What is prostatitis?

What is Prostatitis?

Prostatitis is an inflammation and/or infection of the prostate gland that affects approximately 9.3% of men in their lifetime, presenting as distinct clinical entities that require different diagnostic and treatment approaches. 1, 2

Classification and Clinical Forms

Prostatitis encompasses four distinct categories, each with unique characteristics:

Acute Bacterial Prostatitis (ABP)

• Represents a urinary tract infection involving the prostate, typically presenting with fever, chills, and systemic symptoms 2
• Caused by gram-negative bacteria in 80-97% of cases, most commonly Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa 1, 2
• Gram-positive organisms (Staphylococcus aureus, Enterococcus species, Group B streptococci) account for the remaining cases 1
• Pathogens migrate from the urethra or bladder in up to 90% of cases 1

Chronic Bacterial Prostatitis (CBP)

• Defined as persistent bacterial infection of the prostate, typically manifesting as recurrent urinary tract infections from the same bacterial strain 2
• Up to 74% of cases are due to gram-negative organisms, particularly E. coli, with other pathogens including Proteus mirabilis, Enterobacter species, and Serratia marcescens 1
• Fewer than 10% of all prostatitis cases are confirmed to have bacterial infection 1

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

• The most prevalent form of prostatitis and the least understood 3
• Presents as pelvic pain or discomfort for at least 3 months, associated with urinary symptoms such as frequency 2
• Not caused by a culturable infectious agent, requiring different management focused on symptom relief rather than antimicrobials 1
• Diagnosed by exclusion when evaluation does not identify infection, cancer, urinary obstruction, or retention 2

Asymptomatic Inflammatory Prostatitis

• An incidental finding in patients being evaluated for other urologic conditions 4

Clinical Presentation

Symptoms of Bacterial Prostatitis

• Non-specific urological symptoms including hematuria, increased urinary frequency, difficulty voiding 5
• Pain patterns: abdominal, lumbar, suprapubic, rectal, or perineal discomfort 5, 6
• Systemic features in acute cases: fever, chills, malaise 2

Symptoms of CP/CPPS

• Chronic pelvic pain lasting ≥3 months as the defining feature 2
• Urinary symptoms including frequency and urgency 2
• Sexual discomfort and dysfunction 3

Diagnostic Approach

For Acute Bacterial Prostatitis

• Avoid prostatic massage or vigorous digital rectal examination due to risk of bacteremia (strong recommendation) 5, 1
• Obtain midstream urine dipstick to check nitrite and leukocytes 5
• Collect midstream urine culture to identify causative organisms and guide antibiotic therapy 5, 1
• Draw blood cultures and complete blood count, especially in febrile patients 5, 1
• Consider transrectal ultrasound in selected cases to rule out prostatic abscess 5, 1

For Chronic Bacterial Prostatitis

• Perform the Meares-Stamey 2- or 4-glass test (strong recommendation), which includes first-void urine, midstream urine, expressed prostatic secretions, and post-massage urine 5, 1, 7
• A positive result requires a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine 1
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species 5, 1, 7
• Do not routinely perform microbiological analysis of ejaculate alone 5

For CP/CPPS

• Diagnosis is based on exclusion of other urologic conditions after comprehensive evaluation 2
• Use the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure symptom severity (scale 0-43), with a 6-point change considered clinically meaningful 2

Common Pitfalls

• Never perform prostatic massage in suspected acute bacterial prostatitis, as this can precipitate bacteremia and sepsis 5, 1
• Do not assume all prostatitis is infectious—the majority of cases (>90%) are not bacterial and will not respond to antibiotics 1
• Recognize that CP/CPPS may respond to non-prostate-centered treatments such as physical therapy, myofascial trigger point release, and relaxation techniques rather than antimicrobials 3
• Understand that proper classification is essential, as the four types require vastly different treatment approaches 3, 6