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][4][5]

• Bacterial
  • E. coli is the pathogen most commonly involved.
  • C. trachomatis and N. gonorrhoeae should be considered in patients with STD risk factors.
  • Mycobacterial infections are rare.
• Nonbacterial: Viral infections are rare.

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) ^[9][10][11]

• 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 “Antibiotic therapy for bacterial prostatitis” in “Treatment”)
    • Additional options: anticonvulsants (e.g., pregabalin), tricyclic antidepressants (e.g., nortriptyline)
  • Supportive treatment options
    • Cognitive behavioral therapy
    • Physical therapy
    • Biofeedback
    • Sacral neurostimulation
    • Thermal therapy

Bacterial prostatitis is a clinical diagnosis based on history and physical examination, including digital rectal examination (DRE).

Approach ^[12][13]

• Obtain urine studies to support the diagnosis and identify the causative pathogen.
• Consider additional studies, e.g.:
  • Patients with risk factors or signs of sepsis: laboratory studies
  • Patients with suspected complications (e.g., prostatic abscess, UTO): 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, refer to a urologist.

Urine studies ^[12][13]

• Routine studies
  • 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]
• 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 ^[9]
  • Four-glass test (historical): cultures of four urine samples obtained before, during, and after prostate massage ^[9][10]

Additional evaluation ^[12][13]

• Laboratory studies
  • CBC: patients at risk of complications (e.g., age > 65 years, febrility, BPH, transurethral catherization) ^[12]
  • BMP: patients with suspected UTO and/or acute kidney injury
  • Blood cultures: patients with signs of sepsis
  • Urethral swab and culture: patients with STD risk factors
• Imaging
  • Transrectal ultrasound: patients with suspected prostate abscess ^[12]
  • Bladder ultrasound: patients with signs of lower UTO (to assess for postvoid residual volume)

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. ^[12]

General principles ^[12][13]

• Initiate empiric antibiotic therapy as soon as possible.
  • Adjust to culture results.
  • Repeat urine culture ≥ 1 week after the end of treatment to ensure resolution.
• Offer supportive care to all patients.
• 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 referral for all patients, especially those with chronic or severe acute prostatitis.

Empiric antibiotic therapy ^[10][12][13]

• Mild acute and chronic infections
  • Common regimens
    • Oral fluoroquinolones (e.g., ciprofloxacin; , levofloxacin ) (off label for acute prostatitis) ^[12]
    • Trimethoprim/sulfamethoxazole (off label for both acute and chronic prostatitis) ^[12]
  • Suspected STD: N. gonorrhoeae and C. trachomatis coverage (e.g., cefixime followed by doxycycline ) ^[12]
  • Alternative options for chronic bacterial prostatitis include macrolides (e.g., azithromycin) and tetracyclines (e.g., doxycycline). ^[10][14]
  • Duration
    • 2–4 weeks for mild acute infections
    • 4–12 weeks for chronic infections
• Severe acute infections ^[13]
  • IV fluoroquinolones (e.g., ciprofloxacin, levofloxacin ) with/without an aminoglycoside (e.g., gentamicin ) (off label) ^[12][13]
  • Beta lactams (e.g., piperacillin/tazobactam ) PLUS an aminoglycoside (e.g., gentamicin ) (off label) ^[12][13]
  • Duration: 4–6 weeks

Supportive care ^[13]

• 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

• 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.