Prostatitis, Chronic Bacterial

Irritative voiding symptoms

Perineal or suprapubic discomfort, often dull and poorly localized

Abnormal expressed prostatic secretions and positive 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

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

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

Symptomatic relief may be provided by

• Anti-inflammatory agents (indomethacin, ibuprofen)

• Hot sitz baths

• Alpha-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 beta-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