Diagnostic Assessment — Chronic Bacterial Prostatitis
Example 1 of 1 · fictitious patient (Veteran CO)
Diagnostic Assessment
Chronic Bacterial Prostatitis
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CO, date of birth 11 February 1968, Australian Army, Driver, Royal Australian Corps of Transport (later Sergeant, transport supervisor), enlisted 15 July 1986, medically discharged 20 October 2012. Operational service: East Timor, 12 January 2000 to 30 June 2000 (warlike); Iraq, 10 April 2005 to 25 August 2005 (warlike); Afghanistan, 05 February 2008 to 30 September 2008 (warlike).
Occupational History
As a transport driver and convoy commander the veteran drove heavy trucks on long-distance convoys, often for 10 to 14 hours a day, seated in vibrating cabs in extreme heat, wearing body armour. Convoy procedures in threat areas did not allow stops, so drivers routinely restricted their fluid intake and held their urine for many hours.
Drivers on operations are exposed to dehydration, heat illness, whole-body vibration, vehicle accidents and blast, and have limited access to toilets and hygiene facilities. Field conditions and prolonged absence from home also raise the risk of urinary and sexually transmitted infections, and medical care on convoy routes is limited.
History
Veteran CO, a transport driver in the Australian Army, developed chronic bacterial prostatitis on 28 October 2005 after acute bacterial prostatitis on warlike service in Iraq in August 2005, which followed gonococcal urethritis, months of convoy-related dehydration and urine holding, urethral catheterisation for retention and a transrectal prostate biopsy, in a man with diabetes, prostatic calculi and a urethral stricture. The condition worsened in July 2008 in Afghanistan with a fluoroquinolone-resistant infection after further instrumentation.
Timeline
- 17 Mar 2003 — At a periodic health examination the veteran's fasting glucose was 8.1 mmol/L and HbA1c 7.2 per cent. Type 2 diabetes mellitus was diagnosed and metformin commenced. BMI 29.4. Urinalysis was normal and he had no urinary symptoms. "type 2 diabetes, metformin started"
- 14 Jun 2005 — During warlike service in Iraq the veteran presented with urethral discharge and dysuria a week after a period of leave in the region. Urethral swab culture grew Neisseria gonorrhoeae and he was treated with ceftriaxone and azithromycin. The Medical Officer also recorded that he was drinking about 1.5 litres a day on convoys in temperatures above 45 degrees and passing urine only twice in 14-hour driving days. "gonococcal urethritis, poor fluid intake"
- 02 Aug 2005 — He presented to the role 2 facility with fever of 39.4 degrees, rigors, perineal pain and acute urinary retention. Digital rectal examination showed a tender, boggy prostate. A urethral catheter was inserted with difficulty, causing bleeding. Urine culture grew Escherichia coli. Acute bacterial prostatitis was diagnosed. Because of supply constraints he received only seven days of ciprofloxacin, against a recommended four weeks. "acute prostatitis, catheter, E. coli"
- 21 Sep 2005 — After return to Australia his PSA was 18 ng/mL, and a urologist performed a transrectal ultrasound-guided prostate biopsy. Histology showed chronic active prostatitis with no malignancy. The ultrasound showed multiple prostatic calculi. Uroflowmetry showed a reduced maximum flow rate of 9 mL/s. "TRUS biopsy, prostatic calculi"
- 28 Oct 2005 — The veteran presented to the garrison health centre with recurrent dysuria, frequency, perineal and testicular pain and painful ejaculation. Urine culture again grew Escherichia coli with the same sensitivity pattern as in August. A urologist was consulted and a prolonged course of trimethoprim-sulfamethoxazole was started. "recurrent E. coli UTI, same organism"
- 16 Jan 2006 — A urologist performed a four-glass localisation test, which showed Escherichia coli in expressed prostatic secretions and post-massage urine at ten times the count in the urethral and midstream specimens. Chronic bacterial prostatitis was diagnosed. Cystoscopy showed a bulbar urethral stricture attributed to the traumatic catheterisation, and urodynamic studies showed dysfunctional voiding. NIH-CPSI score 24. "chronic bacterial prostatitis, four-glass positive"
- 22 Apr 2008 — On warlike service in Afghanistan the veteran developed urinary retention from recurrence of the urethral stricture and underwent flexible cystoscopy and suprapubic catheterisation at the role 3 hospital. The catheter was removed after ten days. "stricture recurrence, catheterised"
- 14 Jul 2008 — He was admitted to the role 3 hospital in Afghanistan with fever, rigors, severe perineal pain and urosepsis. Blood and urine cultures grew fluoroquinolone-resistant, extended-spectrum beta-lactamase producing Escherichia coli. He was treated with intravenous meropenem. Urology review was not available in theatre. NIH-CPSI score rose to 34 and transrectal ultrasound on return showed a 9 mm prostatic abscess. "resistant E. coli urosepsis, NIH-CPSI 34"
Symptoms
At onset the veteran had recurrent burning on passing urine, frequency, urgency, a poor stream, perineal and testicular pain, pain on ejaculation and intermittent low-grade fevers, recurring whenever antibiotics were stopped. The pain was worse after long periods of sitting in a vehicle.
