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Emergency And Acute Medicine – Prostatitis
Prostatitis refers to inflammation of the prostate and includes acute bacterial prostatitis, chronic bacterial prostatitis, chronic nonbacterial prostatitis, and chronic pelvic pain syndrome (CPPS). Acute bacterial prostatitis is an acute febrile illness in which systemic symptoms such as fever, chills, malaise, and myalgias may precede urinary complaints. Patients may appear toxic and often have concurrent cystitis. A prostatic abscess, once a common complication, is now rare except in immunocompromised patients and presents with persistent fever, rectal pain, leukocytosis despite treatment, and a fluctuant mass on rectal examination. Chronic bacterial prostatitis accounts for about 10% of cases and is the most common cause of recurrent urinary tract infections in men. Chronic nonbacterial prostatitis presents with similar symptoms but without positive cultures. CPPS involves prostatic-type pain without inflammatory cells or identifiable bacteria.
Acute prostatitis is usually caused by a single bacterial organism. In men younger than 35 years, common pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis. In men 35 years and older, typical organisms include Escherichia coli and other Enterobacteriaceae, as well as Klebsiella, Proteus, Pseudomonas, and Enterococcus species. Rare causes include Salmonella, Clostridia, tuberculosis, fungi, and Cryptococcus neoformans in patients with AIDS. Chronic bacterial prostatitis is most commonly due to Enterobacteriaceae, followed by Enterococcus and Pseudomonas aeruginosa. Chronic nonbacterial prostatitis may involve atypical organisms such as Chlamydia, Ureaplasma, Trichomonas, or Mycoplasma, although causation is uncertain.
Patients typically report irritative voiding symptoms including frequency, urgency, and dysuria, along with low back, perineal, suprapubic, or testicular pain. Obstructive symptoms and urinary retention may occur. Ejaculatory pain or hematospermia can be present. Acute prostatitis is characterized by fever and systemic symptoms, whereas chronic prostatitis most often presents with relapsing dysuria. On examination, acute prostatitis reveals an exquisitely tender, warm, swollen, firm, or boggy prostate on digital rectal examination. Prostatic massage should be avoided in the acute setting because it may precipitate bacteremia. In chronic prostatitis, the examination is often normal.
Evaluation includes urinalysis with microscopy and urine culture. In acutely ill patients, complete blood count, electrolytes, and blood cultures may be helpful. In men younger than 35 years or when sexually transmitted infection is suspected, testing for syphilis and other sexually transmitted infections should be performed. In chronic prostatitis or CPPS, expressed prostatic secretions may be obtained after massage (outside the acute setting) for Gram stain and culture. Imaging is not routinely indicated in acute prostatitis but should be obtained if a prostatic abscess is suspected, using transrectal ultrasound or pelvic CT with contrast.
Management begins with supportive care and appropriate antibiotics. Patients with suspected prostatic abscess require urgent urologic consultation and drainage, often under ultrasound guidance. Urinary tract instrumentation should be avoided in acute prostatitis; if urinary retention occurs, suprapubic catheterization is preferred. Intravenous fluids, analgesics including NSAIDs or narcotics, stool softeners, and bed rest are beneficial. Irritative voiding symptoms may persist for months and can be managed symptomatically.
For acute prostatitis requiring parenteral therapy, options include intravenous fluoroquinolones, third-generation cephalosporins, beta-lactam/beta-lactamase inhibitor combinations, or other broad-spectrum antibiotics depending on severity and suspected organism. In younger men with suspected gonococcal or chlamydial infection, ceftriaxone followed by doxycycline is recommended. In men older than 35 years with suspected coliform organisms, oral fluoroquinolones or trimethoprim-sulfamethoxazole are typically prescribed for at least 2–4 weeks, with some experts recommending longer courses. Chronic bacterial prostatitis generally requires prolonged antibiotic therapy for 4–6 weeks or longer. For CPPS, alpha-adrenergic blockers such as tamsulosin or doxazosin may help alleviate symptoms, and management is often coordinated with urology.
Admission is indicated for patients with acute prostatitis who appear toxic, are hypotensive, immunocompromised, or have urinary retention. Nontoxic, immunocompetent patients who can tolerate oral medications and have reliable follow-up may be discharged with close outpatient care. Chronic prostatitis rarely requires admission unless there are features of acute infection. All patients should have urologic follow-up.
Distinguishing acute from chronic prostatitis is essential, as treatment duration and urgency differ. Prostatitis should be considered even in sexually active adolescent males. Failure to improve with appropriate antibiotics warrants evaluation for prostatic abscess, even in immunocompetent individuals.
