Chapter 16-3: Acute Prostatitis

TEXTBOOK PRESENTATION

Acute prostatitis typically presents with dysuria, low back pain, perineal pain or ejaculatory pain with fever, chills, and myalgias. Patients often have associated urinary symptoms including frequency, urgency, or obstruction.

DISEASE HIGHLIGHTS

1. Acute bacterial prostatitis is an infection of the prostate gland that occurs from an ascending urethral infection or through reflux of infected urine into the prostate through the ejaculatory or prostatic ducts.

2. Frequent pathogens include gram-negative coliform bacteria, E coli, Klebsiella, Proteus, enterococci, and Pseudomonas.

3. Sexually transmitted bacteria, such as Gonorrhea and Chlamydia, may also be the cause.

EVIDENCE-BASED DIAGNOSIS

1. Although prostatitis may present with classic symptoms of low back pain, dysuria, and perineal pain, the disease may also present with nonspecific symptoms such as myalgias, malaise, or nausea and vomiting. Patients may also present with obstructive symptoms, such as, hesitancy, incomplete voiding, and weak stream.

2. On physical exam, the prostate gland may be tender, warm, swollen, or firm.

3. Theoretically, infection may be induced or worsened by rigorous digital rectal exam so this is not recommended if acute bacterial prostatitis is suspected.

4. Prostate massage

   1. Traditionally, prostatic massage to examine prostatic secretions for white blood cells and bacteria has been advocated.

   2. This test has not been validated, and it is not recommended because it is difficult to perform, painful, and may worsen infection.

5. Urinalysis or urine dipstick

   1. May show signs consistent with cystitis (eg, leukocyte esterase, nitrites, or white blood cells)

   2. May also be normal

6. Often the pathogen will be identified by urine culture; however, urine culture can be negative in acute prostatitis.

7. A urine sample should be sent for polymerase chain reaction (PCR) testing for gonorrhea and chlamydia if a sexually transmitted pathogen is suspected.

8. A post void residual should be determined in patients in whom obstruction is suspected.

9. Diagnosis is made based on a combination of the history, physical exam, and urine studies. No single test is diagnostic for acute prostatitis.

TREATMENT

1. First-line antibiotics include a fluoroquinolone or TMP-SMX. If an STI is likely, treatment for gonorrhea and chlamydia should also be given.

2. While nitrofurantoin is used to treat cystitis, it is ineffective in prostatitis because it does not penetrate the prostate well.

3. The duration of antibiotics should be at least 4–6 weeks.

4. Treatment with pain medications and stool softeners are also helpful.

5. Patients with severe infection or medically complex patients should be admitted for IV antibiotic therapy.

6. Patients who do not respond to treatment should be evaluated for a prostatic abscess. Although a prostatic abscess may be palpable on exam, CT, MRI, or transrectal ultrasonography are required to confirm diagnosis. Drainage or resection can be necessary.

7. Prostatitis will elevate prostate-specific antigen (PSA) levels.