Symptoms of Prostatitis
Prostatitis presents with pelvic pain or discomfort lasting at least 3 months, typically localized to the perineum, suprapubic region, testicles, or tip of the penis, often accompanied by urinary symptoms including frequency, urgency, and dysuria. 1, 2
Clinical Presentation by Type
Acute Bacterial Prostatitis
- Fever or chills with acute urinary tract infection symptoms including dysuria, urinary frequency, and urgency 2
- Tender prostate on digital rectal examination 3
- Systemic symptoms of infection with rapid onset 2
- Caused by gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) in 80-97% of cases 2
Chronic Bacterial Prostatitis
- Recurrent urinary tract infections from the same bacterial strain 2, 4
- Pelvic pain and lower urinary tract symptoms that are less acute than bacterial prostatitis 4
- Up to 74% caused by gram-negative organisms, particularly E. coli 2
- May present with variety of pelvic pain and voiding symptoms 3
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
This accounts for more than 90% of all chronic prostatitis cases and has the most variable presentation 4:
Pain characteristics:
- Pelvic pain or discomfort for at least 3 months (defining feature) 1, 2
- Pain localized to perineum, suprapubic region, testicles, or tip of penis 1, 2
- Pain exacerbated by urination or ejaculation 1
- Many patients describe "pressure" rather than "pain" 1
Urinary symptoms:
- Urinary frequency 2
- Urinary urgency (though patients experience more constant urge to void to relieve pain) 1
- Dysuria 4
- Nocturia 1
- Sense of incomplete bladder emptying 1
Critical Diagnostic Distinctions
Important overlap exists between CP/CPPS and interstitial cystitis/bladder pain syndrome (IC/BPS), particularly in men whose pain is perceived to be bladder-related 1. Some patients meet criteria for both conditions and may require combined treatment approaches 1.
The European Association of Urology emphasizes that fewer than 10% of prostatitis cases are confirmed to have bacterial infection, making the distinction between bacterial and non-bacterial forms critical 5.
Common Pitfall
Persistence of pain, discomfort, and irritative voiding symptoms beyond 3 months should alert clinicians to the possibility of chronic prostatitis/chronic pelvic pain syndrome rather than simple urethritis or acute infection 5. Do not dismiss patients who describe "pressure" rather than "pain" as this is common in CP/CPPS and IC/BPS 1.
Treatment Overview
Acute Bacterial Prostatitis
- Broad-spectrum intravenous or oral antibiotics (piperacillin-tazobactam, ceftriaxone, or ciprofloxacin) for 2-4 weeks with 92-97% success rate 2
- Do not perform prostatic massage due to risk of bacteremia 1
Chronic Bacterial Prostatitis
- Fluoroquinolones (levofloxacin or ciprofloxacin) for minimum 4 weeks as first-line therapy 5, 2
- If 4-6 weeks effective but symptoms recur, another course may be prescribed, possibly with alpha blockers or analgesics 4
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
- Alpha-blockers (tamsulosin, alfuzosin) as first-line therapy for CP/CPPS with urinary symptoms, with NIH-CPSI score improvement of -10.8 to -4.8 compared to placebo 2
- Anti-inflammatory drugs (ibuprofen) show modest benefit with NIH-CPSI score difference of -2.5 to -1.7 2
- Pregabalin shows NIH-CPSI score difference of -2.4 2
- Four to six weeks of antibiotics may be tried despite lack of confirmed infection 4
- Pelvic floor physical therapy and pain management techniques for refractory cases 4