He now reports perineal and pelvic pain on most days, frequency, nocturia two to three times a night, a slow stream and painful ejaculation, with flare-ups several times a year requiring long antibiotic courses. He cannot sit for long periods, has had to give up long-distance driving work and reports a substantial effect on his intimate relationship.
Imaging
- 21 Sep 2005 — Transrectal ultrasound of the prostate: "Prostate volume 38 mL. Multiple echogenic calculi in the peripheral and transition zones. Heterogeneous peripheral zone consistent with prostatitis."
- 16 Jan 2006 — Retrograde urethrogram: "Short-segment bulbar urethral stricture, narrowing the lumen to about 6 mm."
- 30 Jul 2008 — Transrectal ultrasound of the prostate: "9 mm hypoechoic collection in the left peripheral zone consistent with a small prostatic abscess. Multiple prostatic calculi, increased in number since 2005."
Onset Date
The most likely date of onset of this condition is 28 Oct 2005.
At that date the veteran was serving full time with a transport regiment in Australia, two months after returning from warlike service in Iraq, where he had acute bacterial prostatitis treated with only seven days of antibiotics. He had type 2 diabetes, prostatic calculi and a developing urethral stricture, and he had undergone catheterisation and a prostate biopsy in the preceding three months.
This date is appropriate because his post-deployment review of 05 September 2005 recorded resolution of the acute infection with sterile urine, and the recurrence with the same organism was first documented on 28 October 2005, the day he presented. Chronic bacterial prostatitis is defined by recurrent infection with the same organism originating in the prostate, and this recurrence marks its clinical onset. It falls within uninterrupted full-time service.
For the acute prostatitis and sexually transmitted infection factors, the one year before onset runs from 28 Oct 2004 to 28 Oct 2005 and includes the gonococcal urethritis of 14 Jun 2005 and the acute bacterial prostatitis of 02 Aug 2005. For the instrumentation factors, the three months before onset run from 28 Jul 2005 to 28 Oct 2005 and include the catheterisation of 02 Aug 2005 and the biopsy of 21 Sep 2005. For the dehydration, urine holding and prolonged sitting factors, the six months before onset run from 28 Apr 2005 to 28 Oct 2005, which include his convoy duties in Iraq from 28 Apr 2005 to 25 Aug 2005 and his long-distance driving duties in Australia from September 2005. Diabetes, prostatic calculi, the urethral stricture and dysfunctional voiding were present at onset.
For the worsening factors, the period after onset runs from 28 Oct 2005 to the documented worsening on 14 Jul 2008. The three months before the worsening run from 14 Apr 2008 to 14 Jul 2008 and include the cystoscopy and suprapubic catheterisation of 22 Apr 2008 in Afghanistan. The recurrent urethral stricture and the resistant organism were present at the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Chronic Bacterial Prostatitis (ICD-10-AM N41.1), National Institutes of Health category II prostatitis. No Statement of Principles has been determined for chronic bacterial prostatitis.
Chronic bacterial prostatitis is a persistent bacterial infection of the prostate gland, usually with Escherichia coli or other gut bacteria, causing recurrent urinary tract infections with the same organism and pelvic, perineal and genital pain lasting more than three months. Bacteria reach the prostate by reflux of infected urine into the prostatic ducts, through instrumentation of the urethra or prostate, or after an incompletely treated acute prostatitis, and they persist in biofilms and around prostatic calculi where antibiotics penetrate poorly. Urethral stricture, dysfunctional voiding, dehydration and diabetes increase the risk.
The veteran's condition followed acute bacterial prostatitis on warlike service in Iraq in August 2005, inadequately treated because of supply constraints. It began on 28 October 2005, was confirmed on 16 January 2006 and worsened with a resistant organism and prostatic abscess in Afghanistan in July 2008.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
28 October 2005.
When did the veteran first present to a health / medical provider for this condition?
28 October 2005.
When was the condition confirmed / formally diagnosed?
16 January 2006.
When did the veteran first present to you (or your practice) for this condition?
15 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a urologist on 16 January 2006 with a four-glass localisation test, which showed Escherichia coli in the expressed prostatic secretions and post-massage urine at ten times the count in the first-void and midstream specimens, localising the infection to the prostate. This followed recurrent urinary tract infections with the same organism and the same sensitivity pattern in August and October 2005, and more than three months of pelvic and perineal pain and voiding symptoms.
