Nicholas J. Kuntz, MD
Judd W. Moul, MD, FACS
BASICS
DESCRIPTION
• Acute bacterial prostatitis is cute, potentially life-threatening bacterial infection of the prostate
• The symptoms are typically severe and sudden and usually cause the patient to seek emergency care
• The NIH prostatitis classification system it is referred to as NIH:I
EPIDEMIOLOGY
Incidence
• Least common form of prostatitis
– 1–5%
• Incidence peaks at 20–40 yr (1)[B]
• Not affected by race and ethnicity (1)[B]
Prevalence
Estimated to be ∼10% for all types of prostatitis worldwide (1)[B]
RISK FACTORS
• Bladder outlet obstruction
– Benign prostatic hyperplasia (BPH)
– Stricture disease
• Previous episodes of prostatitis
• Lower urinary tract procedures
– Prostate biopsy or urethral catheterization
• Phimosis
• Immunocompromised
– Human immunodeficiency virus (HIV)
• Immunosuppression
– Diabetes
• Indwelling urethral catheter
• Urinary tract infection (UTI)
• History of sexually transmitted disease
Genetics
Not applicable
PATHOPHYSIOLOGY
• Intraprostatic reflux of infected urine
• Ascending urethral infection:
– Unprotected sexual intercourse
– Urologic instrumentation
– Prolonged catheterization
• Direct invasion or lymphogenous spread from the rectum
– Following biopsy, BPH procedures
• Hematogenous seeding
– Staphylococcus aureus most common, including methicillin-resistant strands (MRSA)
• Usually a single bacterial uropathogen
– Escherichia coli 87% (2)[B]
– Pseudomonas, Proteus, Klebsiella
– Enterococci 5–10%
• Sexually active and <35 yr
– Neisseria gonorrhoeae
• Severe immunocompromise (HIV/AIDS)
– Mycobacterium tuberculosis, Serratia, Salmonella, and fungi (Candida, Histoplasma, Aspergillus, Cryptococcus) (1)[B]
• NIH classification: (3)[A]
– I: Acute bacterial prostatitis
– II: Chronic bacterial prostatitis: Recurrent infection
– III: Chronic abacterial prostatitis/chronic pelvic pain syndrome (CPPS): No demonstrable infection:
IIIA: Inflammatory CPPS: White blood cells (WBCs) present in semen/expressed prostatic secretions or voided bladder urine (VB3)
IIIB: Noninflammatory CPPS: WBCs not present in semen/expressed prostatic secretions or voided bladder urine (VB3)
– IV: Asymptomatic inflammatory prostatitis: Detected by prostate biopsy or presence of WBCs in prostatic secretions during evaluation for other disorders
ASSOCIATED CONDITIONS
• BPH
• Urethral stricture disease
• Diabetes
• HIV
• UTI
GENERAL PREVENTION
• Safe sex practices may prevent some cases.
• Management of underlying BPH, DM, etc.
DIAGNOSIS
HISTORY
• Systemic symptoms
– Fever, chills, malaise, arthralgia, myalgia
• Irritative or obstructive voiding symptoms
– Dysuria, urgency, frequency
• Acute urinary retention (20%)
– Due to bladder neck spasm
• Perineal/rectal pain, lower back pain
PHYSICAL EXAM
ALERT
Avoid vigorous prostatic exam or massage in a patient with suspected acute bacterial prostatitis. This may cause bacteremia and sepsis. Likewise urethral instrumentation should be avoided if possible (4)[C].
• Vital signs:
– Signs of sepsis including fever, tachycardia, and hypotension
• Abdominal exam:
– Palpable bladder or abdominal fullness suggesting acute urinary retention
• Digital rectal exam (DRE):
– Perform cautiously
– Exquisitely tender, warm, boggy, swollen prostate gland
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Complete blood count
– Leukocytosis with left shift
• Urinalysis
– Proteinuria, pyuria, and hematuria
– Positive leukocyte esterase and nitrite has a sensitivity of 68–88% (1)[B]
• Urine culture
• Blood cultures
– Particularly for immunosuppressed patients
• Prostate-specific antigen (PSA)
– Little clinical value in the acute setting
– Will be elevated in the majority of cases
– Should be repeated 1–2 mo following treatment
Imaging
• Not routinely required
• Indicated if fever persists despite appropriate treatment to evaluate for prostatic abscess
– CT scan
Area of low attenuation
Rim enhancing with IV contrast
– Ultrasound
Hypoechoic lesion
– MRI
High intensity on T2-weighted images
Rim enhancing with gadolinium
Diagnostic Procedures/Surgery
None: Clinical diagnosis
Pathologic Findings
Prostate biopsy is contraindicated in the presence of acute bacterial prostatitis
DIFFERENTIAL DIAGNOSIS
• UTI
• Pyelonephritis
• Chronic bacterial prostatitis
• Granulomatous prostatitis
• Perirectal abscess
• Prostate cancer
• Prostatic abscess
• Prostatodynia
TREATMENT
GENERAL MEASURES
• Indications for admission and IV antibiotics:
– High fever
– Significant leukocytosis
– Sepsis
• Analgesics/antipyretics
• Stool softeners
• Bladder drainage if there is evidence of urinary retention:
– A urethral catheter should be placed cautiously
– With any difficulty or if the patient is too uncomfortable, percutaneous suprapubic tube should be placed
• If no clinical response in 48 hr despite appropriate treatment consider prostatic abscess
• Postprostate biopsy prostatitis suspect resistance to fluoroquinolones
MEDICATION
First Line (4)[C]
• Antibiotics with high lipid solubility and concentrated in prostatic tissue
– Fluoroquinolones
Levofloxacin, 250–750 mg daily IV or by mouth (PO)
Ciprofloxacin, 250–750 mg PO twice daily (BID), 400 mg IV BID
Ampicillin with gentamicin (ampicillin 1–2 g IV every 4–6 hr, 500 mg PO every 6 hr; gentamicin 1–2 mg/kg IV every 8–12 hr or daily dosing 4–7 mg/kg every 24 hr IV)
Ceftriaxone 1–2 g IV or IM daily
– Afebrile 24–48 hr may change to oral antibiotics
• Adjust antibiotic regimen based on urine and/or blood culture results
• Transition to oral antibiotic following resolution of acute toxicity
• Total antibiotic duration: 2–4 wk
Second Line
• Oral antibiotics are a reasonable 1st option in nontoxic patients.
