What are the symptoms and treatment options for prostatitis?

Symptoms of Prostatitis

Prostatitis presents with a characteristic set of symptoms including pelvic pain, urinary symptoms, and sometimes sexual dysfunction, with treatment varying based on the specific type of prostatitis (acute bacterial, chronic bacterial, or chronic pelvic pain syndrome). 1, 2

Types of Prostatitis and Their Symptoms

Acute Bacterial Prostatitis (ABP)

• Primary symptoms:
  • Sudden onset of severe pelvic pain (perineum, suprapubic region, testicles)
  • Fever and chills
  • Malaise and systemic symptoms
  • Urinary urgency, frequency, and dysuria
  • Difficulty voiding or urinary retention
  • Weak urinary stream
  • Sense of incomplete bladder emptying 1, 3

Chronic Bacterial Prostatitis (CBP)

• Primary symptoms:
  • Persistent or recurrent pelvic pain (lasting >3 months)
  • Urinary symptoms (frequency, urgency, nocturia)
  • Dysuria
  • Sense of incomplete emptying
  • Urinary hesitancy or weak stream
  • Recurrent urinary tract infections 1, 4

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

• Primary symptoms:
  • Chronic pelvic pain (perineum, suprapubic region, testicles, penis tip, lower abdomen, back, or rectum)
  • Pain or discomfort during or after ejaculation
  • Urinary symptoms similar to CBP
  • Pain described as pressure or discomfort rather than frank pain
  • Symptoms lasting more than 3 months 2, 5

Diagnostic Approach

For Acute Bacterial Prostatitis:

• Do not perform prostatic massage (strong recommendation) 1
• Obtain midstream urine dipstick to check for nitrite and leukocytes
• Collect midstream urine culture to guide antibiotic treatment
• Obtain blood culture and complete blood count
• Consider transrectal ultrasound if prostatic abscess is suspected 1, 3

For Chronic Bacterial Prostatitis:

• Perform the Meares and Stamey 2- or 4-glass test (strong recommendation)
• Conduct microbiological evaluation for atypical pathogens (Chlamydia trachomatis, Mycoplasma species)
• Do not rely solely on ejaculate analysis for diagnosis 1, 4

Treatment Approaches

Acute Bacterial Prostatitis:

• Antibiotic therapy:
  • Outpatient: Oral fluoroquinolones (e.g., levofloxacin) or trimethoprim-sulfamethoxazole for 4 weeks 6, 4
  • Inpatient (for severely ill patients): Parenteral broad-spectrum antibiotics (ceftriaxone plus doxycycline, piperacillin/tazobactam) 3
• Supportive measures:
  • Adequate hydration
  • Pain management
  • Alpha-blockers for urinary symptoms 2

Chronic Bacterial Prostatitis:

• Prolonged antibiotic therapy:
  • Fluoroquinolones (e.g., levofloxacin 500 mg daily for 28 days) 6
  • Treatment duration: 6-12 weeks 4
• Microbiologic eradication rates with levofloxacin: approximately 75% 6

Chronic Prostatitis/Chronic Pelvic Pain Syndrome:

• First-line treatment:
  • Alpha-1 adrenoceptor antagonists (α1-blockers)
  • Self-management techniques (education, reassurance, lifestyle modifications) 2
• For urinary symptoms:
  • Normal urodynamics: α1-blockers and self-management
  • Detrusor overactivity: Anticholinergic medications or beta-3 agonists 2

Potential Complications of Untreated Prostatitis

• Progression from acute to chronic prostatitis
• Formation of prostatic abscess requiring surgical intervention
• Recurrent urinary tract infections
• Long-term pelvic pain and urinary symptoms
• Sexual dysfunction
• Reduced quality of life 7

Important Considerations

• Acute bacterial prostatitis is rare in healthy adult men without underlying conditions
• Underlying conditions to consider: sexually transmitted diseases, benign prostatic hyperplasia, urinary stones, and malignant tumors 7
• Regular follow-up is recommended for all patients receiving treatment 2
• Phytotherapeutic agents may be considered as complementary treatment to reduce symptom burden, though evidence is limited 8

Remember that prompt diagnosis and appropriate treatment of prostatitis are essential to prevent complications and improve quality of life.