Prostate biopsy on 21 September 2005 showed chronic active prostatitis without malignancy, and transrectal ultrasound showed prostatic calculi. The NIH Chronic Prostatitis Symptom Index score was 24. These findings meet the accepted National Institutes of Health criteria for chronic bacterial prostatitis (category II). The worsening on 14 July 2008 was documented by culture of a resistant organism, a rise in the symptom index to 34 and a prostatic abscess on ultrasound.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for chronic bacterial prostatitis, so the Statements of Principles do not limit the factors that can be considered. The claim is decided on the sound medical-scientific evidence of what causes and worsens the condition, applied to the veteran's service. The recognised causes below are drawn from the urological literature and are set out in Statement of Principles style.
Legislation: the clinical onset of this condition was on 28 October 2005, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The causes arose largely on warlike service in Iraq in 2005, and the worsening occurred on warlike service in Afghanistan in 2008. For conditions with Statements of Principles, the Reasonable Hypothesis standard applies to operational service and the Balance of Probabilities standard to peacetime service, and the same beneficial approach is applied here.
Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: having acute bacterial prostatitis within the one year before the clinical onset of chronic bacterial prostatitis; — MET
- On warlike service in Iraq on 02 August 2005 the veteran had acute bacterial prostatitis, with fever of 39.4 degrees, a tender boggy prostate and Escherichia coli in the urine. Because of supply constraints in theatre he received only seven days of ciprofloxacin instead of the recommended four weeks. This occurred within the one year before onset, from 28 October 2004 to 28 October 2005, and the same organism recurred at onset.
Cause 2: having a sexually transmitted infection of the urethra within the one year before the clinical onset of chronic bacterial prostatitis; — MET
- Gonococcal urethritis was diagnosed on 14 June 2005 during warlike service in Iraq, with Neisseria gonorrhoeae grown on urethral swab culture. The infection was contracted during a period of leave in the region and caused urethral inflammation that predisposed to ascending prostatic infection. It occurred within the one year before onset.
Cause 3: undergoing urethral catheterisation or other urethral instrumentation within the three months before the clinical onset of chronic bacterial prostatitis; — MET
- A urethral catheter was inserted with difficulty and bleeding at the role 2 facility in Iraq on 02 August 2005 for acute urinary retention. This was within the three months before onset, from 28 July 2005 to 28 October 2005, and it caused the urethral trauma that later formed a stricture.
Cause 4: undergoing transrectal prostate biopsy within the three months before the clinical onset of chronic bacterial prostatitis; — MET
- A urologist performed a transrectal ultrasound-guided prostate biopsy on 21 September 2005, within the three months before onset, to investigate a PSA of 18 ng/mL that had risen with the service-related acute prostatitis. Transrectal biopsy passes the needle through the rectal wall into the prostate and introduces bowel bacteria.
Cause 5: having prostatic calculi at the time of the clinical onset of chronic bacterial prostatitis; — MET
- Transrectal ultrasound on 21 September 2005 showed multiple calculi in the peripheral and transition zones of the prostate, which harbour bacteria in biofilm beyond the reach of antibiotics. The calculi were associated with the prostatic inflammation and urinary stasis that followed his convoy duties and acute prostatitis, and were present at onset on 28 October 2005.
Cause 6: having bladder outlet obstruction, including urethral stricture, at the time of the clinical onset of chronic bacterial prostatitis; — MET
- Uroflowmetry on 21 September 2005 showed a maximum flow rate of 9 mL/s, and cystoscopy and urethrography on 16 January 2006 confirmed a bulbar urethral stricture caused by the traumatic catheterisation of 02 August 2005 in Iraq. The obstruction was present at onset on 28 October 2005 and promotes reflux of infected urine into the prostatic ducts.
Cause 7: having dysfunctional voiding with habitual voluntary urine retention for at least the six months before the clinical onset of chronic bacterial prostatitis; — MET
- Throughout the six months before onset, from 28 April 2005 to 28 October 2005, the veteran habitually held his urine for 10 to 14 hours on convoy duty in Iraq, where convoy procedures in threat areas prohibited stops, and he continued the pattern after return. Urodynamic studies on 16 January 2006 confirmed dysfunctional voiding with high voiding pressures, which drive urine into the prostatic ducts.
Cause 8: being chronically dehydrated, with a fluid intake inadequate for the climate and workload, for at least one month within the six months before the clinical onset of chronic bacterial prostatitis; — MET
- From 28 April 2005 to 25 August 2005 on warlike service in Iraq the veteran drank about 1.5 litres a day while driving 14-hour convoys in temperatures above 45 degrees, recorded by the Medical Officer on 14 June 2005, producing concentrated urine and infrequent voiding for almost four months within the six months before onset.
