Urology Book

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Expressed Prostatic Secretion

Aka: Expressed Prostatic Secretion, Prostatic Massage, Segmented Urine Culture, Four Glass Test
  1. Indications
    1. Chronic Prostatitis
  2. Contraindications
    1. Acute Prostatitis (may result in bacteremia)
  3. Preparation
    1. Patient pre-hydrates before appointment
    2. Patient avoids sexual intercourse for 48 hours prior
  4. Technique
    1. Patient with full Bladder and desires to void
    2. Retract foreskin and cleanse penis
      1. See Clean Catch Urine Collection
      2. Uncircumsized men maintain foreskin retraction
    3. Collect midstream urine for premassage Urine Culture
    4. Patient stops voiding
    5. Examiner massages Prostate from periphery to midline
      1. Not recommended in Acute Prostatitis
    6. Collect a few drops of secretion from Urethra
    7. Collect 10 ml of urine for postmassage Urine Culture
    8. Refrigerate urine samples
      1. Send both samples for urine microscopy of sediment
      2. Send both samples for Urine Culture
  5. Technique Variations: Four Glass Test
    1. Rarely used
      1. Not found useful in Chronic Prostatitis
      2. Nickel (2003) J Urol 170:818-22 [PubMed]
    2. Collect first 10 ml of urine (before midstream)
      1. Assesses for Urethritis
    3. Collect mid-stream pre-massage Urine Culture (as above)
    4. Expressed Prostatic Secretions cultured
    5. Post-massage Urine Culture of 10 ml (as above)
  6. Interpretation
    1. Findings suggestive of Prostatitis
      1. Urine Leukocytes >10 WBC/hpf in Post-massage sample
      2. Post-massage Urine Culture positive
        1. Pre-massage Urine Culture sterile
        2. Pre-massage <1 log colony/ml under post-massage
    2. Findings suggestive of cystitis
      1. Significant bacteriuria in pre-massage sample
  7. References
    1. Meares (1991) Med Clin North Am 75:405-24 [PubMed]
    2. Nickel (1995) Tech Urol 1:162-7

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