What further evaluation or treatment is recommended for a 50-year-old patient with prostate tenderness and dysuria, undergoing urinalysis, for suspected prostatitis?

Evaluation of Suspected Acute Bacterial Prostatitis

In addition to urinalysis, you should obtain a urine culture, perform a digital rectal examination (DRE), and assess for systemic signs of infection including fever, as these are essential for confirming acute bacterial prostatitis and guiding antibiotic selection. 1, 2

Essential Additional Examination Components

Digital Rectal Examination (DRE)

• Perform a DRE to assess for a tender, enlarged, or boggy prostate, which are characteristic findings in acute bacterial prostatitis 3, 2
• The physical examination should also include assessment of the suprapubic area to rule out bladder distention and evaluate for urinary retention 4
• Avoid vigorous prostatic massage during acute infection, as this can precipitate bacteremia and worsen systemic symptoms 1

Systemic Assessment

• Check for fever, chills, rigors, or signs of sepsis, as acute bacterial prostatitis frequently presents with systemic symptoms and may require hospitalization 1, 2
• Assess whether the patient can voluntarily urinate, as urinary retention is common and may require catheterization 2
• Evaluate for nausea, emesis, or inability to tolerate oral intake, which would necessitate intravenous therapy 2

Required Laboratory Studies

Urine Culture

• Obtain urine culture in all patients with suspected acute bacterial prostatitis to identify the causative organism and determine antibiotic sensitivity patterns 1, 2
• Gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) cause 80-97% of acute bacterial prostatitis cases 1

Additional Testing Based on Severity

• Consider complete blood count and blood cultures if the patient appears systemically ill or has risk factors for sepsis 2
• Serum PSA should not be obtained during acute infection, as it will be artificially elevated 4

Immediate Treatment Considerations

Antibiotic Therapy

• Initiate broad-spectrum antibiotics immediately after obtaining cultures - first-line options include oral ciprofloxacin, intravenous ceftriaxone plus doxycycline, or piperacillin-tazobactam for 2-4 weeks 1, 2
• Fluoroquinolones (ciprofloxacin, levofloxacin) achieve 92-97% success rates when prescribed for 2-4 weeks 1

Hospitalization Criteria

• Hospitalize patients who are systemically ill, unable to urinate voluntarily, unable to tolerate oral intake, or have risk factors for antibiotic resistance 2
• These patients require broad-spectrum intravenous antibiotics and close monitoring 2

Critical Pitfalls to Avoid

• Do not delay antibiotic therapy while waiting for culture results - acute bacterial prostatitis can rapidly progress to sepsis and requires immediate empiric treatment 1, 2
• Do not perform vigorous prostatic massage during the acute phase, as this can cause bacteremia 1
• Do not assume this is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) - the presence of prostate tenderness and dysuria with acute onset strongly suggests bacterial infection requiring antibiotics, not the symptom management approach used for CP/CPPS 1, 5
• Ensure adequate treatment duration of 2-4 weeks - shorter courses lead to treatment failure and progression to chronic bacterial prostatitis 1, 2