Acute Prostatitis

Definition

Acute prostatitis: severe, potentially life-threatening, bacterial infection of the prostate

• Account for ~10% of all prostatitis

 

Chronic prostatitis: urogenital pain that lasts at least 3 months

• Common: represents ~1% of all primary care consultations and ~8% of urology outpatient appointments
• Most common form of prostatitis: accounts for 90-95% of all prostatitis

Causative Agent

Acute prostatitis is almost exclusively infective, caused by bacterial infection.

 

Most commonly caused by urinary pathogens:

• E. coli (up to 50%)
• Pseudomonas aeruginosa
• Klebsiella
• Enterococcus
• Enterobacter
• Proteus and Serratia species

Rarely, it can be caused by STIs (e.g. Chlamydia trachomatis, Neisseria gonorrhoea)

Risk Factors

Risk factors include:

• Recent instrumentation of the urinary tract (e.g. cytoscopy)
• Transrectal prostate biopsy (risk persists despite antibiotic prophylaxis and antiseptic procedures)
• Urolithiasis
• Indwelling urinary catheters
• Presence of urinary tract abnormalities or obstruction (e.g. BPH, prostate cancer, bladder cancer)
• Immunocompromised state

Clinical Features

Features suggestive of prostatitis:

• Perineal / penile / rectal pain
• Pain on ejaculation
• Low back pain
• Voiding LUTS (hesitancy, straining to urinate, weak / intermittent stream)
• Features of systemic upset are common (e.g. fever, chills, rigours)
• DRE: tender, swollen, and warm prostate

 

Acute bacterial prostatitis often coexists with, or arises from a UTI. Therefore, clinical features of a UTI may also be present

Complications

Short-term complications:

• Acute urinary retention – common complication and may be a presenting feature
• Bacteria and sepsis – high risk
• Prostatic abscess (rare, but may require surgical intervention)

 

Long-term complications:

• 10% will develop chronic prostatitis or chronic pelvic syndrome
• ~13% will experience recurrence, and require a longer course of antibiotics

Diagnosis

If acute prostatitis is suspected, perform the following tests:

• Check for UTI
  • Urinalysis
  • MSU sample for MC&S
• FBC
• Blood cultures

 

Conditional tests:

• STI screening (first void urine for NAAT)
• Trans-rectal ultrasound (only to rule out prostatic abscess)

Management

Conservative / General Management

Advice on the following:

• The course of acute prostatitis is several weeks
• Drink enough fluids to avoid dehydration

Offer pain relief with paracetamol +/- low-dose weak opioid or ibuprofen.

Antibiotic Therapy

Offer oral antibiotics to all patients:

• 1st line: ciprofloxacin / ofloxacin for 14 days
• 2nd line: trimethoprim for 14 days
• 3rd line (after discussion with specialist): levofloxacin OR co-trimoxazole for 14 days

Chronic Prostatitis

Definition

Chronic prostatitis: symptoms of prostatitis lasting for at least 3 months

• Common: represents ~1% of all primary care consultations and ~8% of urology outpatient appointments
• Most common form of prostatitis: accounts for 90-95% of all prostatitis

Aetiology

Unlike acute bacterial prostatitis, which is almost invariably infectious. Chronic prostatitis can be either:

• Non-bacterial – called chronic pelvic pain syndrome (multifactorial in origin)
• Bacterial (a small subset) – called chronic bacterial prostatitis

 

Chronic bacterial prostatitis can be caused by:

• Undertreated acute bacterial prostatitis (in ~10% patients with acute prostatitis)
• UTI
• Lymphogenous spread of rectal bacteria
• Recurrent UTI with prostatic reflux
• STI (rare)

Similar to acute bacterial prostatitis, the most common implicated organism in chronic bacterial prostatitis is E. coli.

Clinical Features

Symptoms must present for at least 3 months for it to be chronic prostatitis:

Pain / discomfort (most common)	Location of pain: Perineum – most common Inguinal region Suprapubic region Scrotum, testis, or penis (esp. penile tip) Lower back / abdomen / rectum
LUTS	Voiding symptoms (e.g. straining, hesitancy, and weak stream) Storage symptoms (e.g. urinary urgency, frequency, and nocturia) Dysuria
Sexual dysfunction	Erectile dysfunction Pain or discomfort during or after ejaculation Premature ejaculation Decreased libido
Other associations	Psychosocial symptoms (e.g. anxiety, depression, reduced quality of life) are common due to the chronicity of the disabling symptoms. IBS is present in 22-31% of patients with chronic prostatitis (mainly chronic pelvic pain syndrome), and can cause increased pain severity

Investigation and Diagnosis

Perform the following tests in ALL patients:

UTI screen	Perform a urine dipstick and MSU for MC&S +ve Urine culture indicates chronic bacterial prostatitis However, unless an acute UTI is present, the urine culture may be normal in men with chronic bacterial prostatitis (check previous reports)
STI screen	Obtain first void urine for NAAT to test for chlamydia and gonorrhoea   Consider sending a urethral swab for trichomoniasis, esp. in sexually active men younger than 35 y/o with multiple sexual partners or recent partner change

Management

Management of suspected chronic bacterial prostatitis (indicated by a history of UTI or an episode of acute prostatitis within the last 12 months):

• Refer to urology
• Offer analgesia (paracetamol and/or NSAID)
• Offer antibiotics while awaiting ofr referral
  • Trimethoprim for 4-6 weeks, or
  • Doxycycline for 4-6 weeks

 

Otherwise, patient requires multimodal treatment, targeting the main symptom:

Symptom	Management
Pain	Paracetamol and/or NSAID Physiotherapy may help with pain related to pelvic floor dysfunction Acupuncture Do NOT prescribe opioids
LUTS	Alpha blocker (e.g. doxazosin or tamsulosin) for voiding symptoms
Constipation	Stool softners (e.g. lactulose, docusate) for painful defecation
Sexual dysfunction	Prioritise non-pharmacological treatments to reduce anxiety about sexual functions Consider PDE-5 inhibitors for erectile dysfunction
Psychosocial symptoms	CBT Conselling Antidepressants

References