According to the National Institute of Health, prostatitis can be divided into four groups.
They include acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis.
But if you were diagnosed with fungal prostatitis you may not be able to find the diagnosis in the usual sources.
Where is fungal prostatitis in this classification? What do you need to know about this condition?
This information is not available on most informative sites because fungal prostatitis is rare. But in this article, we will review all you need to know about this type of prostatitis.
What is fungal prostatitis?
Fungal prostatitis is a prostate infection caused by fungi. It is a very unusual type of prostatitis. However, even if the incidence of fungi infection is much lower than bacterial agents, it is still important to consider.
Fungal prostatitis is a complex entity and does not happen in the usual patients with prostate problems. Similar to other types of prostatitis, it causes lower urinary tract symptoms. It may even mimic prostate cancer and sometimes coexists with this disease.
Moreover, fungal prostatitis may become a source of systemic infection. These agents could spread to other organs, which is often a sign of immune problems. In many cases, the patients are immunocompromised and have recurrent urinary tract infection symptoms.
You may not find fungal prostatitis in the usual classification given by the National Institute of Health. However, it is covered by the spectrum of chronic prostatitis/chronic pelvic pain syndrome. It behaves as such, and some patients may develop this condition for years with very uncomfortable symptoms.
6 signs and symptoms of fungal prostatitis
The experience with fungal prostatitis tells urologists that it has various patterns instead of only one. Some patients develop more symptoms than others.
The disease is sometimes associated with additional health problems. There is sometimes pain and tenderness, but it is not required to make a diagnosis.
The most common symptoms we find in case reports include (1):
- Prostate enlargement: The prostate can be swollen and slightly larger than usual. An ultrasound scan may display the exact changes found in the typical bacterial prostatitis. In the case of an enlarged prostate, it is essential to differentiate prostatitis from benign prostatic hyperplasia.
- Prostatic tenderness and pain: The prostate is tender when manipulated in digital rectal examination or during a prostatic massage. It may also become very painful, even without direct manipulation.
- Lower urinary tract symptoms: Fungal prostatitis is similar to acute and chronic bacterial prostatitis in this aspect. Patients often develop one or more lower urinary tract symptoms. They include increased urinary frequency, reductions in the urinary stream, urine retention, and more. There is a recorded case where the patient had bladder outlet obstruction and no other clinical manifestation of fungal disease.
- Epididymal induration: This is more common in cases of genitourinary blastomycosis. These patients develop infection of the prostate, the epididymis, the testis, prepuce, kidneys, and adjacent organs.
- Fever: Some patients may also develop a moderate fever along with urinary symptoms. It usually doesn’t reach 40 ºC, but it is persistent until the patient is treated with antifungal drugs.
- Cloudy urine: Sometimes, patients develop a sign called pyuria. This is an accumulation of white blood cells in the urine. Thus, the urine contains pus and turns cloudy instead of clear.
The most common complication of fungal prostatitis is the formation of a prostatic abscess. In most cases recorded by the literature, the patients had a prostatic abscess drained and analyzed.
The results yielded Candida species or another fungus, and treatment started depending on the agent. If not treated correctly, a prostatic abscess may drain to the abdominal cavity and cause life-threatening peritonitis (2,3).
Another complication of fungal prostatitis is epididymo-orchitis. The infection may migrate from the prostate to the epididymis and then reach the testicles. Orchitis is very painful and may affect fertility (4).
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What causes fungal prostatitis?
In most cases, patients with fungal prostatitis are immunocompromised. They are either older men with severe immune problems, patients under immunosuppressant therapy, or infected with the human immunodeficiency virus (HIV).
These patients are more likely to suffer from opportunistic infections with different agents.
Candida albicans and other Candida species
The fourth most common bloodstream infection is caused by Candida species. They include C. Albicans, C. glabrata, and C. krusei.
Candida species often reach the prostate gland through the bloodstream and colonize the organ. In other cases, the problem comes from a urinary tract infection such as cystitis and obstructive uropathy (2,3).
This is perhaps the second most common cause of fungal prostatitis. The most common agent is Cryptococcus neoformans.
