Prostatitis, Acute Bacterial

KEY FEATURES

Essentials of Diagnosis

• Fever

• Irritative voiding symptoms

• Perineal or suprapubic pain

• Exquisite tenderness on rectal examination

• Positive urine culture

General Considerations

• Usual causative organisms: Escherichia coli and Pseudomonas

• Less common: Enterococcus

• Routes of infection

  • Ascent up the urethra

  • Reflux of infected urine into the prostatic ducts

  • Lymphatic and hematogenous routes are probably rare

CLINICAL FINDINGS

Symptoms and Signs

• Symptoms may follow chronic dysfunctional voiding, urinary retention, and pushing to urinate

• Perineal, sacral, or suprapubic pain

• Fever

• Irritative voiding complaints

• Obstructive symptoms (as inflamed prostate swells)

• Urinary retention

• Warm, exquisitely tender prostate

Differential Diagnosis

• Epididymitis

• Diverticulitis

• Urinary retention from benign or malignant prostatic enlargement

• Chronic bacterial prostatitis

• Nonbacterial prostatitis

• Chronic pelvic pain syndrome

DIAGNOSIS

Laboratory Tests

• Complete blood count: leukocytosis and a left shift

• Urinalysis: pyuria, bacteriuria, hematuria

• Urine culture: positive

Imaging Studies

• Pelvic CT or transrectal ultrasound is indicated in patients who do not respond to antibiotics in 24–48 hours

Diagnostic Procedures

• Care should be taken to perform a gentle rectal examination, since vigorous manipulation of an infected prostate may result in septicemia

TREATMENT

Medications

• Hospitalization may be required

• Parenteral antibiotics with broad coverage should be initiated until organism sensitivities are available

  • Intravenous ampicillin and an aminoglycoside until afebrile for 24–48 hours, then oral antibiotics (eg, quinolones if organism is sensitive) for 4–6 weeks

• In the hospital: Ampicillin, 2 g intravenously every 6 hours, plus gentamicin, 1.5 mg/kg intravenously every 8 hours, for 21 days

• Outpatient regimens

  • Ciprofloxacin, 250–500 mg orally every 12 hours for 21 days

  • Trimethoprim-sulfamethoxazole, 160/800 mg orally every 12 hours for 21 days (increasing resistance noted [up to 20%])

Therapeutic Procedures

• If urinary retention develops, an in-and-out catheterization to relieve the initial obstruction, or short-term (12 hours) small indwelling urinary catheter, is appropriate

OUTCOME

Follow-Up

• Posttreatment urine culture

• Posttreatment examination of expressed prostatic secretions after completion of therapy

Complications

• Acute prostatitis can progress to prostatic abscess

Prognosis

• Appropriate antibiotic therapy eradicates bacteria causing acute bacterial prostatitis

• Progression to chronic bacterial prostatitis is rare

When to Refer

• Evidence of urinary retention

• Evidence of chronic prostatitis

When to Admit

• Signs of sepsis

• Need for surgical drainage ...