Symptoms of Prostatitis
The hallmark symptoms of prostatitis include pelvic pain, urinary frequency, urgency, painful ejaculation, and a sense of incomplete emptying. 1
Types of Prostatitis and Their Symptoms
Prostatitis is classified into four categories according to the National Institutes of Health (NIH), each with distinct symptom presentations:
1. Acute Bacterial Prostatitis
- Pain symptoms: Severe perineal, suprapubic, or rectal pain
- Urinary symptoms: Frequency, urgency, dysuria, nocturia, and urinary retention
- Systemic symptoms: Fever, chills, malaise, nausea, and vomiting 2, 3
- Physical findings: Tender, enlarged, or boggy prostate on digital rectal examination 3
2. Chronic Bacterial Prostatitis
- Pain symptoms: Persistent or recurrent perineal, testicular, penile, or lower back pain
- Urinary symptoms: Frequency, urgency, hesitancy, weak stream, and sense of incomplete emptying
- Sexual symptoms: Painful ejaculation
- Systemic symptoms: Usually absent or mild 4
- Key feature: Recurrent urinary tract infections with the same pathogen 4
3. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
- Pain location: Perineum, suprapubic region, testicles, penis tip, lower abdomen, back, or rectum
- Pain characteristics: Often described as pressure or discomfort rather than frank pain
- Urinary symptoms: Similar to chronic bacterial prostatitis
- Duration: Symptoms persisting for more than 3 months 1
4. Asymptomatic Inflammatory Prostatitis
- No symptoms (diagnosed incidentally during evaluation for other conditions) 2
Diagnostic Considerations
When evaluating a patient with suspected prostatitis, it's important to differentiate between the different types:
- Acute bacterial prostatitis: Diagnosis is primarily based on history, physical examination, and urinalysis/urine culture 3
- Chronic bacterial prostatitis: Requires documentation of recurrent UTIs with the same organism and culture of expressed prostatic secretions 4
- CP/CPPS: A diagnosis of exclusion after ruling out bacterial causes 2
Treatment Approaches
Acute Bacterial Prostatitis
- Antibiotics: First-line treatment with appropriate antibiotics for 2-4 weeks
- Hospitalization: Consider for patients who are systemically ill or unable to urinate
- Common regimens: Ceftriaxone and doxycycline, ciprofloxacin, or piperacillin/tazobactam 3
Chronic Bacterial Prostatitis
- Antibiotics: Prolonged course (6-12 weeks) with agents that penetrate prostatic tissue
- Preferred agents: Fluoroquinolones (e.g., levofloxacin 500 mg daily for 28 days) or trimethoprim-sulfamethoxazole 5, 4
- Supportive measures: Alpha-1 adrenoceptor antagonists may help relieve symptoms 1
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
- First-line: Alpha-1 adrenoceptor antagonists and self-management techniques
- Self-management: Education, reassurance, and lifestyle modifications
- Multimodal approach: May include pain management, physical therapy, and psychological support 1
Important Clinical Considerations
- Prostatitis affects 25-50% of men over their lifetime and is often overlooked due to indeterminate symptoms 6
- Failure to recognize acute bacterial prostatitis can lead to:
- Treatment failure and possible progression to prostatic abscess
- Transition to chronic prostatitis
- Missing underlying conditions (e.g., benign prostatic hyperplasia, urinary stones, malignancies) 6
- Regular follow-up is recommended for all patients receiving treatment for prostatitis 1
Common Pitfalls to Avoid
- Inadequate duration of antibiotic therapy: Too short a course can lead to recurrence
- Failure to evaluate for underlying conditions: Prostatitis may be secondary to other genitourinary issues
- Missing complications: Prostatic abscess formation requires different management
- Overlooking non-bacterial causes: Most cases of prostatitis are non-bacterial and require different management approaches
- Inadequate symptom management: Even after bacterial eradication, symptoms may persist and require specific treatment 7