How do you differentiate prostatitis from a urinary tract infection (UTI)?

Differentiating Prostatitis from UTI

Prostatitis is distinguished from simple UTI by the presence of prostate tenderness on digital rectal examination, systemic symptoms (fever, chills), and pelvic/perineal pain, whereas uncomplicated UTI presents with dysuria and bladder symptoms without prostate involvement. 1, 2

Key Clinical Features That Distinguish Prostatitis

Acute Bacterial Prostatitis

• Tender, boggy prostate on digital rectal examination is the hallmark finding that differentiates prostatitis from simple cystitis 1, 2, 3
• Systemic symptoms including fever, chills, and malaise are typically present, unlike uncomplicated UTI 1, 2
• Pelvic, perineal, or rectal pain/discomfort is characteristic and often severe 1, 3, 4
• May present with obstructive voiding symptoms due to prostatic swelling 2, 4

Chronic Bacterial Prostatitis

• Recurrent UTIs from the same bacterial strain is the defining feature 1, 4
• Presents with chronic pelvic pain, perineal discomfort, or voiding symptoms lasting weeks to months 1, 4
• Digital rectal examination may reveal a normal or slightly tender prostate, less dramatic than acute prostatitis 3, 4

Diagnostic Approach

Essential Diagnostic Tests

• Urinalysis and urine culture should be performed in all cases to identify bacteriuria and pyuria 5
• Digital rectal examination is mandatory to assess prostate tenderness, size, and consistency 5
• The presence of pyuria (>5-10 WBC/μL) plus acute urinary symptoms confirms true infection rather than asymptomatic bacteriuria 6

Distinguishing Features on History

• Location of pain: Prostatitis causes pelvic, perineal, or rectal pain; simple UTI causes suprapubic pain and dysuria 1, 3
• Fever and systemic symptoms: Present in acute prostatitis but typically absent in uncomplicated cystitis 1, 2
• Pattern of recurrence: Chronic bacterial prostatitis presents as recurrent UTIs with the same organism 1, 4

Physical Examination Findings

• Prostate tenderness on digital rectal examination is present in acute bacterial prostatitis and may be present in chronic bacterial prostatitis 5, 1, 3
• A boggy, swollen prostate suggests acute prostatitis 2, 3
• Avoid vigorous prostatic massage in acute prostatitis as it may precipitate bacteremia 2, 3

Critical Pitfalls to Avoid

• Do not confuse asymptomatic bacteriuria with infection: Positive urine culture without pyuria or symptoms represents colonization, not infection, and should not be treated in most cases 5, 6
• Do not miss urethritis: If urethral discharge is present with dysuria, consider sexually transmitted urethritis rather than UTI or prostatitis, which requires different treatment and partner notification 5, 7
• In men with UTI symptoms, always examine the prostate: UTI in men is considered complicated and warrants evaluation for prostatitis or underlying urological abnormality 5, 1
• Treatment duration differs significantly: Simple UTI requires 3-7 days of antibiotics, acute bacterial prostatitis requires 2-4 weeks, and chronic bacterial prostatitis requires at least 4-6 weeks 1, 8, 4

Treatment Implications

Acute Bacterial Prostatitis

• Requires broad-spectrum IV or oral antibiotics for 2-4 weeks (piperacillin-tazobactam, ceftriaxone, or ciprofloxacin) with 92-97% success rate 1
• Hospitalization may be required for severe cases with systemic toxicity 1, 2

Chronic Bacterial Prostatitis

• Requires minimum 4-6 weeks of fluoroquinolones (levofloxacin or ciprofloxacin) due to poor prostatic penetration of most antibiotics 1, 8, 4
• May require long-term suppressive therapy if recurrent 8, 4

Uncomplicated UTI

• Requires only 3-7 days of oral antibiotics with agents like nitrofurantoin or trimethoprim-sulfamethoxazole 5