What is the appropriate treatment for a man presenting with dysuria, fever, and extreme prostate tenderness, with a palpable and tense prostate, suspected of having acute prostatitis?

Acute Bacterial Prostatitis

This patient has acute bacterial prostatitis and requires immediate empiric broad-spectrum antibiotic therapy, with hospitalization strongly considered given the systemic symptoms and severe prostatic inflammation. 1, 2

Differential Diagnosis

The clinical presentation of dysuria, fever, extreme prostate tenderness with a palpable and tense prostate is pathognomonic for acute bacterial prostatitis. 1, 2 Key differentials to consider include:

• Acute bacterial prostatitis (most likely): The combination of fever, dysuria, and an extremely tender, tense prostate on digital rectal examination is diagnostic. 2, 3
• Prostatic abscess: Should be suspected if the patient fails to respond to appropriate antibiotics within 48-72 hours or presents with severe systemic toxicity. 4
• Acute pyelonephritis: Would present with flank pain and costovertebral angle tenderness rather than prostatic tenderness. 5
• Acute epididymitis: Would show scrotal swelling and tenderness rather than prostatic findings. 6

Immediate Diagnostic Workup

Obtain urine culture and antimicrobial susceptibility testing in all cases before initiating antibiotics, but do not delay treatment while awaiting results. 2, 3

• Urinalysis should be performed, though diagnosis is primarily clinical based on history and digital rectal examination. 2, 3
• Blood cultures should be obtained if the patient appears systemically ill or septic. 2
• Avoid vigorous prostatic massage as this can precipitate bacteremia and worsen sepsis. 2, 4
• Imaging (ultrasound or CT) is not routinely needed unless prostatic abscess is suspected due to failure to improve after 48-72 hours of appropriate therapy. 4

Treatment Algorithm

Hospitalization Criteria

Hospitalize patients who meet any of the following criteria: 2

• Systemically ill appearance or signs of sepsis
• Unable to voluntarily urinate (urinary retention)
• Unable to tolerate oral intake
• Risk factors for antibiotic resistance (recent antibiotic use, healthcare exposure)
• Immunocompromised status (diabetes, cirrhosis, HIV) 4

Antibiotic Selection

For outpatient management (mild-moderate cases):

• Ciprofloxacin 500 mg orally every 12 hours for 2-4 weeks is first-line, with 92-97% success rate. 1, 2
• Alternative: Levofloxacin 500 mg orally daily 7, 1
• Duration: Minimum 2-4 weeks, with continuation for at least 2-4 weeks after symptom resolution. 1, 8

For hospitalized patients (severe cases or systemic illness):

• Intravenous piperacillin-tazobactam OR 1, 2
• Intravenous ceftriaxone plus doxycycline OR 2
• Intravenous ciprofloxacin 400 mg every 12 hours 9, 2
• Switch to oral fluoroquinolones once clinically improved and able to tolerate oral intake. 9, 2

Pathogen Coverage

The causative organisms are gram-negative bacteria in 80-97% of cases, predominantly Escherichia coli, Klebsiella, and Pseudomonas. 1, 4 Fluoroquinolones provide excellent prostatic penetration and cover these organisms effectively. 1, 8

Supportive Management

• Urinary retention management: If the patient cannot void, place a suprapubic catheter rather than urethral catheter to avoid further prostatic trauma. 2
• Analgesics for pain control (NSAIDs or acetaminophen). 8
• Adequate hydration. 2
• Stool softeners to avoid straining during defecation. 2

Follow-up and Monitoring

Reassess within 48-72 hours to ensure clinical improvement. 2, 8

• If no improvement or worsening after 48-72 hours of appropriate antibiotics, obtain imaging (transrectal ultrasound or CT) to evaluate for prostatic abscess. 4
• Urine culture should be repeated if symptoms persist or recur within 2 weeks after treatment completion. 8
• Do not stop antibiotics before 2-4 weeks without clinical improvement assessment. 1, 8

Critical Pitfalls to Avoid

• Never perform vigorous prostatic massage in acute prostatitis as it risks bacteremia and septic shock. 2, 4
• Do not use nitrofurantoin or fosfomycin for prostatitis as they achieve inadequate prostatic tissue concentrations. 6
• Do not treat for less than 2-4 weeks even if symptoms resolve earlier, as inadequate duration increases risk of chronic bacterial prostatitis. 1, 8
• In immunocompromised patients (diabetes, cirrhosis, HIV), consider atypical organisms and broader coverage, as these patients have higher risk of complications including abscess formation. 4