Prostatitis refers to inflammation of the prostate and includes acute bacterial prostatitis, chronic bacterial prostatitis, chronic nonbacterial prostatitis, and chronic pelvic pain syndrome (CPPS). Acute bacterial prostatitis is an acute febrile illness in which systemic symptoms such as fever, chills, malaise, and myalgias may precede urinary complaints. Patients may appear toxic and often have concurrent cystitis. A prostatic abscess, once a common complication, is now rare except in immunocompromised patients and presents with persistent fever, rectal pain, leukocytosis despite treatment, and a fluctuant mass on rectal examination. Chronic bacterial prostatitis accounts for about 10% of cases and is the most common cause of recurrent urinary tract infections in men. Chronic nonbacterial prostatitis presents with similar symptoms but without positive cultures. CPPS involves prostatic-type pain without inflammatory cells or identifiable bacteria.
Acute prostatitis is usually caused by a single bacterial organism. In men younger than 35 years, common pathogens include Neisseria gonorrhoeae and Chlamydia trachomatis. In men 35 years and older, typical organisms include Escherichia coli and other Enterobacteriaceae, as well as Klebsiella, Proteus, Pseudomonas, and Enterococcus species. Rare causes include Salmonella, Clostridia, tuberculosis, fungi, and Cryptococcus neoformans in patients with AIDS. Chronic bacterial prostatitis is most commonly due to Enterobacteriaceae, followed by Enterococcus and Pseudomonas aeruginosa. Chronic nonbacterial prostatitis may involve atypical organisms such as Chlamydia, Ureaplasma, Trichomonas, or Mycoplasma, although causation is uncertain.
Patients typically report irritative voiding symptoms including frequency, urgency, and dysuria, along with low back, perineal, suprapubic, or testicular pain. Obstructive symptoms and urinary retention may occur. Ejaculatory pain or hematospermia can be present. Acute prostatitis is characterized by fever and systemic symptoms, whereas chronic prostatitis most often presents with relapsing dysuria. On examination, acute prostatitis reveals an exquisitely tender, warm, swollen, firm, or boggy prostate on digital rectal examination. Prostatic massage should be avoided in the acute setting because it may precipitate bacteremia. In chronic prostatitis, the examination is often normal.
Evaluation includes urinalysis with microscopy and urine culture. In acutely ill patients, complete blood count, electrolytes, and blood cultures may be helpful. In men younger than 35 years or when sexually transmitted infection is suspected, testing for syphilis and other sexually transmitted infections should be performed. In chronic prostatitis or CPPS, expressed prostatic secretions may be obtained after massage (outside the acute setting) for Gram stain and culture. Imaging is not routinely indicated in acute prostatitis but should be obtained if a prostatic abscess is suspected, using transrectal ultrasound or pelvic CT with contrast.
Management begins with supportive care and appropriate antibiotics. Patients with suspected prostatic abscess require urgent urologic consultation and drainage, often under ultrasound guidance. Urinary tract instrumentation should be avoided in acute prostatitis; if urinary retention occurs, suprapubic catheterization is preferred. Intravenous fluids, analgesics including NSAIDs or narcotics, stool softeners, and bed rest are beneficial. Irritative voiding symptoms may persist for months and can be managed symptomatically.
For acute prostatitis requiring parenteral therapy, options include intravenous fluoroquinolones, third-generation cephalosporins, beta-lactam/beta-lactamase inhibitor combinations, or other broad-spectrum antibiotics depending on severity and suspected organism. In younger men with suspected gonococcal or chlamydial infection, ceftriaxone followed by doxycycline is recommended. In men older than 35 years with suspected coliform organisms, oral fluoroquinolones or trimethoprim-sulfamethoxazole are typically prescribed for at least 2–4 weeks, with some experts recommending longer courses. Chronic bacterial prostatitis generally requires prolonged antibiotic therapy for 4–6 weeks or longer. For CPPS, alpha-adrenergic blockers such as tamsulosin or doxazosin may help alleviate symptoms, and management is often coordinated with urology.
Admission is indicated for patients with acute prostatitis who appear toxic, are hypotensive, immunocompromised, or have urinary retention. Nontoxic, immunocompetent patients who can tolerate oral medications and have reliable follow-up may be discharged with close outpatient care. Chronic prostatitis rarely requires admission unless there are features of acute infection. All patients should have urologic follow-up.
Distinguishing acute from chronic prostatitis is essential, as treatment duration and urgency differ. Prostatitis should be considered even in sexually active adolescent males. Failure to improve with appropriate antibiotics warrants evaluation for prostatic abscess, even in immunocompetent individuals.
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