Prostatitis Summary

Common Pathogens

  • E. coli (50% cases)
  • Pseudomonas
  • Klebsiella
  • Enterococcus
  • STIs (Chlamydia/Gonorrhea)

Key Symptoms

  • Dysuria, frequency, urgency
  • Perineal/rectal pain
  • Fever, rigors
  • Acute urinary retention

Examination

  • Tender, boggy prostate on DRE
  • Perform gently (sepsis risk)
  • No prostatic massage
  • Costovertebral tenderness

Antibiotic Treatment

  • Severe: IV antibiotics
  • Mild: Ciprofloxacin 500mg BD
  • Duration: 14-28 days
  • Review at 48 hours

Complications

  • Prostatic abscess
  • Sepsis
  • Urinary retention
  • Chronic prostatitis

Investigations

  • MSU dipstick & culture
  • FBC, CRP
  • Blood cultures if febrile
  • STI screen if indicated

Acute Prostatitis

Definition

Acute prostatitis is a painful inflammation within the prostate that is usually accompanied by evidence of recent or ongoing infection. Acute bacterial prostatitis is a severe, potentially life-threatening bacterial infection of the prostate.

Causes

Common Pathogens

  • Escherichia coli (50% of cases)
  • Pseudomonas aeruginosa
  • Klebsiella species
  • Enterococcus species
  • Proteus species

Other Causes

  • Sexually transmitted infections:
    • Chlamydia trachomatis
    • Neisseria gonorrhoeae
  • Post-procedural:
    • Urethral instrumentation
    • Catheterization

Clinical Features

Urinary Symptoms

  • Dysuria, frequency, urgency
  • Acute urinary retention
  • Obstructive voiding:
    • Hesitancy
    • Weak stream
    • Straining

Pain Symptoms

  • Perineal, penile, rectal pain
  • Low back pain
  • Painful ejaculation

Systemic Symptoms

  • Fever, rigors
  • Tachycardia
  • Arthralgia/myalgia

Examination Findings

  • Tender, boggy prostate on DRE
  • Costovertebral angle tenderness
  • Distended bladder

Investigations

Essential Tests

  • Mid-stream urine (MSU): Dipstick, culture & sensitivity
  • Blood tests: FBC, CRP, blood cultures if febrile
  • Digital rectal exam (DRE): Perform gently (risk of sepsis)
  • STI screen: NAAT for gonorrhoea/chlamydia in high-risk patients

Important Note

Do not perform prostatic massage for secretions as this may cause bacteremia or abscess formation.

Differential Diagnosis

Prostatic Conditions

  • Benign prostatic hyperplasia
  • Chronic prostatitis
  • Prostate cancer

Other Conditions

  • Urinary tract infection
  • Epididymo-orchitis
  • Bladder/colorectal cancer

Management

Severe Cases (Sepsis/Systemic Illness)

  • Admit to hospital
  • IV antibiotics:
    • Broad-spectrum penicillin
    • 3rd-gen cephalosporin
    • Fluoroquinolone
  • Supportive care:
    • IV fluids
    • Analgesia (avoid opioids if possible)
    • Suprapubic catheter if retention

Mild-Moderate Cases

  • Oral antibiotics (14-28 days):
    • 1st line: Ciprofloxacin 500mg BD or Ofloxacin 200mg BD
    • Alternatives: Trimethoprim 200mg BD, Levofloxacin 500mg OD
  • Symptom control:
    • Paracetamol/NSAIDs
    • Stool softeners if painful defecation
  • Follow-up: Review at 48 hours with culture results

Complications

Acute

  • Prostatic abscess (requires drainage)
  • Bacteremia/sepsis
  • Acute urinary retention

Chronic

  • Chronic prostatitis
  • Epididymitis
  • Pyelonephritis

Chronic Prostatitis/CPPS

Definition

≥3 months of urogenital pain with LUTS and sexual dysfunction, without proven infection (90% of chronic cases).

Management

  • First-line:
    • Alpha-blockers (4-6 weeks)
    • Antibiotics (if inflammatory: trimethoprim/doxycycline)
  • Supportive:
    • Cognitive behavioral therapy
    • Acupuncture
    • Pelvic floor physiotherapy