The Clinical and Pathologic Relevance of a Prostate MRI Diagnosis of "Prostatitis" - Beyond the Abstract

Many articles about prostatitis start with obligatory language saying how “not much is known” about the etiology and treatment is frustrating. Perhaps that’s true if every man with pain between his nipples and knees is given antibiotics until they improve or go to the next doctor. Following the simple syndrome-based NIH classification system and evidence-based therapies leads to successful outcomes in the majority of patients. Part of the confusion is that there are 4 distinct syndromes with little in common that are all given the name Prostatitis.

The latest entry in prostatitis confusion is prostate MRI, typically ordered due to concern for prostate cancer searching for PiRads lesion targets for fusion biopsy. If there are MRI changes not consistent with the PiRads criteria they are often described as “prostatitis”. When our expert radiologists were challenged for the data supporting this diagnosis they had to admit that there really wasn’t much, but that the tissue disruption was assumed to be from inflammation. Nevertheless, we began to get a steady stream of patients in our prostatitis clinic who were asymptomatic but referred for prostatitis findings on MRI. This was the impetus to retrospectively look at our patient population who had prostate MRI and correlate prostatitis findings with symptoms or signs of clinical prostatitis.

It was not surprising to us that this MRI finding did not correlate with any documented symptoms. While more patients with prostatitis on MRI had inflammation seen on their prostate biopsy, the clinical difference was small (57% vs 43%) and indeed 43% of those with positive MRI had no inflammation on biopsy. Since asymptomatic prostate inflammation (NIH category IV) does not require treatment, patients should be reassured that their MRI has not identified a disease they have requiring intervention. Furthermore, to decrease patient anxiety, our radiology colleagues should be encouraged to describe the image appearance but not give it the prostatitis label.

Written by: Daniel Shoskes MD, FRCSC, Professor of Urology, Director, The Center for Men’s Health, Director, The Novick Center for Clinical and Translational Research, Glickman Urological and Kidney Institute, The Cleveland Clinic

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