– Fluoroquinolones (see above oral dose) for 10 days (4)[C]
– Trimethoprim–sulfamethoxazole 160/800 mg PO every 12 hr
• If STD is suspected (sexually active male younger than 35 yr) empiric treatment with ceftriaxone 250 mg IM and doxycycline 100 mg BID for 7 days may be warranted, but this is controversial (5)[C]
SURGERY/OTHER PROCEDURES
• Suprapubic tube placement
– If Foley catheter cannot be passed easily in setting of acute urinary retention
• If prostatic abscess develops, surgical drainage of prostatic abscess is usually required (4)[B]
– Transrectal or perineal needle aspiration
Ultrasound guided
Local anesthetic
– Transurethral drainage
Incision or unroofing
Resection may be associated with higher rates of sepsis
– Open drainage
If less invasive methods fail
Abscess extends beyond prostate
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Limited, if any role in the acute setting
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• If initial response to therapy is favorable then patient prognosis is excellent.
• Studies using quinolone antibiotics suggest that a negative culture after 7 days of therapy is predictive of a long-term response.
• If the patient with suspected bacterial prostatitis is not responding to initial empiric therapy, consider prostatic abscess.
COMPLICATIONS
• Prostatic abscess
• Decreased fertility
• Epididymitis
• Chronic prostatitis
• Emphysematous prostatitis
• Pyelonephritis
• Sepsis
• Urinary retention
FOLLOW-UP
Patient Monitoring
• Follow-up urine cultures to verify that the infection has cleared and that chronic bacterial prostatitis is not present.
• If PSA was obtained during the acute episode, and was elevated, repeat in 1–2 mo to resolution.
Patient Resources
Urology Care Foundation. http://www.urologyhealth.org/urology/index.cfm?article=15
REFERENCES
1. Ramakrishnan K, Salinas RC. Prostatitis: Acute and chronic. Prim Care. 2010;37(3):547–563, viii–ix.
2. Millan-Rodriguez F, Palou J, Bujons-Tur A, et al. Acute bacterial prostatitis: Two different sub-categories according to a previous manipulation of the lower urinary tract. World J Urol. 2006;24(1):45–50.
3. Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236–237.
4. National Guideline C. Prostatitis and chronic pelvic pain syndrome. In: Guidelines On Urological Infections Rockville MD: Agency for Healthcare Research and Quality. [5/15/2013]. Available from www.guideline.gov/content.aspx?id=14811&search=prostatitis.
5. Etienne M, Chavanet P, Sibert L, et al. Acute bacterial prostatitis: Heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis. BMC Infect Dis. 2008;8:12.
ADDITIONAL READING
• Barozzi L, Pavlica P. Prostatic abscess: Diagnosis and treatment. AJR Am J Roentgenol. 1998;(3):753–757.
• Lipsky BA. Prostatitis and urinary tract infection in men: What’s new; what’s true? Am J Med. 1999;(3):327–334.
• Nickel JC. Prostatitis: Myths and realities. Urology. 1998;51(3):362–366.
• Pewitt ED, Schaeffer AJ. Urinary tract infection urology, including acute and chronic prostatitis. Infect Dis Clin North Am. 1997;11(3):623–646.
• Schaeffer AJ. Chronic prostatitis and the chronic pelvic pain syndrome. N Engl J Med. 2006;355:1690–1698.
See Also (Topic, Algorithm, Media)
• Prostate Biopsy, Infections and Complications
• Prostate, Abscess
• Prostatitis, Acute, Bacterial (NIH I) Image 
• Prostatitis, Chronic Nonbacterial, Inflammatory and Noninflammatory (NIH CP/CPPS III A and B)
• Prostatitis, Chronic, Bacterial (NIH II)
• Prostatitis, General Considerations
• Prostatitis, Granulomatous
• Urinary Tract Infection (UTI), Adult Male
CODES
ICD9
• 041.49 Other and unspecified Escherichia coli [E. coli]
• 098.12 Gonococcal prostatitis (acute)
• 601.0 Acute prostatitis
ICD10
• A54.22 Gonococcal prostatitis
• B96.20 Unsp Escherichia coli as the cause of diseases classd elswhr
• N41.0 Acute prostatitis
CLINICAL/SURGICAL PEARLS
• E. coli is most common organism in acute bacterial prostatitis.
• Avoid vigorous prostatic exam or massage during an episode of acute bacterial prostatitis.
• It is not advisable to measure serum PSA during an episode of acute bacterial prostatitis as it will most likely be falsely elevated.
• Urinary retention requires bladder drainage.
• May require hospital admission and IV antibiotics.
• Consider prostatic abscess if no clinical response in 48 hr.