Signs and Symptoms
History
- Irritative voiding symptoms:
- 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
Diagnostic 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 (VDRL) or rapid plasma regain (RPR)
- 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.)
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 hydrocodone/acetaminophen: 1-2 tabs PO q4h not to exceed 4 g acetaminophen in 24 hr
- NSAIDs such as ibuprofen: 800 mg PO t.i.d
- Parenteral antibiotic therapy for acute prostatitis:
- 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 b.i.d × 10-14 d
- Levofloxacin: 500 mg PO every day for 10-14 d
- Ofloxacin: 400 mg PO × 1, then 300 mg PO b.i.d × 10-14 d
- 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 b.i.d × 14 d
- Levofloxacin: 500 mg PO every day for 14 d
- Ofloxacin: 200 mg PO b.i.d × 14 d
- Trimethoprim/sulfamethoxazole: 1 double-strength (DS) tab or 2 regular-strength tabs PO b.i.d × 28 d
- Outpatient therapy for chronic bacterial prostatitis (Enterobacteriaceae, Enterococcus, or P. aeruginosa):
- Ciprofloxacin: 500 mg PO b.i.d for 4 wk
- Levofloxacin: 500 mg PO every day for 4 wk
- Ofloxacin: 300 mg PO b.i.d for 6 wk
- Trimethoprim/sulfamethoxazole DS: 1 tab PO b.i.d for 1-3 mo
- CPPS:
- Tamsulosin: 0.4 mg PO every day
- Doxazosin: 1 mg PO (immediate release) every day
- Peripheral -adrenergic blocking agents have been used with some success; consult a urologist
- Prazosin: 1 mg PO b.i.d/t.i.d
- Terazosin: 1 mg PO q.h.s
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