Is a semen culture and sensitivity test part of the diagnostic workup for prostatitis?

Semen Culture is NOT Routinely Recommended for Prostatitis Workup

The 2024 European Association of Urology guidelines explicitly state: "Do not routinely perform microbiological analysis of the ejaculate alone to diagnose chronic bacterial prostatitis" (weak recommendation). 1

Diagnostic Approach Based on Prostatitis Type

Acute Bacterial Prostatitis (ABP)

• Midstream urine culture is the primary diagnostic test for acute bacterial prostatitis 1
• Blood cultures and complete blood count should be obtained in febrile patients 1
• Prostatic massage is contraindicated in acute bacterial prostatitis due to bacteremia risk (strong recommendation) 1
• Semen culture has no role in acute prostatitis workup 1

Chronic Bacterial Prostatitis (CBP)

• The Meares-Stamey 2- or 4-glass test is the gold standard for diagnosing chronic bacterial prostatitis (strong recommendation) 1
• This test requires a 10-fold higher bacterial count in expressed prostatic secretions (EPS) compared to midstream urine 1, 2
• Semen culture alone should not be used routinely for diagnosis 1
• Testing for atypical pathogens (Chlamydia trachomatis, Mycoplasma species) should be performed in chronic bacterial prostatitis 1

Why Semen Culture is Not Recommended as Routine

The guideline recommendation against routine semen culture is based on several factors:

• Semen culture alone lacks standardization and cannot differentiate between prostatic infection and contamination from the urethra or seminal vesicles 1
• The Meares-Stamey test provides superior localization of infection to the prostate specifically 1
• Semen culture has limited sensitivity (45%) when compared to the reference standard Meares-Stamey test 3

When Semen Culture May Have Limited Utility

While not routinely recommended, research suggests semen culture may occasionally be considered:

• A positive semen culture has high specificity (94%) and may suffice to start antibiotic treatment in symptomatic patients 3
• However, a negative semen culture does not rule out chronic bacterial prostatitis (sensitivity only 45%) 3
• Some studies suggest semen culture has higher sensitivity than EPS alone for Gram-negative organisms (97% vs 82.4%), but this does not override guideline recommendations against routine use 4

Recommended Diagnostic Algorithm

For suspected acute bacterial prostatitis:

1. Obtain midstream urine culture (not semen) 1
2. Collect blood cultures if febrile 1
3. Avoid prostatic massage 1

For suspected chronic bacterial prostatitis:

1. Perform the Meares-Stamey 2- or 4-glass test as the primary diagnostic method 1
2. Test for atypical pathogens (Chlamydia, Mycoplasma) 1
3. Do not rely on semen culture alone 1

Common Pitfall to Avoid

Do not order semen culture as a standalone test for prostatitis diagnosis. The 2024 EAU guidelines are clear that microbiological analysis of ejaculate alone should not be performed routinely for chronic bacterial prostatitis diagnosis. 1 If microbiological confirmation is needed, use the Meares-Stamey test instead. 1