat urinalysis 3 days later showed the following values: occult blood, 3+ positive; nitrite, positive; leukocyte esterase, moderately positive; RBC count, more than 182/HPF; and WBC count, 18/HPF. Laboratory test results for T vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis were all negative. These results presented a more characteristic appearance of prostatitis.

Diagnosis. Because the repeat urinalysis results were consistent with infection, repeat culture tests were performed, but no bacterial growth was reported. The results were negative for T vaginalis. Because of these findings, the patient received a diagnosis of prostatitis.

Prostatitis is the infection or inflammation of the prostate gland. The bacteria are in the prostate, and the urine passes through the prostatic urethra. However, the microbial population in the urine was too low in our patient to lead to a positive culture result. Subsequent urinalysis did show WBCs and nitrites, which is to be expected because the prostatic massage mobilized infectious elements (WBCs and nitrites), but not the microbes (bacteria), from the prostate. No bacteria grew in the collected culture after massage, a finding that is consistent with trichomoniasis as opposed to bacterial prostatitis.

Discussion. Acute infection of the prostate is frequently linked with infection in other parts of the urinary tract. Furthermore, patients may present with findings consistent with cystitis or pyelonephritis. The presentation could include fever, chills, dysuria, urgency, myalgias and varying degrees of obstruction.¹

Results of urine cultures of patients with prostatitis frequently are negative for pathogens. A study by Forrest and Schmidt² showed that of all the men evaluated for prostatitis (N = 92), only 5% to 10% had a true bacteriologic condition as evidenced by positive urine culture results. Furthermore, fastidious organisms that cannot be cultured may cause nonbacterial prostatitis routinely from a urinary specimen. These organisms include C trachomatis, Ureaplasma urealyticum, T vaginalis, N gonorrhoeae, viruses, and fungi.²

Prostatitis can present in a variety of nonspecific ways and may have multiple causes. To help understand our patient’s presentation, acute bacterial prostatitis may be thought of as a subtype of a urinary tract infection.¹ Two major mechanisms have been proposed for acute prostate infection. The first is reflux of infected urine into the glandular prostatic tissue via the ejaculatory and prostatic ducts. The second is ascending urethral infection from the meatus, particularly during sexual intercourse. Importantly, patients may present with findings similar to cystitis or pyelonephritis, because acute infection of the prostate is often associated with infection in other parts of the urinary tract.³ The most common pathogens associated with acute prostatitis are Escherichia coli, Proteus species, Enterobacteriaceae (eg, Klebsiella, Enterobacter, Serratia),⁴ and Pseudomonas aeruginosa, none of which were found in our patient.

Clinical and laboratory diagnosis of trichomoniasis is more complex in male patients.⁵ This is chiefly due to the fact that T vaginalis can infect numerous sites of the male genitourinary tract, and in practice, it is possible to find organisms in one specimen but not in another when testing samples from the same individual.⁶ On the other hand, the number of organisms in male specimen cultures is relatively very small, and this number usually does not increase over the incubation period.

Trichomoniasis is the most common curable sexually transmitted disease.⁷ In the United States, an estimated 3.7 million people have the infection, but about 70% to 85% of those infected remain asymptomatic.⁷

Outcome of the case. The patient was discharged 5 days after admission with no symptoms of urinary retention, flank pain, or hypertension. An infectious disease physician, just prior to discharge, had assumed his care and chose to provide a brief course of ciprofloxacin, 500 mg, due to the results of the second urinalysis that showed signs of infection despite negative cultures. The angiotensin-converting enzyme inhibitor lisinopril was changed to amlodipine, 5 mg daily, due to acute kidney injury that was noted on admission. The patient was advised to inform his partner(s) of T vaginalis exposure, and test results were negative for HIV and hepatitis B and C viruses.

References:

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2. Forrest JB, Schmidt S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity. J Urol. 2004;172(6 pt 2):2561-2562.
3. Meares EM. Prostatitis. Med Clin North Am. 1991;75:405–24.
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7. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.