> Table of Contents > Prostatitis
Kyle Stephens, DO, MPH
Vincent Lo, MD, FAAFP
image BASICS
  • Painful or inflammatory condition affecting the prostate gland with or without bacterial etiology, often characterized by urogenital pain, voiding symptoms, and/or sexual dysfunction
  • Significant impact on quality of life
  • <10% bacteria-proven infection
  • National Institutes of Health's classification
    • Class I: Acute bacterial prostatitis: symptomatic with fever, perineal pain, dysuria, and obstructive symptoms; polymorphonuclear leukocytes (PMNL) and bacteria in urine
    • Class II: Chronic bacterial prostatitis: symptomatic chronic or recurrent bacterial infection with pain and voiding disturbances; PMNL and bacteria in expressed prostatic secretions (EPS), or urine after prostate massage, or in semen
    • Class III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
      • Inflammatory (Subtype IIIA): chronic symptoms with PMNL in EPS/urine after prostate massage or in semen
      • Noninflammatory (Subtype IIIB): chronic symptoms without presence of PMNL in EPS/urine after prostate massage or in semen
    • Class IV: Asymptomatic inflammatory prostatitis: incidental finding during prostate biopsy for infertility, cancer workup; presence of PMNL and/or bacteria in EPS/urine after prostatic massage or in semen
  • System(s) affected: genitourinary, renal, reproductive
  • Two million cases annually in the United States
  • Predominant age: 30 to 50 years old, sexually active; chronic is more common in those >50 years.
  • Bacterial prostatitis occurs more frequently in patients with HIV.
  • Affects approximately 8.2% of males (1)
  • Lifetime probability of diagnosis >25% (1)
  • Accounts for 8% of visits to urologists and 1% of visits to primary care physicians (2)
  • Percentage of cases by class: Class I: <1%, Class II: 5-10%, Class III: 80-90%, Class IV: 10% (3)
  • Acute bacterial prostatitis (Class I)
    • Likely, etiology from ascending urethral infection with intraprostatic reflux of infected urine into prostatic ducts, often associated with cystitis
    • Can occur after instrumentation of prostate
    • Usually gram-negative bacteria (Escherichia coli (most common); Proteus, Klebsiella, Serratia, and Enterobacter species; Pseudomonas aeruginosa)
    • Rarely, gram-positive bacteria (Staphylococcus aureus, Streptococcus, and Enterococcus species).
    • Confirmed Staphylococcal prostatitis should warrant evaluation for hematogenous spread, including endovascular source.
    • Atypical bacteria include Chlamydia trachomatis, Trichomonas vaginalis, and Ureaplasma urealyticum.
    • Consider Neisseria gonorrhoeae or Chlamydia trachomatis in sexually active men <35 years.
  • Chronic bacterial prostatitis (class II)
    • Similar pathogens as discussed earlier
    • Often occurs as recurrent episodes of infection by same organism
    • Progression from acute to chronic prostatitis is poorly understood but could result from inadequate treatment of acute prostatitis.
  • CP/CPPS (class III)
    • Unclear etiology, possibly due to difficult-to-culture infection
    • Inciting agent may cause inflammation or neurological damage in or around the prostate and lead to pelvic floor neuromuscular and/or neuropathic pain.
  • Urinary tract infections
  • HIV infection
  • Prostatic calculi
  • Urethral stricture
  • Urinary catheterization: indwelling, intermittent
  • Genitourinary instrumentation including prostate biopsy (especially in patients with prior quinolone intake), transurethral resection of prostate, cystoscopy
  • Urinary retention
  • Benign prostatic hypertrophy
  • Unprotected sexual intercourse
  • Trauma (e.g. bicycle, horseback riding)
Antibiotic prophylaxis for genitourinary instrumentation and prostatic biopsy
  • Benign prostatic hypertrophy
  • Cystitis
  • Urethritis
  • Sexual dysfunction
  • Vital signs (unstable vitals suggest sepsis)
  • Back exam (CVA tenderness)
  • Abdominal exam (bladder distension)
  • Prostate exam
    • Class I: Prostate is very tender, warm, firm, edematous.
