What are the symptoms and treatment options for prostatitis?

Symptoms of Prostatitis

Prostatitis presents with distinct symptom patterns depending on the type: acute bacterial prostatitis causes fever, chills, and severe urinary symptoms with systemic illness, while chronic bacterial prostatitis manifests as recurrent urinary tract infections, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized primarily by persistent pelvic pain lasting at least 3 months with associated urinary symptoms but without consistent bacterial infection. 1

Acute Bacterial Prostatitis Symptoms

Pain and Systemic Features:

• Pelvic pain is a cardinal feature, often accompanied by perineal, suprapubic, or lower back discomfort 2
• Fever and chills are characteristic systemic manifestations 1, 2
• Malaise, nausea, and emesis frequently occur, indicating systemic infection 2

Urinary Symptoms:

• Dysuria (painful urination) is nearly universal 2
• Urinary frequency and urgency are prominent 1
• Urinary retention may develop in severe cases 2

Physical Examination Findings:

• Digital rectal examination reveals a tender, enlarged, or boggy prostate 2
• Note: Prostatic massage should not be performed in acute bacterial prostatitis due to risk of bacteremia 3

Chronic Bacterial Prostatitis Symptoms

Recurrent Pattern:

• Recurrent urinary tract infections with the same bacterial organism identified on repeated cultures 4
• Episodes of dysuria, frequency, and urgency that temporarily improve with antibiotics but recur 4
• Pelvic pain that is typically less severe than acute prostatitis 4

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

Pain Characteristics:

• Pelvic pain or discomfort for at least 3 months is the defining feature 1
• Pain localized to the perineum, suprapubic region, testicles, or tip of the penis 5
• Pain is often exacerbated by urination or ejaculation 5
• Many patients describe "pressure" rather than pain, and some may deny pain entirely 5

Associated Urinary Symptoms:

• Urinary frequency is commonly reported 1
• Sense of incomplete bladder emptying 5
• Nocturia (nighttime urination) 5
• Urinary urgency, though patients with CP/CPPS experience a more constant urge to void to relieve pain, unlike overactive bladder patients who void to avoid incontinence 5

Important Diagnostic Distinction:

• CP/CPPS is diagnosed when evaluation (history, physical examination, urine culture, and postvoid residual measurement) does not identify other causes such as infection, cancer, urinary obstruction, or urinary retention 1
• The condition accounts for more than 90% of chronic prostatitis cases 4

Symptom Overlap with Interstitial Cystitis/Bladder Pain Syndrome

Critical Clinical Consideration:

• Men with symptoms meeting criteria for CP/CPPS may also have interstitial cystitis/bladder pain syndrome (IC/BPS), as the clinical characteristics are very similar 5
• IC/BPS should be strongly considered in men whose pain is perceived to be related to the bladder 5
• Some men have symptoms meeting criteria for both conditions and may benefit from combined treatment approaches 5

Treatment Overview

Acute Bacterial Prostatitis:

• Broad-spectrum antibiotics (piperacillin-tazobactam, ceftriaxone, or ciprofloxacin) for 2-4 weeks with a 92-97% success rate 1
• Hospitalization with intravenous antibiotics for systemically ill patients, those unable to urinate voluntarily, unable to tolerate oral intake, or with risk factors for antibiotic resistance 2

Chronic Bacterial Prostatitis:

• Fluoroquinolones (levofloxacin or ciprofloxacin) for a minimum of 4 weeks as first-line therapy 3, 1
• If effective but symptoms recur, another course may be prescribed, possibly combined with alpha blockers 4

Chronic Prostatitis/Chronic Pelvic Pain Syndrome:

• Alpha-blockers (tamsulosin, alfuzosin) are first-line for patients with urinary symptoms, showing significant symptom improvement 1
• Other options include anti-inflammatory drugs (ibuprofen), pregabalin, and pollen extract, though with more modest benefits 1
• A 4-6 week course of antibiotics may be tried despite lack of bacterial infection, with weak supporting evidence 4
• Multimodal approach tailored to patient presentation using the UPOINT phenotyping system (Urinary, Psychosocial, Organ-specific, Infection, Neurologic/systemic, Tenderness) 4

Common Pitfalls

Overlooking Acute Bacterial Prostatitis:

• Failure to recognize ABP can lead to treatment failure, progression to prostatic abscess requiring surgery, or transition to chronic prostatitis requiring long-term antibiotics with poor response rates 6
• ABP is rare in healthy men; its presence should prompt evaluation for underlying diseases including sexually transmitted infections, benign prostatic hyperplasia, urinary stones, or malignant tumors 6

Misdiagnosis:

• Chronic prostatitis must be differentiated from interstitial cystitis/bladder pain syndrome, pelvic floor dysfunction, prostate and bladder cancers, benign prostatic hyperplasia, and urolithiasis 4
• Accurate microbiological evaluation is crucial, including testing for atypical pathogens such as Chlamydia trachomatis and Mycoplasma species in chronic bacterial prostatitis 3