Predisposing conditions include immune suppression, chronic diseases such as diabetes mellitus, and prostate cancer.
After recovering from meningitis, many AIDS patients have positive urine cultures with Cryptococcus. Thus, the prostate becomes a reservoir for this species (5).
Candida is the most common cause, but there are recorded cases of prostatic aspergilla infection, too. The most commonly identified species is Aspergillus fumigatus.
This is sometimes a cause of severe prostatitis, but it is a quiescent infection discovered incidentally in other cases. It is more common in patients with diabetes mellitus, those who use antibiotics for a long time, and those with an indwelling bladder catheter.
Detecting aspergillus in the prostate should be followed by a thorough assessment of the genitourinary system and thorax to rule out other foci of infection (4,5,6).
In most cases, this agent is not only involved in prostatitis. The same patient may develop epididymitis and infections in other genitourinary organs (7,8).
Other fungal agents of prostatitis include Coccidioides species (coccidioidomycosis), Histoplasma species (histoplasmosis), and contamination with Lycopodium clavatum spores and the fungus Hansenula fabianii (1).
In some cases, it remains unclear how fungi invade the prostate. It could be due to a previous bladder infection. Some authors describe the possibility of sexual transmission, especially in young and healthy patients (9).
One of the signs that should make doctors consider fungal infections in the prostate is an immunocompromised patient with chronic urinary symptoms that do not respond to antibiotic therapy. This patient can be under immunosuppressive therapy or may simply have diabetes or another chronic condition.
The following exams may come in handy in such patients (1):
- Digital rectal examination: The prostate will be swollen and tender in most cases. This exam is also important to consider prostate cancer in the same patient.
- Urine culture and cytology: This exam often yields the fungi and other microorganisms responsible for the infection. It may also show pyuria, an accumulation of white blood cells in the urine.
- Cytology of transurethral drainage of the prostate: If the patient has a prostatic abscess, draining the abscess and performing a cytology study is helpful for a diagnosis.
- Prostatic ultrasound: This exam can be done through the pubic area, but it is more accurate with transrectal ultrasound. It may show swelling and edema in the prostate. Sometimes patients with fungal prostatitis develop emphysematous changes in the gland. There are cases in which Cryptococcus fungal prostatitis mimics prostate cancer. The lesions look very similar on an ultrasound scan.
- Abdominal CT scan: This is a more accurate way to evaluate the prostate when in doubt. The exam often shows an enlarged prostate with fluid-filled densities, corresponding to a prostatic abscess.
- Complete blood count: It is sometimes helpful as it displays leukocytosis, pointing to an acute infection.
Treatment for fungal prostatitis
Depending on the comorbidities, and the current state of the patient, treatment may include the following procedures and drugs:
- Systemic antifungal drugs: Doctors tend to recommend treating fungal prostatitis with antifungal drugs for one month or more. One or two antifungal drugs can be chosen depending on the severity of the condition. Success has been reported after administering ketoconazole, amphotericin B, itraconazole, among others. Choosing the drug depends on the fungal agent infecting the prostate.
- Transurethral drainage of the prostate: If you choose this line of treatment, this and other surgical procedures on fungal prostatitis should be performed carefully. There is an account of disseminated Cryptococcus infection after transurethral resection of the prostate (10).
Invasive candidiasis in the prostate is the most common type of fungal prostatitis. This type of infection can be similar to acute prostatitis and chronic prostatitis caused by bacteria. However, it usually falls in the category of a prostatitis syndrome known as chronic prostatitis/chronic pelvic pain syndrome.
This type of infectious prostatitis usually features chronic inflammation resistant to antibiotics. Urine tests and drainage of a prostate abscess show Candida overgrowth in the prostate.
It is more common in patients with immunosuppressive drugs, HIV, and chronic disease, resulting in reduced immune function. Patients with recurrent UTI should also be tested to evaluate the possibility of fungal prostatitis. Doctors often recommend treatment using antifungal agents, and it is usually prolonged. A prostatic abscess is the most common complication. When not treated, the infection may also spread to the epididymis and the testis, causing significant scrotal pain and fertility issues.