Acute Prostatitis: Clinical Presentation and Diagnostic Workup
Acute bacterial prostatitis presents with acute pelvic pain, lower urinary tract symptoms (dysuria, frequency, urgency), and systemic features including fever, chills, and malaise, requiring immediate urine culture and blood work while strictly avoiding prostatic massage. 1
Clinical Symptoms
Cardinal Features
- Pelvic pain is the hallmark symptom, often acute in onset and may or may not be related to voiding 2, 3
- Lower urinary tract symptoms including dysuria, urinary frequency, urgency, and potentially urinary retention 3
- Systemic symptoms such as fever, chills, nausea, emesis, and malaise distinguish acute from chronic forms 3
Additional Presentations
- Suprapubic pain or tenderness can accompany bladder involvement 4
- Ejaculatory pain may be present 5
- Hematuria or hematospermia occur in some cases, though hematuria is not typical and should prompt consideration of alternative diagnoses 2, 6
- Up to 20% may lack classic bladder symptoms, presenting primarily with fever and flank pain, making diagnosis more challenging 4
Physical Examination Findings
Critical Examination Technique
- Perform gentle digital rectal examination (DRE) to assess for a tender, enlarged, or boggy prostate 3
- Never perform prostatic massage or vigorous DRE in suspected acute bacterial prostatitis—this is a strong contraindication due to risk of bacteremia and sepsis 1, 4, 7
- Check for nodules during DRE 2
- Examine for suprapubic tenderness on abdominal examination 3
Essential Investigations
First-Line Diagnostic Tests (Obtain Before DRE)
Urine Studies:
- Midstream urine dipstick to check for nitrites and leukocytes 1
- Midstream urine culture is the primary diagnostic test to identify causative organisms (E. coli in 64% of cases) and guide antibiotic therapy 1, 4, 7
Blood Work:
- Blood cultures should be obtained in all febrile patients 1, 7
- Complete blood count to assess for leukocytosis 1, 7
Imaging Studies
Transrectal Ultrasound:
- Perform in selected cases to rule out prostatic abscess, particularly if symptoms persist despite appropriate antibiotics or if the patient appears systemically toxic 1, 7, 6
- This is critical because if an abscess develops, antibiotics alone are insufficient—drainage is mandatory for source control 7
Tests to AVOID in Acute Bacterial Prostatitis
- Do NOT perform prostatic massage (strong recommendation from European Association of Urology) 1, 4, 7
- Do NOT perform the Meares-Stamey 2- or 4-glass test in acute cases—this is reserved for chronic bacterial prostatitis diagnosis 1, 8
- Do NOT routinely perform microbiological analysis of ejaculate alone 1
Microbiological Considerations
Common Pathogens
- Gram-negative bacteria cause 80-97% of cases, with E. coli being the most common, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa 4
- Gram-positive bacteria including Staphylococcus aureus, Enterococcus species, and Group B streptococci are less common causes 4
- In men under 35 years, consider atypical pathogens including Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species 4, 7
Route of Infection
- In up to 90% of cases, pathogens migrate from the urethra or bladder, highlighting the importance of considering the entire urinary tract 4, 6
Common Diagnostic Pitfalls
- Hematuria presence should prompt evaluation for alternative diagnoses (30-40% association with urinary tract malignancy), as it is not a reliable indicator of isolated acute bacterial prostatitis 6
- Consider upper urinary tract infection (pyelonephritis with prostatic involvement) when fever, flank pain, and urinary symptoms coexist 4, 6
- Avoid delaying empiric antibiotics while awaiting culture results in systemically ill patients 7
- Failure to identify prostatic abscess leads to treatment failure—maintain high suspicion if symptoms persist beyond 48-72 hours of appropriate therapy 7