DESCRIPTION

• Acute (bacterial) prostatitis:
  • Acute febrile illness
  • Systemic symptoms may appear days before localizing urinary symptoms appear.
  • Patients may appear toxic and usually have a concurrent cystitis.
• Prostatic abscess:
  • Once common after acute prostatitis, now rare except in immunocompromised patients
  • Fever, rectal pain, and leukocytosis despite treatment
  • Fluctuant mass on rectal exam
• Chronic bacterial prostatitis:
  • ~10% of cases of prostatitis
  • Most common cause of recurrent UTI in men
  • WBC and bacteria may be present in expressed prostatic secretions (EPS).
• Chronic nonbacterial prostatitis (also called prostatosis):
  • Same symptoms as chronic bacterial prostatitis but unable to culture organisms from urine or EPS
• Chronic pelvic pain syndrome (CPPS):
  • Symptoms referable to the prostate
  • No inflammatory cells are found
  • No bacteria cultured from the urine or EPS

ETIOLOGY

• Usually a single-organism bacterial infection of the prostate
• Acute prostatitis:
  • Age < 35 yr:
    • Neisseria gonorrhoeae and Chlamydia trachomatis are usual etiologies.
  • Age ≥35 yr:
    • Enterobacteriaceae or Escherichia coli (usual), Klebsiella, Pseudomonas, Enterococcus, and Proteus also seen
  • Rarely may be caused by Salmonella, Clostridia, tuberculosis, or fungi.
  • Cryptococcus neoformans in AIDS patients
• Chronic bacterial prostatitis:
  • Enterobacteriaceae (80%), Enterococcus (15%), and Pseudomonas aeruginosa
• Chronic nonbacterial prostatitis:
  • Possible role for Chlamydia, Ureaplasma urealyticum, Trichomonas vaginalis, and Mycoplasma hominis

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

History

• Irritative voiding symptoms:
  • Frequency, urgency, dysuria
• Low back pain
• Perineal, suprapubic, or testicular pain
• Bladder outlet obstruction and urinary retention
• Ejaculatory symptoms such as hematospermia
• Acute prostatitis:
  • Fever, chills
  • Malaise
  • Arthralgias or myalgias
• Primary symptom in chronic prostatitis is relapsing dysuria.

Physical Exam

• Acute prostatitis:
  • Exquisitely prostate tenderness
  • Warm, swollen
  • Firm or boggy prostate
  • Acutely inflamed prostate should not be massaged because that may precipitate hematogenous spread of organisms.
• In chronic prostatitis, the exam is usually normal.

DIAGNOSIS TESTS & INTERPRETATION

Lab

• Urinalysis (with microscopy) and culture
• Acute prostatitis:
  • CBC, electrolytes, and blood cultures may be helpful in the acutely ill patient.
  • If < 35 yr old or suspected sexual transmission, test for syphilis:
    • Venereal Disease Research Lab or rapid plasma reagin
• Chronic prostatitis/CPPS:
  • Prostatic massage between voiding may be used to capture EPS for Gram stain and culture if organism or white cells not present in the urine.

Imaging

• Not indicated in acute prostatitis
• If prostatic abscess suspected, transrectal US or pelvic CT with IV and rectal contrast will confirm diagnosis.

Diagnostic Procedures/Surgery

Not applicable in ED

DIFFERENTIAL DIAGNOSIS

• Benign prostatic hyperplasia
• Cystitis
• Epididymitis
• Orchitis
• Perirectal/perianal abscess
• Proctitis
• Prostatic carcinoma
• Prostatic infarction
• Pyelonephritis
• Seminal vesiculitis
• Urethritis
• Urolithiasis
• Vesicular calculi
• Other causes of lower back pain (strain, disc disease, sacroiliac joint disease, etc.)

[Outline]

• SIGNS AND SYMPTOMS
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

INITIAL STABILIZATION/THERAPY

Initial resuscitative measures as indicated

ED TREATMENT/PROCEDURES

• Prostatic abscess requires urgent urologic consultation and transrectal US-guided aspiration.
• Antibiotic therapy should be initiated in ED (see Medications).
• Urinary tract instrumentation should be avoided:
  • If patient has painful urinary retention in acute prostatitis, suprapubic needle aspiration or suprapubic catheter placement should be performed.
• Many patients will benefit from IV fluid.
• Pain control with NSAIDs and narcotic analgesics as needed
• Stool softeners
• Bed rest
• Irritative voiding symptoms may persist for months after antibiotic therapy and may be treated with NSAIDs.

