Prostatitis

Prostatitis is an inflammation of the prostate gland that is of either infectious (acute bacterial prostatitis and chronic bacterial prostatitis) or noninfectious (chronic pelvic pain syndrome) origin. Bacterial prostatitis is most often caused by Escherichia coli. Patients with acute bacterial prostatitis typically present with spiking fevers, chills, perineal pain, and symptoms of bladder irritation. The presentation of chronic bacterial prostatitis is more subtle, including symptoms of urinary tract infections such as dysuria and increased urinary frequency and urgency. The prostate is typically tender and boggy in acute bacterial prostatitis and mildly tender or normal in chronic bacterial prostatitis. For bacterial prostatitis, diagnosis aims to identify the causative organism via urine culture, and empirical antibiotic treatment is the primary approach. Acute prostatitis can lead to life-threatening complications (e.g., acute urinary retention, prostatic abscess formation, sepsis) that may require additional treatment, such as suprapubic catheterization or ultrasound-guided abscess drainage. Chronic pelvic pain syndrome (CPPS) is characterized by chronic urogenital pain without evidence of urinary tract infection. Affected individuals may also experience lower urinary tract symptoms and erectile dysfunction. The etiology is unknown. A multimodal treatment approach with a symptomatic focus is recommended.

• Common urologic diagnosis in men < 50 years of age ^[1][2]
• In men, there is an ∼ 8% lifetime risk of developing prostatitis.
• Bacterial prostatitis (2–5% of cases): most commonly men between 20 and 50 years of age
• Chronic pelvic pain syndrome (90–95% of cases): primarily men between 40 and 60 years of age

Epidemiological data refers to the US, unless otherwise specified.

Acute prostatitis ^[3]

• E. coli (most common)
• Other bacteria that cause UTI
• Sexually transmitted infections (e.g., C. trachomatis and N. gonorrhoeae)
• Rarer pathogens: mycobacteria, fungi, staphylococci, streptococci

Chronic prostatitis

• Bacterial
  • E. coli
  • Other Enterobacteriaceae
• Nonbacterial
  • Immune response to a prior UTI
  • Nerve damage in the pelvic region
  • Chemical irritation (chemical prostatitis)
  • Pelvic floor muscle dysfunction
  • Parasitic or viral infections

Other causes for acute or chronic bacterial prostatitis

• Other genitourinary tract infections (e.g., urethritis, cystitis, epididymitis)
• Genitourinary tract interventions (e.g., indwelling catheter, transurethral surgery, prostate biopsy)
• Voiding dysfunction and bladder outlet obstruction

Chronic pelvic pain syndrome (CPPS) ^[7][8][9]

• Definition: chronic urogenital pain with no evidence of urinary tract infection
• Epidemiology: 90–95% of prostatitis cases
• Etiology
  • Exact etiology unknown
  • Possible factors: infection, inflammation, autoimmune processes, neurological damage
• Clinical features
  • Lower urinary tract symptoms
  • See “Overview of clinical features of bacterial prostatitis and chronic pelvic pain syndrome.”
• Diagnostics
  • CPPS is a diagnosis of exclusion.
  • Evaluate for bacterial prostatitis.
  • Consult urology for further testing, e.g.:
    • CPPS-specific assessments
    • Imaging (e.g., transrectal ultrasound, pelvic CT and/or MRI)
    • Semen culture and analysis
    • Urodynamic studies
    • Cystoscopy
• Management
  • Multimodal approach combining pharmacological and supportive treatment
  • Pharmacological treatment options
    • Alpha blockers (e.g., tamsulosin, doxazosin)
    • 5-alpha-reductase inhibitors (e.g., finasteride)
    • Antibiotics (see “Empiric antibiotics for prostatitis.”)
    • Additional options: anticonvulsants (e.g., pregabalin), tricyclic antidepressants (e.g., nortriptyline)
  • Supportive treatment options
    • Cognitive behavioral therapy
    • Physical therapy
    • Biofeedback
    • Sacral neurostimulation
    • Thermal therapy

Approach ^[3][10]

• Bacterial prostatitis is a clinical diagnosis based on history and physical examination, including digital rectal examination (DRE).
• Obtain urine studies to support the diagnosis and identify the causative pathogen.
• Consider additional studies based on individual risk, e.g., STI testing, laboratory studies, and imaging.
• Consult urology as needed for specific diagnostic tests (e.g., fractional urine examination).

