Appropriate History, Physical Examination, and Treatment Plan for Prostatitis
The appropriate approach to prostatitis requires classification of the type (acute bacterial, chronic bacterial, chronic pelvic pain syndrome, or asymptomatic), followed by targeted evaluation and treatment based on this classification. 1, 2
History Taking
- Ask about urinary symptoms including dysuria, frequency, urgency, nocturia, and urinary retention 1
- Assess for pelvic or perineal pain, ejaculatory pain, and sexual dysfunction 3
- Document fever, chills, malaise (suggesting acute infection) 4
- Inquire about previous episodes of prostatitis or recurrent UTIs 5
- Ask about recent urologic procedures (catheterization, cystoscopy, prostate biopsy) 4
- Document current medications and antibiotic history 5
- Assess for risk factors including sexual activity, urinary tract abnormalities, and immunosuppression 6
Physical Examination
- Perform digital rectal examination (DRE) to assess for tender, enlarged, or boggy prostate (avoid in suspected acute bacterial prostatitis) 1, 4
- Check vital signs for fever and hemodynamic stability 4
- Perform focused abdominal examination for suprapubic tenderness or palpable bladder 1
- Conduct genital examination to rule out other sources of symptoms 4
- Perform focused neurological examination to assess lower extremity neuromuscular function and anal sphincter tone 1
Diagnostic Testing
- Urinalysis by dipstick or microscopic examination to screen for hematuria and UTI 1
- Urine culture to identify causative organisms and guide antibiotic therapy 1
- Blood cultures in patients with suspected acute bacterial prostatitis 1
- For chronic bacterial prostatitis, perform the Meares and Stamey 2- or 4-glass test to localize infection to the prostate 1, 6
- Consider PSA testing in men over 40 years with at least a 10-year life expectancy 1
- Consider transrectal ultrasound in selected cases to rule out prostatic abscess 1
- For patients with nocturia or predominantly storage symptoms, consider frequency-volume charts 1
Treatment Plan
Acute Bacterial Prostatitis
- For outpatient treatment: oral fluoroquinolones (ciprofloxacin 500 mg twice daily or levofloxacin 500 mg once daily) for 2-4 weeks 7, 2, 4
- For hospitalized patients with severe infection: intravenous antibiotics such as ceftriaxone, piperacillin-tazobactam, or ciprofloxacin until clinical improvement, then transition to oral therapy 2, 4
- Supportive measures including adequate hydration and analgesics 4
- Consider alpha-blockers for urinary retention symptoms 1
- Follow-up evaluation to ensure resolution of symptoms 4
Chronic Bacterial Prostatitis
- Fluoroquinolones (levofloxacin 500 mg once daily or ciprofloxacin 500 mg twice daily) for a minimum of 4 weeks 8, 7, 5
- If fluoroquinolone resistance is present, consider trimethoprim-sulfamethoxazole or doxycycline if the pathogen is susceptible 6
- For multidrug-resistant pathogens, consider fosfomycin 6
- Evaluate for response at 2-4 weeks; if improving, continue for an additional 2-4 weeks 5
- Do not continue antibiotics beyond 6-8 weeks without reassessment 5
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
- Alpha-blockers (tamsulosin, alfuzosin) for patients with urinary symptoms 2
- Consider anti-inflammatory drugs (ibuprofen) for pain management 2
- For neuropathic pain components, consider pregabalin 2
- Pollen extract may provide modest symptom improvement 2
- Physical therapy, myofascial trigger point release, and relaxation techniques for cases with muscle tension component 3
Special Considerations
- For patients with recurrent chronic bacterial prostatitis, consider longer courses of antibiotics (up to 12 weeks) 6
- Evaluate for and treat underlying urological conditions 5
- For prostatic abscess, surgical drainage may be necessary 1
- Consider phage therapy for chronic bacterial prostatitis caused by multidrug-resistant organisms when conventional antibiotics fail 9