What causes high fever, chills, dysuria, cloudy urine, and a firm, tender prostate?

Acute Bacterial Prostatitis

The clinical presentation of high fever, chills, dysuria, cloudy urine, and a firm, tender prostate is diagnostic of acute bacterial prostatitis (ABP), a severe urinary tract infection caused predominantly by gram-negative bacteria, most commonly Escherichia coli (80-97% of cases). 1, 2

Causative Organisms

• Primary pathogens: Enterobacterales, particularly E. coli, are responsible for the vast majority of ABP cases 1, 2
• Other gram-negative bacteria: Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Serratia marcescens 1, 2
• Less common: Enterococcus species and other gram-positive organisms in specific populations 1

Clinical Presentation

ABP presents abruptly with systemic inflammatory symptoms combined with lower urinary tract symptoms: 2, 3

• Systemic symptoms: High fever, chills, rigors, malaise, nausea, and potential progression to sepsis 1, 2, 3
• Urinary symptoms: Dysuria, urinary frequency, urgency, cloudy urine, and possible urinary retention 2, 3
• Physical examination findings: Tender, enlarged, boggy, or firm prostate on digital rectal examination 3, 4

Diagnostic Approach

Diagnosis is primarily clinical, based on the characteristic presentation and physical examination findings: 1, 3

• Do NOT perform prostatic massage in ABP as this can precipitate bacteremia and worsen sepsis 1
• Obtain midstream urine for urinalysis and culture to identify the causative organism and guide antibiotic therapy 1, 3
• Blood cultures (two sets) should be obtained in patients with systemic symptoms or suspected urosepsis 1, 3
• Urine dipstick testing for nitrites and leukocyte esterase supports the diagnosis 1

Immediate Management

Broad-spectrum antibiotics must be initiated promptly, with the choice depending on illness severity and local resistance patterns: 1

For Systemically Ill or Hospitalized Patients:

• Intravenous third-generation cephalosporin (e.g., ceftriaxone) 1, 3
• Piperacillin-tazobactam for broader coverage 2, 3
• Combination therapy: Amoxicillin plus aminoglycoside OR second-generation cephalosporin plus aminoglycoside 1

For Outpatients with Mild-Moderate Symptoms:

• Ciprofloxacin (oral) is first-line if local resistance rates are <10% and the patient has not used fluoroquinolones in the last 6 months 1, 5, 2
• Success rate of 92-97% when prescribed for 2-4 weeks for febrile UTI with acute prostatitis 2

Treatment Duration

Antibiotic therapy for ABP should be continued for 2-4 weeks to prevent progression to chronic bacterial prostatitis: 1, 2, 3

• Minimum 7 days, typically 14 days for men to ensure adequate treatment and prevent chronic infection 1
• Longer courses (4 weeks) may be necessary in complicated cases or when response is suboptimal 2, 6

Critical Pitfalls to Avoid

• Do not overlook ABP in patients with fever of unknown origin, as delayed recognition can lead to prostatic abscess formation, chronic prostatitis, or progression to urosepsis 4
• Avoid fluoroquinolones if the patient has used them in the past 6 months or if local resistance exceeds 10% 1
• Do not perform digital rectal examination with excessive manipulation or prostatic massage, as this risks bacteremia 1
• Hospitalization is mandatory for patients who are systemically ill, unable to urinate voluntarily, unable to tolerate oral intake, or have risk factors for antibiotic resistance 3

Risk Factors and Underlying Conditions

ABP is uncommon in healthy men without predisposing factors; always investigate for underlying conditions: 4, 7

• Urological abnormalities: Benign prostatic hyperplasia, urinary stones, bladder outlet obstruction 1, 4
• Iatrogenic causes: Recent transurethral procedures, urethral catheterization, cystoscopy, or transrectal prostate biopsy 3, 7
• Systemic conditions: Diabetes mellitus, immunosuppression, cirrhosis 1, 7
• Sexually transmitted infections should be considered in younger men 4