Prostatitis

BASICS

Definition: Painful or inflammatory condition of the prostate; may or may not be bacterial. Characterized by urogenital pain, voiding symptoms, and/or sexual dysfunction.
NIH Classifications:
Class I: Acute bacterial prostatitis—fever, perineal pain, dysuria, obstructive symptoms; PMNL & bacteria in urine
Class II: Chronic bacterial prostatitis—chronic or recurrent infection; pain and voiding issues; PMNL & bacteria in EPS, post-massage urine, or semen
Class III: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
- IIIA: Inflammatory (PMNL in EPS/urine after massage/semen)
- IIIB: Noninflammatory (no PMNL in EPS/urine/semen)
Class IV: Asymptomatic inflammatory prostatitis—incidental, no symptoms; PMNL/bacteria in EPS/urine/semen

Acute bacterial (Class I): Ascending urethral infection (E. coli most common), often after instrumentation; rarely Staph aureus (evaluate for hematogenous source)
Chronic bacterial (Class II): Same pathogens; recurrent
CP/CPPS (Class III): Unclear; possible inflammation or neuromuscular pain, no clear histologic correlation
Consider: STI pathogens (N. gonorrhoeae, C. trachomatis) in men <35 yrs

Acute: Fever, chills, malaise, low back/pelvic/perineal pain, dysuria, urgency, retention, cloudy urine
Chronic: Insidious, >3 months, pelvic/prostatic/perineal pain, dysuria, low-grade fever, hematospermia, sexual dysfunction

Vital signs (instability suggests sepsis)
Abdominal: Bladder distention, CVA tenderness
Prostate exam:
Acute: Tender, warm, firm, edematous (AVOID vigorous massage—may cause bacteremia)
Chronic/CPPS: Often normal, occasionally enlarged/tender

UTI, pyelonephritis, cystitis, urethritis, epididymitis, proctitis, prostatic abscess, BPH/cancer, stones

Acute: UA, urine C&S, CBC, blood cultures (if sepsis suspected), STI testing (<35 yrs/high risk)
Imaging: Only if abscess or complication suspected (TRUS/CT)
Chronic: Pre/post-prostatic massage urine cultures (optional), urodynamics (optional)
CP/CPPS: Diagnosis of exclusion; NIH-CPSI questionnaire for symptoms

NSAIDs, α1-blockers (for LUTS), antipyretics, sitz baths, hydration, stool softeners, urinary drainage if retention

Acute bacterial (Class I, outpatient):
Fluoroquinolones (ciprofloxacin or levofloxacin)
Trimethoprim-sulfamethoxazole (if low local resistance)
If STI risk: ceftriaxone/cefixime + doxycycline
Duration: 2–4 weeks (may extend to 4–6 weeks)
Acute bacterial (Class I, inpatient):
Urinary drainage
Broad-spectrum IV antibiotics (ceftriaxone, levofloxacin, Zosyn, +/- aminoglycoside)
De-escalate to oral when improved; total duration 2–4 weeks
Chronic bacterial (Class II):
Fluoroquinolones or TMP-SMX for 4–12 weeks
If Enterococcus: moxifloxacin or linezolid
α1-blockers + antibiotics reduce recurrence
CP/CPPS (Class III):
Empiric trial: Caffeine/alcohol avoidance, α1-blockers, NSAIDs, possibly fluoroquinolones

Urology: Failure of antibiotics, persistent symptoms, obstructive LUTS, hematuria, elevated PSA, prostatic abscess
Surgical: Drain abscess, refractory chronic cases

Acute: Fever/dysuria resolve in 2–6 days, usually improved by 3–4 weeks
Chronic: 55–97% cure depending on regimen, but 20% may have reinfection/persistent infection

Prostatic abscess (esp. HIV)
Pyelonephritis, urinary retention, epididymitis, infertility, metastatic infection, ED