Acute Bacterial Prostatitis

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Introduction

Prostatitis refers to an infection or inflammatory process of the prostate gland and is the most common urological diagnosis in men less than 50 years old, having a prevalence of 1.8-8.2%, with the risk increasing with age.1

It is most commonly caused by bacteria, but it can also be abacterial. Acute prostatitis can normally be successfully treated with antibiotics.2

This article will focus on acute prostatitis, but patients can experience chronic prostatitis if their symptoms continue for over three months. Chronic prostatitis will not be discussed in detail in this article.Β 

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Aetiology

The prostate is a gland surrounding the urethra at the neck of the bladder that is part of the male reproductive system, and its main function is to produce fluid for semen.

In the acute setting, prostate inflammation is most commonly associated with organisms entering the gland due to urinary tract infections (UTI), so is most often due to Escherichia coli. However, other potential causes are Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella or Serratia species. Atypical organisms may cause infection in immunosuppressed patients such as Candida. Rarely, it can be a complication of sexually transmitted infections (STI).3

Conditions which cause men to suffer reflux of urine into the prostatic ducts increase the likelihood of bacteria ascending and causing infection.Β Therefore, instrumentation/trauma to the area can also induce an episode of acute prostatitis.Β 

Figure 1. Anatomy of the prostate gland and nearby organs.

Risk factors

The most common risk factor is UTI, but other risk factors can include:3


Clinical features

History

TypicalΒ symptoms of prostatitis include:

  • Genital pain
  • Perineal/rectal/suprapubic pain
  • Lower back pain
  • Lower urinary tract symptoms (e.g. dysuria, frequency, poor stream & urinary retention)
  • Systemic signs (e.g. fever, chills, malaise & features of sepsis)

For more information, see the Geeky Medics guides to urological history taking and male lower urinary tract symptoms history taking.

Clinical examination

Typical clinical findings of prostatitis include:

DREs should be performed gently so as not to induce the release of bacteria into the bloodstream.3


Differential diagnosis

Other diagnoses to consider when suspecting prostatitis include:3

If a patient presents with infection and sepsis, it would also be wise to rule out any other source of infection.


Investigations

Bedside investigations

Relevant bedside investigations for prostatitis include:

  • Basic observations: to assess for pyrexia and signs of sepsis
  • Urinalysis: leucocytes may be present
  • Mid-stream urine sample (MSU): to be sent for microbiology, cultures & sensitivities

Laboratory investigations

Relevant laboratory investigations for prostatitis include:3

  • Baseline bloods including FBC, CRP and U&Es: inflammatory markers may be raised, and renal function may be impairedΒ 
  • Blood cultures
  • Venous blood gas (VBG): to identify raised lactate (sepsis)
  • STI screening can be considered
  • PSA can be considered in more chronic setting to look for underlying cancer diagnosis if symptoms do not improve

Imaging

Radiological investigations are not normally indicated but can include:4

  • Transrectal ultrasound to rule out abscess/cyst if refractory to management

Other investigations

Other investigations to consider in the chronic setting if symptoms refractory/diagnostic uncertainty include:3

  • Cystoscopy
  • Transperineal prostate biopsyΒ 

Diagnosis

Prostatitis is a clinical diagnosis formed from a combination of history and examination findings supported by urine testing. Inflammatory markers and high white cell counts may also indicate infection

. The suspicion should be high if the patient is experiencing a combination of signs and symptoms of:3

  • UTI: frequency & dysuria
  • Bacteraemia: fever, rigors & myalgia
  • Prostatitis: perineal/penile/rectal/low back pain, retention or obstructive urinary symptoms and tender, warm & swollen prostate
Chronic prostatitis

Chronic prostatitis should be suspected if a patient is experiencing pain and lower urinary tract symptoms (LUTS) for more than 3 months. These patients will not usually be systemically unwell like acute prostatitis patients.Β 

To assess the severity of symptoms, you may want to use a scoring system such as the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) or International Prostate Symptom Score (IPSS).1Β However, the management of this condition is more complex and multi-factorial so will not be explored in detail here.Β 


Management

Hospital admission is advisable if there are severe symptoms, signs of sepsis or urinary retention.Β In septic patients,Β the sepsis 6 should be initiated as per guidelines. Patients with urinary retention should be catheterised.Β 

Medical management

Treatment of acute prostatitis involves antibiotics, most commonly a fluoroquinolone (e.g. ciprofloxacin) usually for 14 days.

Antibiotic choice can guided by the results of cultures (once available). As the patient improves IV antibiotics can be stepped down to oral for a total of 2-4 weeks treatment.

Simple analgesia (e.g.) ibuprofen should be provided and paracetamol if the patient is pyrexial. Stronger analgesia may be required, such as opioids, if pain is not controlled.

Sexual health clinic referral for treatment should be arranged if an STI is the suspected cause.3

In chronic prostatitis, an alpha antagonist may also be used, such as tamsulosin, for symptomatic relief.5Β Patients with ongoing symptoms should be referred to urology.Β 

Surgical management

Incision and drainage of pus via transrectal or perineal aspiration may need to be performed if an abscess has developed. This can be done under ultrasound guidance.

If there are signs of un-resolving sepsis, a transurethral resection of the prostate may need to be performed to access and drain the cavity more effectively.6


Complications

If not treated promptly, complications of prostatitis can include:3

  • Sepsis
  • Urinary retention
  • Prostatic abscess
  • Epididymitis & pyelonephritis if the infection becomes more widespread
  • Chronic prostatitis

Key points

  • Prostatitis is an inflammatory process of the prostate gland normally caused by infection.
  • The most common cause is a UTI
  • Symptoms generally consist of painful/tender prostate/perineum/rectum in combination with general signs of infection and may also include lower urinary tract symptoms (LUTs)
  • Prostatitis is a clinical diagnosis but urine samples and blood results will improve diagnostic certainty
  • The mainstay of treatment is antibiotics and the management of any complications, such as sepsis or urinary retention
  • If not treated, the infection may spread further, cause an abscess that will need to be drained or progress to a chronic process if lasting for more than 3 months

Reviewer

Urology registrar


Editor

Dr Jess Speller


References

  1. NICE Guidelines. Prostatitis – Chronic. Published in 2022. Available from: [LINK]
  2. BMJ Best Practice. Acute Prostatitis. Published in March 2022. Available from: [LINK]
  3. NICE Guidelines. Prostatitis – Acute. Published in 2024. Available from: [LINK]
  4. European Association of Urology. Guidelines on urological infections. 2022.
  5. Barbalias GA, Nikiforidis G, Liatsikos EN. Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. J Urol. 1998 Mar;159(3):883-7.
  6. Ackerman AL, Parameshwar PS, Anger JT. Diagnosis and treatment of patients with prostatic abscess in the post-antibiotic era. Int J Urol. 2018 Feb;25(2):103-10.

Image references

  • Figure 1. Created by US government agency National Cancer Institute. License: [Public domain]

 

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