Prostatitis, Chronic Bacterial

Key Features

• 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

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

  • 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