Cause 9: having diabetes mellitus at the time of the clinical onset of chronic bacterial prostatitis; — MET
- Type 2 diabetes mellitus was diagnosed on 17 March 2003 and was present on 28 October 2005, with an HbA1c of 8.4 per cent in September 2005 after poor glycaemic control on deployment, where irregular meals and heat made his treatment hard to manage. Diabetes impairs immune defence against urinary infection.
Cause 10: being seated for at least six hours per day on at least four days per week, with perineal pressure and whole-body vibration, for at least the six months before the clinical onset of chronic bacterial prostatitis; — MET
- From 28 April 2005 to 28 October 2005 the veteran drove heavy trucks for 10 to 14 hours a day, at least five days a week, in Iraq and then on long-distance driving duties in Australia, seated with sustained perineal pressure and whole-body vibration, which promote prostatic congestion and impair drainage.
Worsening factors
Worsening 1: undergoing urethral catheterisation or other urethral instrumentation within the three months before the clinical worsening of chronic bacterial prostatitis; — MET
- On warlike service in Afghanistan on 22 April 2008 the veteran underwent flexible cystoscopy and suprapubic catheterisation for urinary retention from recurrent stricture, with the catheter in place for ten days. This was within the three months before the worsening, from 14 April 2008 to 14 July 2008.
Worsening 2: having bladder outlet obstruction, including urethral stricture, at the time of the clinical worsening of chronic bacterial prostatitis; — MET
- The bulbar urethral stricture caused by catheterisation in Iraq in 2005 had recurred, causing retention in April 2008, and it was present at the worsening on 14 July 2008, as confirmed by urethrography after his return.
Worsening 3: having infection with an antibiotic-resistant organism at the time of the clinical worsening of chronic bacterial prostatitis; — MET
- Cultures on 14 July 2008 grew fluoroquinolone-resistant, extended-spectrum beta-lactamase producing Escherichia coli. The resistance followed repeated and incomplete antibiotic courses for his service-related infection, including the truncated course in Iraq in 2005, and exposure to resistant organisms in the deployed hospital environment.
Worsening 4: inability to obtain appropriate clinical management for chronic bacterial prostatitis. — MET
- In Iraq in August 2005 the veteran received only seven days of antibiotics for acute prostatitis because of supply constraints, against a recommended four weeks, and in Afghanistan from February to September 2008 no urologist was available for his recurrent stricture and infection, so definitive urethroplasty and culture-directed long-term treatment were delayed until after his return. The condition progressed to resistant urosepsis and a prostatic abscess. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The chronic bacterial prostatitis is a sequela of the veteran's accepted acute bacterial prostatitis and gonococcal urethritis on warlike service in Iraq, and of the urethral stricture caused by catheterisation in 2005. Recurrent urinary tract infections, a prostatic abscess and chronic pelvic pain are sequelae of the chronic bacterial prostatitis.
Unintended Consequence
Met. The chronic bacterial prostatitis is in part an unintended consequence of treatment provided by the Commonwealth while the veteran was serving: the traumatic urethral catheterisation in Iraq that caused a urethral stricture, the transrectal prostate biopsy that introduced bowel organisms into the prostate, and the truncated antibiotic course that left the acute infection incompletely treated (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. In August 2005 on warlike service in Iraq the veteran received only seven days of antibiotics for acute bacterial prostatitis because of supply constraints, against a recommended course of four weeks, and the infection became chronic. In Afghanistan in 2008 no urologist was available for his recurrent stricture and infection, and he progressed to resistant urosepsis and a prostatic abscess, with his symptom index rising from 24 to 34. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent adequate treatment amount to an inability to obtain appropriate clinical management. The return of the veteran to an operational deployment with an untreated recurrent stricture is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 17 Mar 2003, Periodic health examination and pathology, Medical Officer
- 14 Jun 2005, Deployed health record and urethral swab culture, Medical Officer, Iraq
- 02 Aug 2005, Role 2 facility record and urine culture, Medical Officer, Iraq
- 05 Sep 2005, Post-deployment health review, Medical Officer
- 21 Sep 2005, Urology consultation, prostate biopsy and transrectal ultrasound reports, Urologist
- 28 Oct 2005, Outpatient health record and urine culture, Medical Officer, Garrison health centre
- 16 Jan 2006, Four-glass test, cystoscopy, urethrogram and urodynamic reports, Urologist
- 22 Apr 2008, Role 3 hospital record, Surgeon, Afghanistan
- 14 Jul 2008, Role 3 hospital admission and culture reports, Physician, Afghanistan
- 30 Jul 2008, Transrectal ultrasound report, Radiologist
- Medical-scientific literature on the causes of chronic bacterial prostatitis (no Statement of Principles determined)