Exercise special caution when performing DRE in patients with suspected acute bacterial prostatitis to avoid causing bacteremia. When in doubt, consult a urologist.

Urine studies ^[3][10]

• Urinalysis (midstream urine); may show characteristic urinalysis findings of UTI (e.g., ↑ WBC).
• Urine Gram stain may be used to visualize bacteria.
• Urine culture: E. coli is most common pathogen (approx. 80% of cases). ^[2]

STI testing ^[10][11]

• Indications
  • Sexually active patients < 35 years old
  • Adults of any age with non-age-related STI risk factors
• Test: NAAT for C. trachomatis and N. gonorrhoeae via urine or urethral swab

Additional evaluation

• Laboratory studies
  • CBC: patients at risk of complications (e.g., age > 65 years, febrile, BPH, transurethral catheterization) ^[3]
  • BMP: patients with suspected UTO and/or acute kidney injury
  • Blood cultures: patients with signs of sepsis
• Imaging
  • Transrectal ultrasound: patients with suspected prostatic abscess ^[3]
  • Bladder ultrasound: patients with signs of lower UTO (to assess for postvoid residual volume)
• Localization tests for chronic bacterial prostatitis (based on fractional urine examination)
  • Two-glass test (preferred): cultures of two urine samples obtained before and after prostatic massage ^[7]
  • Four-glass test (historical): cultures of four urine samples obtained before, during, and after prostate massage ^[7][8]

Prostate-specific antigen may be significantly elevated in patients with acute prostatitis but should not be used for diagnostic purposes. Perform an evaluation for prostate cancer if PSA remains elevated 8 weeks after treatment. ^[3]

Empiric antibiotics for prostatitis ^[3][8][10]

Initiate empiric therapy as soon as possible based on suspected etiology, duration, severity, and local resistance patterns (consult local antibiogram if available).

Mild acute and chronic infections

• Options
  • Oral fluoroquinolones (e.g., ciprofloxacin; , levofloxacin ) (off-label for acute prostatitis) ^[3]
  • Trimethoprim/sulfamethoxazole (off-label for both acute and chronic prostatitis) ^[3]
  • Alternative options for chronic bacterial prostatitis include macrolides (e.g., azithromycin) and tetracyclines (e.g., doxycycline). ^[8][12]
• Duration
  • 2–4 weeks for mild acute infections
  • 4–12 weeks for chronic infections
• Suspected STI: Ceftriaxone followed by doxycycline ) ^[3][11]

Severe acute infections ^[10][12]

• Options (beta-lactam and aminoglycoside use is off-label) ^[10][12][13]
  • IV fluoroquinolones (e.g., ciprofloxacin OR levofloxacin ) with or without an aminoglycoside (e.g., gentamicin ) ^[3][10]
  • IV beta-lactam (e.g., piperacillin/tazobactam OR ceftriaxone ) with or without an aminoglycoside (e.g., gentamicin ) ^[13]
• Duration: 4–6 weeks

Further management

• Adjust antibiotics to culture results.
• Repeat urine culture ≥ 1 week after the end of treatment to ensure resolution. ^[3]
• Evaluate for prostatic abscess if no improvement in 36 hours and arrange drainage if present. ^[13]

Supportive care ^[10]

• NSAIDs for pain and inflammation
• Alpha blockers (e.g., tamsulosin) for lower urinary tract symptoms
• Catheterization for acute urinary retention
  • Short-term: urethral catheterization
  • Long-term: suprapubic catheterization
• Cognitive behavioral therapy and/or physiotherapy for reduction of chronic prostatitis symptoms
• Counseling on STI prevention

Disposition ^[3][10]

• Consider inpatient management for patients with any of the following:
  • Signs of sepsis
  • Urinary retention
  • Risk factors for antibiotic resistance (e.g., recent fluoroquinolone therapy)
  • Oral treatment unsuccessful, contraindicated, or not tolerated
• Consider urology consult for all patients, especially those with chronic or severe acute prostatitis.

• Prostatic abscess
  • Clinical features: genitourinary symptoms similar to acute bacterial prostatitis
  • Rectal exam finding: fluctuant prostate
  • Treatment: antibiotics and transrectal ultrasound-guided drainage
• Acute urinary retention
• Pyelonephritis and sepsis
• Epididymitis

We list the most important complications. The selection is not exhaustive.