How do you differentiate and treat prostatitis vs urinary tract infection (UTI) in males?

Differentiating and Treating Prostatitis vs UTI in Males

The key to differentiating between prostatitis and UTI in males is the location of pain and physical examination findings, with prostatitis typically presenting with perineal, suprapubic, testicular or penile tip pain, while UTIs present with dysuria, frequency, and bladder-related symptoms without prostatic tenderness.

Clinical Presentation Differences

Prostatitis

• Pain characteristics:

  • Perineum, suprapubic region, testicles, or tip of penis 1
  • Pain often exacerbated by urination or ejaculation 1
  • May include sense of incomplete bladder emptying 1

• Physical examination:

  • Tender prostate on digital rectal examination (acute bacterial prostatitis) 2
  • Subacute symptoms in chronic bacterial prostatitis 2

Urinary Tract Infection

• Pain characteristics:

  • Dysuria (burning with urination)
  • Suprapubic pain related to bladder filling 3
  • Pain that improves with urination 3

• Physical examination:

  • Non-tender prostate
  • May have suprapubic tenderness

Diagnostic Approach

Initial Testing for Both Conditions

1. Urinalysis:

   • Look for pyuria, nitrites, or bacteriuria 3
   • Negative results for nitrite and leukocyte esterase often suggest absence of UTI 3

2. Urine culture:

   • Essential to confirm infection and guide antibiotic therapy 3
   • Obtain before starting antibiotics if possible 3

Specific Testing for Prostatitis

1. Meares-Stamey 4-glass test (gold standard):

   • Collection of:
     • First-void urine (VB1)
     • Midstream urine (VB2)
     • Expressed prostatic secretions (EPS)
     • Post-massage urine (VB3) 4
   • Positive when bacterial counts in EPS/VB3 exceed VB1/VB2 by 10-fold

2. Simplified 2-glass test:

   • Pre-massage and post-massage urine samples
   • More practical for office setting

Treatment Algorithm

Acute Bacterial Prostatitis

1. Antibiotic therapy:

   • First-line: Fluoroquinolones (e.g., levofloxacin 500 mg once daily for 28 days) 4, 2
   • Alternative: Trimethoprim-sulfamethoxazole 2
   • Duration: 4 weeks 2

2. Supportive measures:

   • Adequate hydration
   • Analgesics for pain control
   • Alpha-blockers if obstructive symptoms present

Chronic Bacterial Prostatitis

1. Antibiotic therapy:

   • First-line: Fluoroquinolones (e.g., levofloxacin 500 mg once daily) 4, 5
   • Alternative: Trimethoprim-sulfamethoxazole 2
   • Duration: 6-12 weeks 2

2. For recurrent cases:

   • Long-term suppressive antibiotic therapy 2
   • Consider urological evaluation for structural abnormalities 3

Urinary Tract Infection in Males

1. Antibiotic therapy:

   • First-line: Fluoroquinolones (e.g., ciprofloxacin 500 mg twice daily or levofloxacin 750 mg daily) 3
   • Duration: 7-14 days (males require longer treatment than females) 3

2. For recurrent UTIs:

   • Urological evaluation for underlying structural or functional abnormalities 3
   • Surgery if indicated for conditions like bladder stones or recurrent UTIs due to BPH 1

Important Clinical Considerations

1. Male UTIs are considered complicated:

   • Due to anatomical differences and higher likelihood of underlying abnormalities 3
   • Require longer treatment duration than female UTIs

2. Recurrent UTIs in males:

   • Strongly suggest underlying structural or functional abnormalities 3
   • Warrant urological evaluation including cystoscopy 3

3. Prostate-specific considerations:

   • Bacterial persistence in males often indicates underlying structural problems 3
   • Surgery is recommended for patients with recurrent UTIs clearly due to BPH 1

4. Antibiotic resistance concerns:

   • Increasing fluoroquinolone resistance affects management 6
   • Consider local resistance patterns when selecting empiric therapy 3
   • Adjust dosing based on renal function 3

5. Chronic prostatitis/chronic pelvic pain syndrome:

   • Often difficult to treat and may require multimodal approach 7
   • Consider anti-inflammatory agents and alpha-blockers 7

By following this structured approach to diagnosis and treatment, clinicians can effectively differentiate between prostatitis and UTI in male patients and provide appropriate targeted therapy.