What is the appropriate workup and treatment for a patient presenting with symptoms of prostatitis, including pelvic pain, dysuria, and urinary frequency?

Prostatitis Workup and Treatment

Initial Clinical Assessment

For a patient presenting with pelvic pain, dysuria, and urinary frequency, immediately distinguish between acute bacterial prostatitis (which presents with fever/chills and a tender prostate) versus chronic presentations, as this fundamentally changes your diagnostic and treatment approach. 1

History - Key Elements to Elicit

• Duration of symptoms: Acute (<4 weeks) versus chronic (≥3 months) determines the category of prostatitis 1, 2
• Fever and chills: Present in acute bacterial prostatitis (80-97% caused by gram-negative bacteria like E. coli, Klebsiella, Pseudomonas) 1
• Pain location: Perineum, suprapubic region, testicles, or tip of penis suggests chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) 2
• Pain triggers: Exacerbation with urination or ejaculation is characteristic of CP/CPPS 2
• Recurrent UTIs: Same bacterial strain suggests chronic bacterial prostatitis 1
• Sexual history: Assess risk for sexually transmitted urethritis (N. gonorrhoeae, C. trachomatis) in men <35 years 2
• Prior pelvic surgery: High rate in CP/CPPS patients 2

Physical Examination - Critical Findings

• Digital rectal examination (DRE):
  • Do NOT perform prostatic massage in suspected acute bacterial prostatitis due to bacteremia risk 2
  • Assess for prostate tenderness (acute bacterial prostatitis) 1
  • Evaluate for pelvic floor muscle spasm (CP/CPPS) 2
  • Check anal sphincter tone and lower extremity neuromuscular function 3
• Focused neurologic exam: Rule out cauda equina syndrome if bilateral radicular symptoms or progressive perineal sensory loss 2

Diagnostic Testing Algorithm

Mandatory Initial Tests

• Urinalysis and urine culture: Required in all cases to document infection or rule it out 2, 4, 1
• Post-void residual measurement: Rule out urinary retention, which complicates treatment 4
• For suspected urethritis (especially men <35 years sexually active):
  • Gram stain of urethral exudate (>5 PMNs per oil immersion field) 2
  • Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 2

Optional/Selective Tests

• Serum PSA: Offer to men with ≥10-year life expectancy if prostate cancer detection would change management, or if PSA may alter voiding symptom management 3
• Urine cytology: Consider in men with predominantly irritative symptoms 3
• Transrectal ultrasound or pelvic MRI: If ejaculatory duct obstruction suspected (low semen volume, acidic pH, azoospermia) 2
• Emergency MRI: If red flags for cauda equina syndrome present 2

Tests NOT Recommended

• Routine cystoscopy: Not indicated unless Hunner lesions suspected, hematuria present, history of bladder cancer, urethral stricture, or prior lower urinary tract surgery 4

Treatment by Prostatitis Category

Acute Bacterial Prostatitis

Initiate broad-spectrum antibiotics immediately for febrile UTI with acute prostatitis, which achieves 92-97% success rate. 1

• First-line therapy (choose one):
  • Intravenous piperacillin-tazobactam 1
  • Intravenous ceftriaxone 1
  • Oral ciprofloxacin 1
• Duration: 2-4 weeks 1, 5
• Avoid prostatic massage during acute phase 2

Chronic Bacterial Prostatitis

Fluoroquinolones for minimum 4 weeks are first-line therapy, as they penetrate prostatic tissue effectively. 2, 1

• First-line agents:
  • Levofloxacin for ≥4 weeks 2, 1
  • Ciprofloxacin for ≥4 weeks 2, 1
• Alternative: Trimethoprim-sulfamethoxazole (though fluoroquinolones preferred) 5
• Extended therapy: 6-12 weeks may be needed for complete eradication 5, 6
• Reassess at 2-4 weeks: If no improvement, stop and reconsider diagnosis; if improved, continue for additional 2-4 weeks 6
• Test for atypical pathogens: Include Chlamydia trachomatis and Mycoplasma species 2

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

CP/CPPS is a diagnosis of exclusion requiring negative urine cultures and ≥3 months of pelvic pain, with α-blockers as first-line therapy when urinary symptoms predominate. 2, 1

Diagnostic Criteria

• Pelvic pain/discomfort for ≥3 months 2, 1
• Negative urine cultures 2, 1
• No evidence of infection, cancer, obstruction, or retention 1
• Consider NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure severity (0-43 scale; 6-point change is clinically meaningful) 1

Critical Differential: Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

Strongly consider IC/BPS in men with bladder-related pain, as clinical characteristics overlap significantly with CP/CPPS and some patients meet criteria for both conditions. 2, 4

• IC/BPS features: Pain/pressure/discomfort related to bladder, frequency, nocturia, urgent desire to void 4, 7
• Dysuria persisting ≥6 weeks with negative cultures suggests IC/BPS 7
• Some patients require combined treatment approaches for both conditions 2, 4

Treatment Algorithm for CP/CPPS

First-line: α-blockers (when urinary symptoms present):

• Tamsulosin or alfuzosin 1
• NIH-CPSI score improvement: -10.8 to -4.8 versus placebo 1
• Note: α-blockers improve voiding but do not directly address ejaculatory dysfunction or libido 2

Second-line options (modest benefit):

• Anti-inflammatory drugs (ibuprofen): NIH-CPSI difference -2.5 to -1.7 1
• Pregabalin: NIH-CPSI difference -2.4 1
• Pollen extract: NIH-CPSI difference -2.49 1

For IC/BPS phenotype or pelvic floor dysfunction:

• Manual physical therapy targeting pelvic floor trigger points, muscle contractures, painful scars 4, 7
• Amitriptyline 10 mg at bedtime, titrate to 75-100 mg if tolerated 4, 7
• Behavioral modifications: Avoid bladder irritants, stress management, meditation 4, 7
• Multimodal pain management with non-opioid alternatives preferred 4

Avoid:

• Antimuscarinics in patients with cardiovascular instability or hypotension 7
• Beta-3 agonists (mirabegron) preferred over antimuscarinics if overactive bladder medication needed 7

Multimodal Approach for Refractory CP/CPPS

Use UPOINT phenotyping to guide selection of multimodal therapy when single-agent treatment fails. 8

• Stepwise approach combining α-blockers, anti-inflammatories, physical therapy, and neuroleptics often successful 8
• Long-term suppressive antibiotic therapy may be useful in selected patients with recurrent bacteriuria 5

Common Pitfalls to Avoid

• Do not perform prostatic massage in acute bacterial prostatitis - risk of bacteremia 2
• Do not treat male UTIs empirically without culture - represents complicated UTI requiring documented pathogen identification 4
• Do not use short-course (3-5 day) antibiotics in men - minimum 14 days required when prostatitis cannot be excluded 4
• Do not dismiss patients describing "pressure" rather than "pain" - common in IC/BPS and CP/CPPS 2, 7
• Do not continue antibiotics 6-8 weeks without reassessing effectiveness 6
• Recognize that CP/CPPS and IC/BPS have overlapping presentations - some patients meet criteria for both and require combined treatment 2, 4