What are the differences between prostatitis and epididymitis, including their treatments?

Prostatitis vs. Epididymitis: Differential Diagnosis and Treatment

Prostatitis and epididymitis are distinct urological conditions with different etiologies, presentations, and treatment approaches, with antibiotics being the cornerstone of treatment for both conditions but with different regimens based on the likely causative pathogens.

Differential Diagnosis

Prostatitis

• Classification: Four categories according to the American Urological Association 1:

  • Acute bacterial prostatitis
  • Chronic bacterial prostatitis (CBP)
  • Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CPPS) - >90% of cases
  • Asymptomatic inflammatory prostatitis

• Clinical Presentation:

  • Pelvic or genital pain
  • Voiding symptoms (dysuria, frequency, urgency)
  • Sometimes associated with sexual dysfunction
  • Fever and systemic symptoms in acute bacterial prostatitis

• Diagnosis:

  • Meares and Stamey 2- or 4-glass test (gold standard)
  • Midstream urine dipstick and culture
  • Blood cultures and CBC in acute cases
  • Transrectal ultrasound to rule out prostatic abscess

Epididymitis

• Clinical Presentation:

  • Unilateral testicular pain and tenderness
  • Hydrocele and palpable swelling of the epididymis
  • Fever in some cases
  • May have concurrent urethritis

• Diagnosis 2:

  • Gram-stained smear of urethral exudate
  • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
  • Examination of first-void urine for leukocytes
  • Syphilis serology and HIV testing
  • Rule out testicular torsion (surgical emergency)

Etiology

Prostatitis

• Acute/Chronic Bacterial:
  • Primarily Enterobacterales (E. coli, Klebsiella, Proteus) 1
  • Sometimes enterococci
  • Atypical pathogens: Chlamydia trachomatis, Mycoplasma species

Epididymitis

• Age <35 years:

  • Primarily sexually transmitted: C. trachomatis, N. gonorrhoeae 2
  • Also Mycoplasma or Haemophilus species

• Age >35 years:

  • Enterobacterales (similar to UTI pathogens)
  • Associated with urinary tract instrumentation, surgery, or anatomical abnormalities 2

Treatment

Prostatitis

Acute Bacterial Prostatitis

• Antibiotic Therapy:
  • Ciprofloxacin 500 mg twice daily for 2-4 weeks 1
  • Levofloxacin 500 mg once daily for 2-4 weeks
  • Doxycycline 100 mg twice daily for 2-4 weeks (especially for atypical pathogens)

Chronic Bacterial Prostatitis

• Antibiotic Therapy:

  • Ciprofloxacin 500 mg twice daily for 4-6 weeks 1
  • Doxycycline 100 mg twice daily for 4-6 weeks (for atypical pathogens)
  • Trimethoprim-sulfamethoxazole (when local resistance <20%)

• For Specific Pathogens:

  • Chlamydia: Azithromycin 1.0-1.5 g single dose or doxycycline 100 mg twice daily for 7 days
  • Mycoplasma genitalium: Azithromycin 500 mg day 1, then 250 mg for 4 days; if resistant, moxifloxacin 400 mg daily for 7-14 days

• Adjunctive Therapy:

  • Alpha-blockers (alfuzosin, doxazosin, tamsulosin, terazosin) 1

Epididymitis

• For patients <35 years or STI suspected 2:

  • Ceftriaxone 250 mg IM single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days

• For patients >35 years or enteric organisms suspected 2:

  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days

• Adjunctive Measures 2:

  • Bed rest
  • Scrotal elevation
  • Analgesics until fever and local inflammation subside

Key Differences

1. Anatomical Location:

   • Prostatitis: Inflammation of the prostate gland
   • Epididymitis: Inflammation of the epididymis

2. Age Distribution:

   • Epididymitis shows clear age-related pathogen patterns (STIs in younger men, enteric organisms in older men)
   • Prostatitis pathogens are less age-dependent

3. Treatment Duration:

   • Acute prostatitis: 2-4 weeks of antibiotics
   • Chronic prostatitis: 4-6 weeks of antibiotics
   • Epididymitis: 10 days of antibiotics

4. Complications:

   • Prostatitis: Can become chronic, prostatic abscess
   • Epididymitis: Potential infertility, testicular infarction, abscess

Follow-up

Prostatitis

• Clinical reassessment after 2 weeks
• Urine culture at end of treatment
• PSA measurement 3 months after resolution if elevated during infection 1

Epididymitis

• Reevaluation if no improvement within 3 days
• Comprehensive evaluation for persistent swelling/tenderness (consider tumor, abscess, infarction, testicular cancer, TB) 2
• Partner notification and treatment if STI confirmed or suspected

Important Caveats

1. Rule out testicular torsion in all cases of acute scrotal pain - surgical emergency requiring immediate specialist consultation 2

2. Consider prostatic abscess in patients with prostatitis who fail to respond to appropriate antibiotic therapy 1

3. Monitor for fluoroquinolone side effects affecting tendons, muscles, joints, nerves, and central nervous system 1

4. Antibiotic selection for chronic prostatitis should consider prostatic penetration (lipid solubility, low ionization, high dissociation constant, low protein binding, small molecular size) 3

5. Partner management is essential for sexually transmitted infections to prevent reinfection 2