    • Class II: Often normal but enlarged, tender, edematous, nodular prostate also encountered
    • Class III: Often normal prostate
  • Lower urinary tract infection
  • Pyelonephritis
  • Cystitis (bacterial, interstitial)
  • Urethritis
  • Prostatic abscess
  • Acute/chronic urinary retention
  • Benign prostatic hypertrophy Malignancy (prostate, bladder)
  • Obstructive calculi
  • Foreign body
Initial Tests (lab, imaging)
  • Suspected acute prostatitis (Class I)
    • Urinalysis; urine Gram stain/culture and sensitivity
    • CBC with differential; blood culture if fever, chills, or signs of sepsis are present
  • Suspected chronic bacterial prostatitis (class II)
    • Urinalysis; urine/EPS/semen: Gram stain/culture and sensitivity
    • Review previous urine culture results.
    • National Institute of Health—Chronic Prostatitis Symptom Index (NIH-CPSI): 9-question symptom survey (http://www.prostatitis.org/symptomindex.html)
    • Diagnostic gold standard: Meares-Stamey 4-glass test (not performed often)
    • 2-glass test (pre- and postmassage urine testing) more common and easier with equivalent sensitivity and specificity (4)
      • Cultures of mid-stream preprostate massage urine and EPS/postmassage urine
    • Consider urinary flow rate and postvoid residual volume if urinary retention is present.
  • Suspected CP/CPPS (class III)
    • Diagnosis of exclusion
    • Urinalysis; urine/EPS/semen: Gram stain/culture and sensitivity
    • Hematuria if present: urine cytology, cystoscopy, CT urography with or without contrast
    • PSA is not indicated unless malignancy is suspected.
    • Concomitant abdominal pain: CT abdomen
    • Testicular pain: scrotal US
    • Sensation of incomplete bladder emptying: postvoid residual volume with bladder US or catheterization
    • Lumbar radiculopathy: MRI spine
Follow-Up Tests & Special Considerations
  • Failure to respond to initial antibiotic therapy: US, CT, or MRI to image prostate and urology referral
  • US or CT or MRI if prostatic calculi, malignancy, or abscess are suspected
  • Acute bacterial: urinalysis and culture 30 days after initiating treatment
  • Chronic bacterial: urinalysis and culture every 30 days (may take several months of treatment to clear)

Diagnostic Procedures/Other
  • Needle biopsy or aspiration for culture
  • Urodynamic testing (prostatodynia) if indicated
  • Cystoscopy (in persistent nonbacterial prostatitis to rule out bladder cancer, interstitial cystitis)
  • Analgesics/antipyretics/stool softeners
  • Hydration
  • Sitz baths to relieve pain and spasm
  • Suprapubic catheter for urinary retention
  • Anxiolytics, antidepressants if anxiety and/or depression are present
First Line
  • Acute bacterial (outpatient) (3)[A]
    • Fluoroquinolone (ciprofloxacin 500 mg PO q12h or levofloxacin 500 mg PO once daily) for 2 to 4 weeks or
    • Trimethoprim-sulfamethoxazole 1 double-strength tab PO q12h for 2 to 4 weeks or
    • If gram-positive cocci are seen in initial urine Gram stain, start with amoxicillin 500 mg PO q8h. Adjust antibiotics once culture and sensitivities report is available.
    • Local sensitivity pattern should guide therapy.
    • Ceftriaxone 250 mg IM 1 dose plus doxycycline 100 mg PO q12h daily for 1 week or (azithromycin 1 g PO single dose if at risk for sexually transmitted infection (STI) pathogens
  • Acute bacterial (inpatient) (3)[A]
    • Ampicillin 2g IV q6h or fluoroquinolone (ciprofloxacin 400 mg IV q12h or levofloxacin 500 mg q24h); begin oral therapy after afebrile for 24 to 48 hours
  • Chronic bacterial (class II) (3,5,6)[A],(7)[C]
    • Fluoroquinolone (e.g., levofloxacin 500 mg PO) once daily for 4 weeks or ciprofloxacin 500 mg PO q12h for 4 to 12 weeks
    • Combination therapy with azithromycin may help to eradicate atypical pathogens.
    • Anti-inflammatory agents for pain symptoms and &agr;-blockers for urinary symptoms
  • CP/CPPS (class III) (8,9)[A],(7)[C]
    • No universally effective treatment
    • Treatment choice is patient-centered focusing on symptoms relief of four domains: pain, lower urinary tract symptoms (LUTS), psychological stress, and sexual dysfunction.