MEDICATION

• Analgesia:
  • Narcotic, analgesic combinations such as hydroxycodone/acetaminophen: 1–2 tabs PO q4h
  • NSAIDs such as ibuprofen: 800 mg PO TID
• Parenteral antibiotic therapy for acute prostatitis:
  • Levofloxacin: 750 mg IV daily
  • Ampicillin/sulbactam: 3 g IV q6h
  • Cefotaxime: 2 g IV q8h
  • Ceftriaxone: 2 g IV daily
  • Ciprofloxacin: 400 mg IV BID
  • Ofloxacin: 200 mg IV BID
  • Piperacillin/tazobactam: 3.375 g IV q6h or 4.5 g IV q8h
  • Ticarcillin/clavulanate: 3.1 g IV q6h
• Antibiotics for outpatient treatment of acute (≤35 yr old) prostatitis, suspected etiology N. gonorrhoeae or C. trachomatis:
  • Ceftriaxone: 250 mg IM, then doxycycline: 100 mg PO BID × 10–14 days
  • Levofloxacin: 500 mg PO every day for 10–14 days
  • Ofloxacin: 400 mg PO × 1, then 300 mg PO BID × 10–14 days
• Antibiotics for outpatient treatment of acute (> 35 yr old) prostatitis, suspected etiology Enterobacteriaceae (coliforms); some authorities recommend 3–4 wk of therapy:
  • Ciprofloxacin: 500 mg PO BID × 14 days
  • Levofloxacin: 500 mg PO every day for 14 days
  • Ofloxacin: 200 mg PO BID × 14 days
  • Trimethoprim/sulfamethoxazole: 1 double-strength (DS) tab or 2 regular-strength tabs PO BID × 28 days
• Outpatient therapy for chronic bacterial prostatitis (Enterobacteriaceae, Enterococcus, or P. aeruginosa):
  • Ciprofloxacin: 500 mg PO BID for 4 wk
  • Levofloxacin: 500 mg PO every day for 4 wk
  • Ofloxacin: 300 mg PO BID for 6 wk
  • Trimethoprim/sulfamethoxazole DS: 1 tab PO BID for 1–3 mo
• CPPS:
  • Tamsulosin: 0.4 mg PO every day
  • Doxazosin: 1 mg PO (immediate release) every day
  • Peripheral β-adrenergic blocking agents have been used with some success; consult a urologist.
  • Prazosin: 1 mg PO BID/TID
  • Terazosin: 1 mg PO qhs

[Outline]

• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Acute prostatitis:
  • Patients who appear ill or toxic
  • Hypotension
  • Urinary retention
• Chronic prostatitis:
  • Admission generally not warranted unless patient has signs or symptoms of acute prostatitis.

Discharge Criteria

• Acute prostatitis:
  • Patient must be nontoxic.
  • Able to take fluids and oral medications (analgesia and antibiotics)
  • Urinate without difficulty
  • Immunocompetent
  • Relatively free of concurrent underlying disease
  • Have appropriate follow-up care
• Chronic prostatitis: Appropriate follow-up care should be available.

Issues for Referral

Patient with either acute or chronic prostatitis should be referred to an urologist.

• Obtain a good history to distinguish acute from chronic prostatitis, as longer antibiotic therapy may be warranted.
• Consider this diagnosis even in sexually active adolescent males.
• Acutely ill males with antibiotic treatment failure for prostatitis should be evaluated for abscess regardless of immunocompetence.

ICD9

• 601.0 Acute prostatitis
• 601.1 Chronic prostatitis
• 601.9 Prostatitis, unspecified

ICD10

• N41.0 Acute prostatitis
• N41.1 Chronic prostatitis
• N41.9 Inflammatory disease of prostate, unspecified

[Outline]

• ICD9
• ICD10

• Hedayati T, Keegan M. Prostatitis. eMedicine. Available at www.emedicine.medscape.com/article/785418. Updated July 29, 2009.
• Pontari MA. Chronic prostatitis/chronic pelvic pain syndrome. Urol Clin North Am. 2008;35(1):81–89, vi.
• Schaeffer AJ. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med. 2006;355:1690–1698.
• Takhar S, Moran G. Diagnosis and management of urinary tract infection in the emergency department and outpatient settings. Inf Disease Clin of North America. 2014;28(1):1–168.
• Touma NF, Nickel JC. Prostatitis and chronic pelvic pain syndrome in men. Med Clin North Am. 2011;95(1):75–86.

Nicole M. Franks