Diagnosis (I) Diagnostic principles It is recommended to diagnose prostatitis according to the NIH classification. Type I: Diagnosis depends mainly on medical history, physical examination and bacterial culture results of blood and urine. Rectal examination of the patient is mandatory, but prostate massage is contraindicated. Before applying antibiotic therapy, mid-stage urine culture or blood culture should be performed. When the patient’s condition does not improve after 36 hours of standardized management, transrectal ultrasound and other tests are recommended to comprehensively evaluate the lower urinary tract pathology and to clarify the presence of prostate abscess. Type II and III (chronic prostatitis): detailed history, comprehensive physical examination (including rectal fingerprinting), routine examination of urine and prostate massage fluid are required. The NIH chronic prostatitis symptom index[2] (NIH-CPSI, see Appendix I) is recommended for symptom scoring. The “two-cup method” or “four-cup method” is recommended for pathogen localization. For definitive diagnosis and differential diagnosis, optional tests include: semen analysis or bacterial culture, prostate-specific antigen (PSA), urine cytology, transabdominal or transrectal ultrasound (including residual urine measurement), uroflow rate, urodynamics, CT, MRI, urethrocystoscopy, and prostate biopsy. Type IV: asymptomatic, detected on examination of prostate massage fluid (EPS), semen, urine after prostate massage, biopsy of prostate tissue and pathologic examination of prostatectomy specimens. (ii) Diagnostic methods The specific diagnostic methods for prostatitis include: 1. Clinical symptoms When diagnosing prostatitis, a detailed history should be taken to understand the cause of the disease or its triggers; ask about the nature of the pain, its characteristics, its location, its degree, and the abnormalities of urination; learn about the course of treatment and its recurrence; evaluate the impact of the disease on the quality of life; and learn about the past history, personal history, and sexual life. Type I: sudden onset of the disease, manifested by chills, fever, fatigue, weakness and other systemic symptoms, accompanied by perineal and suprapubic pain, urinary tract irritation and dysuria, or even acute urinary retention. Types II and III: Clinical symptoms are similar, with pain and abnormal urination. Type II may present with recurrent lower urinary tract infections. Type III is mainly characterized by pain in the pelvic region, which can be seen in the perineum, penis, perianal area, urethra, pubic bone or lumbosacral area. Abnormal urination can be manifested as urinary urgency, frequent urination, painful urination and increased nocturia. As the chronic pain remains untreated, the patient’s quality of life decreases, and there may be sexual dysfunction, anxiety, depression, insomnia, memory loss, and so on. Type IV: No clinical symptoms. Due to the relative lack of objective indicators for diagnosing chronic prostatitis and the controversy surrounding it, the NIH-CPSI is recommended for symptom evaluation.The NIH-CPSI consists of 3 main parts with 9 questions (0-43 points). The first part assesses the location, frequency, and severity of pain and consists of questions 1-4 (0-21 points); the second part is urinary symptoms and assesses the severity of dysuria and dyspareunia and consists of questions 5-6 (0-10 points); and the third part evaluates the impact on quality of life and consists of questions 7-9 (0-12 points). The third part assesses the impact on quality of life, consisting of questions 7 to 9 (0 to 12 points). It has been translated into several languages and is widely used in the assessment of symptoms and efficacy of chronic prostatitis. 2, physical examination Diagnosis of prostatitis, should carry out a comprehensive physical examination, focusing on the genitourinary system. The first thing you need to do is to check the patient’s lower abdomen, lumbar-sacral area, perineum, penis, urethral orifice, testicles, epididymis, and spermatic cord for abnormalities, which will help in the diagnosis and differential diagnosis. Rectal examination is very important for the diagnosis of prostatitis and helps to identify perineal, rectal and neurological lesions or other diseases of the prostate, while EPS is obtained through prostate massage. Type I: Suprapubic tenderness and discomfort can be detected on physical examination, and in cases of urinary retention, the bladder can be palpated in the suprapubic bulge. Rectal examination may reveal enlarged prostate, tenderness, elevated local temperature and irregular shape. Prostate massage is contraindicated. Types II and III: Rectal examination may reveal the size and texture of the prostate, the presence or absence of nodules, the presence or absence of tenderness and its extent, the tension of the pelvic floor muscles, the presence or absence of pelvic wall pressure and pain, and massage of the prostate gland to obtain EPS. Before rectal examination, it is recommended that urine should be collected for routine analysis and bacterial culture of the urine. (1) EPS routine examination EPS routine examination usually adopts wet smear method and blood cell counting plate method for microscopic examination, the latter has better accuracy. In normal EPS, leukocytes are <10/HP, lecithin bodies are evenly distributed throughout the field of view, pH 6.3-6.5, and erythrocytes and epithelial cells are absent or occasionally seen. When leukocytes >10/HP, the number of lecithin bodies is reduced and diagnostic. The number of leukocytes does not correlate with the severity of symptoms. Macrophages with components such as phagocytosed lecithin bodies or cellular debris in the cytoplasm are also characteristic of