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For further information, see CMDT Part 23-03: Genitourinary Tract Infections

Key Features

  • Irritative voiding symptoms

  • Perineal or suprapubic discomfort, often dull and poorly localized

  • Positive expressed prostatic secretions and culture

  • Although chronic bacterial prostatitis may evolve from acute bacterial prostatitis, over half of affected men have no history of acute infection

  • Most common: gram-negative rods

  • Less common: Enterococcus

Clinical Findings

  • Variable; most have varying degrees of irritative voiding symptoms, urethral pain, and obstructive urinary symptoms

  • Low back and perineal pain

  • Many patients (25–43%) report a history of urinary tract infections

  • Physical examination is often unremarkable; prostate may feel normal, boggy, or indurated

Diagnosis

  • Urinalysis is normal unless a secondary cystitis is present

  • A postvoid residual urine volume should be measured to evaluate for urinary retention

  • Expressed prostatic secretions and/or a postprostatic massage voided urine demonstrate increased numbers of leukocytes (> 5–10 per high-power field) and bacterial growth when cultured

  • Culture of the secretions and/or the postprostatic massage urine specimen is necessary to make the diagnosis

  • Leukocyte and bacterial counts from expressed prostatic secretions do not correlate with severity of symptoms

  • Differential diagnosis

    • Nonbacterial prostatitis

    • Chronic pelvic pain

    • Interstitial cystitis

    • Chronic urethritis

    • Perianal disease

Treatment

  • Symptomatic relief may be provided by

    • Anti-inflammatory agents (indomethacin, ibuprofen)

    • Hot sitz baths

    • α-Blockers (tamsulosin, alfuzosin, silodosin)

  • If patients are febrile or systemically ill, they may require admission and initial intravenous therapy with broad-spectrum antibiotics such as ampicillin plus gentamicin, a third-generation cephalosporin, or a fluoroquinolone

    • Ampicillin, 1 g every 6 hours, plus gentamicin, 1 mg/kg every 8 hours, intravenously for 14 days

    • Ceftriaxone, 1 g daily intravenously for 14 days

    • Ciprofloxacin, 400 mg every 12 hours intravenously for 14 days

  • Therapy would then continue with oral trimethoprim-sulfamethoxazole, fluoroquinolones, or an extended spectrum β-lactamase antibiotic based on culture and sensitivities of expressed prostatic secretion or postprostatic massage urine

    • Trimethoprim-sulfamethoxazole, 160/800 mg every 12 hours orally for 14 days (increasing resistance noted [up to 20%])

    • Ciprofloxacin, 500 mg every 12 hours orally for 7 days (increasing resistance has been noted)

    • Levofloxacin, 750 mg daily orally for 5 days

  • The optimal duration of therapy remains controversial, ranging from 4 to 6 weeks

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