      • &agr;-Blockers, antibiotics, and combinations of these therapies achieve greatest improvement in clinical symptoms scores compared to placebo.
      • Tamsulosin 0.4 mg PO once daily at bedtime for 4 to 6 weeks. Continue if there is a positive response.
Second Line
  • Piperacillin or ticarcillin with aminoglycoside, erythromycin, tetracycline, cephalexin, fluoroquinolones, (dicloxacillin, nafcillin IV, vancomycin IV
  • Finasteride (in patients >45 years, class IIIA, and enlarged prostate glands)
  • Atypical: may benefit from erythromycin, doxycycline
Urology referral if antibiotic treatment fails, symptoms persist (especially obstructive voiding symptoms), hematuria, elevated PSA, or for surgical drainage if an abscess persists after ≥1 week of therapy
  • Psychotherapy if sexual dysfunction is present
  • 5-&agr;-reductase inhibitors, nonsteroidal anti-inflammatory medications, pelvic floor physical therapy, transurethral microwave thermotherapy (7)[C]
Surgical resection for intractable chronic disease or to drain an abscess (7)[C]
Class III: Acupuncture, phytotherapies (pollen extract, quercetin), heat therapy, and myofascial release have limited data to support (7)[C],(10)[A].
Admission Criteria/Initial Stabilization
  • Proven or suspected abscess
  • Unstable vital signs (sepsis)
  • Immunocompromised
  • Failed outpatient treatment
  • Negative urine culture at 7 days predictive of cure after completion of treatment course
  • Consider prostatic abscess in patients who do not respond well to therapy.
Patient Monitoring
NIH Chronic Prostatitis Symptom Index (NIH-CPSI): 9 questions, which can be used to evaluate severity of patient symptoms and response to treatment within three domains:
  • Pain
  • Urinary symptoms
  • Quality of life
  • Fever and dysuria usually resolve in 2 to 6 days.
  • Acute infection usually improves in 3 to 4 weeks.
  • Course of chronic prostatitis is often prolonged and difficult to cure; 55-97% cure rate depending on population and drug used
  • 20% have reinfection or persistent infection.
1. Krieger JN, Lee SW, Jeon J, et al. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008;31(Suppl 1):S85-S90.
2. Collins MM, Stafford RS, O'Leary MP, et al. How common is prostatitis? A national survey of physician visits. J Urol. 1998;159(4):1224-1228.
3. Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostatitis. Clin Infect Dis. 2010;50(12):1641-1652.
4. Nickel JC, Shoskes D, Wang Y, et al. How does the pre-massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119-124.
5. Videčnik Zorman J, Matičič M, Jeverica S, et al. Diagnosis and treatment of bacterial prostatitis. Acta Dermatovenerol Alp Pannonica Adriat. 2015;24(2):25-29.
6. Perletti G, Marras E, Wagenlehner FM, et al. Antimicrobial therapy for chronic bacterial prostatitis. Cochrane Database Syst Rev. 2013;(8):CD009071.
7. Rees J, Abrahams M, Doble A, et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015;116(4):509-525. doi:10.1111/bju.13101.
8. Zhu Y, Wang C, Pang X, et al. Antibiotics are not beneficial in the management of category III prostatitis: a meta analysis. Urol J. 2014;11(2);1377-1385.
9. Anothaisintawee T, Attia J, Nickel JC, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: a systematic review and network meta-analysis. JAMA. 2011;305(1):78-86.
10. Anderson RU, Wise D, Sawyer T, et al. 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training. J Urol. 2011;185(4):1294-1299.
See Also
  • Prostate Cancer; Prostatic Hyperplasia, Benign (BPH); Urinary Tract Infection (UTI) in Males
  • Algorithm: Hematuria
  • N41.9 Inflammatory disease of prostate, unspecified
  • N41.0 Acute prostatitis
  • N41.1 Chronic prostatitis
Clinical Pearls
  • Vigorous prostatic massage is contraindicated in acute prostatitis.
  • Antibiotic therapy is not proven to be effective in CP/CPPS (Class III) (8).
  • At least 14 to 30 days of antibiotic therapy is required for acute prostatitis; longer for chronic bacterial prostatitis
  • Imaging is often not needed.