prostatitis. Bacterial, fungal, and trichomonas pathogens can be detected in the EPS when the prostate is infected with these pathogens. In addition, in order to clearly distinguish the components of EPS such as leukocytes, EPS can be identified by methods such as Gram staining. If EPS cannot be collected after prostate massage, it is not advisable to repeat the massage several times, and the patient can be allowed to retain the urine after prostate massage for analysis. (2) Urine routine analysis and urine sediment examination Urine routine analysis and urine sediment examination are auxiliary methods to exclude urinary tract infection and diagnose prostatitis. (3) Bacteriological examination ① Ⅰ type should be stained microscopy of mid-range urine, bacterial culture and drug sensitivity test, as well as blood culture and drug sensitivity test. ② Chronic prostatitis (type II and type III) We recommend “two-cup method” or “four-cup method” for pathogen localization test. Four-cup method”: In 1968, Meares and Stamey proposed the method of sequential collection of segmented urine and EPS for isolation and culture (referred to as the “four-cup method”). The “two-cup method”: the “four-cup method” is complicated, time-consuming and expensive, and the “two-cup method” is usually recommended in clinical practice. The “two-cup method” is performed by obtaining urine before and after prostate massage for microscopic examination and bacterial culture. (4) Other pathogens ① Chlamydia trachomatis detection: Chlamydia trachomatis detection methods include culture method, immunofluorescence method, speckled gold immunofiltration method, polymerase chain reaction and ligase chain reaction. The culture method only detects live Ct and is not recommended for clinical application due to cost, time and technical level. At present, the main use of highly sensitive and specific PCR and LCR technology to detect the nucleic acid component of Ct. ② Mycoplasma detection: the mycoplasma that may cause prostate infection are mainly Ureaplasma urealyticum and Mycoplasma hominis. Culture method is the gold standard for Uu and Mh detection, combined with drug sensitivity test can provide help for clinical diagnosis and treatment; immunological detection and nucleic acid amplification technology are also used in mycoplasma detection. Since Chlamydia trachomatis and Mycoplasma can also be present in the male urethra, it is recommended that a urethral swab be taken first, and after ruling out urethral infection, an EPS test should be performed to further clarify whether the infection is in the prostate. In addition, for other pathogens in EPS, such as fungi, the detection method is mainly direct smear staining microscopy and isolation and culture; viruses are usually detected by prostate tissue culture or PCR technology. (5) Other laboratory tests Patients with prostatitis may have abnormal semen quality, such as leukocytosis, non-liquefaction of semen, hematospermia, and decreased sperm quality. Elevated PSA is also seen in some patients with chronic prostatitis [28]. Urine cytology has some value in differentiating from carcinoma in situ of the bladder. 4. Instrumental examination (1) Ultrasound: Although ultrasound examination in patients with prostatitis can reveal uneven prostate echogenicity, prostate stones or calcification, and periprostatic venous plexus dilatation, there is still a lack of specific manifestations of ultrasound in the diagnosis of prostatitis, and it is not possible to utilize ultrasound for the typing of prostatitis. However, ultrasound can provide a more accurate picture of the kidneys, bladder, and residual urine in patients with prostatitis, which is helpful in excluding organic lesions of the urinary tract. Transrectal ultrasound is valuable for identifying prostate, seminal vesicle, and ejaculatory duct lesions, as well as diagnosing and draining prostate abscesses. (2) urodynamics: ① uroflow rate, uroflow rate examination can be a general understanding of the patient’s urinary status, help prostatitis and urinary disorders related to disease identification; ② invasive urodynamics, research shows that prostatitis patients invasive urodynamics can be found in the bladder outlet obstruction, urethral functional obstruction, bladder urethral muscle contractility or urethra urethra muscle no reflexes and urethra muscle instability and other bladder Urethral dysfunction. Invasive urodynamic examination may be chosen to clarify the diagnosis when there is clinical suspicion of the above voiding dysfunction, or when there are obvious abnormalities in urinary flow rate and residual urine. (Cystourethroscopy Cystourethroscopy is an invasive test and is not recommended for patients with prostatitis. In some cases, such as patients with hematuria, urinalysis obvious abnormalities, other tests suggest that the bladder urethral pathology can choose cystourethroscopy to clarify the diagnosis. 5, CT and MRI are potentially valuable in identifying pelvic organ lesions such as seminal vesicles and ejaculatory ducts, but the diagnostic value of prostatitis itself is still unclear. (Differential diagnosis: Type III prostatitis lacks an objective and specific diagnostic basis, and should be differentiated from diseases that may cause pain in the pelvic region and urinary abnormalities, and patients with predominantly urinary abnormalities should be clearly identified as having bladder outlet obstruction and bladder function abnormalities. Diseases to be differentiated include: benign prostatic hyperplasia, testicular epididymal and spermatic cord disease, overactive bladder, neurogenic bladder, interstitial cystitis, adenocystitis, sexually transmitted diseases, bladder tumors, prostate cancer, anorectal disease, lumbar spine disease, and central and peripheral neuropathy.