How does prostatitis typically present in men, and what are the differences among its subtypes?

Presentation of Prostatitis

Prostatitis presents differently based on its subtype: acute bacterial prostatitis manifests with sudden-onset fever, chills, severe pelvic/perineal pain, and obstructive voiding symptoms, while chronic bacterial prostatitis causes recurrent urinary tract infections with persistent pelvic pain, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) presents with prolonged pelvic pain and urinary symptoms without documented bacterial infection. 1, 2, 3

Acute Bacterial Prostatitis (NIH Category I)

Cardinal Symptoms

• Systemic manifestations: Fever, chills, rigors, malaise, and in severe cases hypotension suggesting progression to urosepsis (occurs in 7.3% of cases) 1, 2, 3
• Genitourinary pain: Severe perineal, suprapubic, lower back, or rectal pain; pain may radiate to the testicles or tip of penis 4, 1
• Voiding symptoms: Dysuria, urinary frequency, urgency, nocturia, and potential acute urinary retention due to prostatic swelling blocking urinary flow 1, 2, 5
• Additional features: Pain with ejaculation, obstructive voiding symptoms, and occasionally hematuria 1, 3

Physical Examination Findings

• Digital rectal examination reveals an exquisitely tender, swollen, boggy prostate 1, 5
• Critical caveat: Avoid vigorous prostatic massage or aggressive digital rectal examination due to risk of inducing bacteremia and sepsis [1, @11@]
• Suprapubic tenderness may accompany bladder involvement 1

Diagnostic Considerations

• Up to 20% of patients may lack classic bladder symptoms, making diagnosis more challenging 1
• The condition can mimic acute pyelonephritis, particularly when fever and flank pain predominate 1

Chronic Bacterial Prostatitis (NIH Category II)

Characteristic Pattern

• Recurrent urinary tract infections with the same uropathogen documented on culture, distinguishing it from other prostatitis subtypes 2, 3, 6
• Episodes of bacteriuria separated by asymptomatic intervals 3

Symptom Complex

• Persistent or intermittent pelvic pain affecting the perineum, suprapubic region, lower back, testicles, or penile tip 4, 2
• Voiding symptoms including frequency, urgency, dysuria, and sensation of incomplete bladder emptying 4, 3
• Painful ejaculation is common 2, 3
• Symptoms typically present for more than 3 months 2, 6

Diagnostic Gold Standard

• Meares-Stamey 4-glass test demonstrates a 10-fold higher bacterial count in expressed prostatic secretions compared to midstream urine, with 90% accuracy in localizing infection 1, 2, 3
• A simplified 2-specimen variant (midstream urine and expressed prostatic secretions only) can be used 1

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (NIH Category III)

Defining Features

• Pelvic pain for more than 3 of the previous 6 months without documented urinary tract infections from uropathogens 2, 6
• This is the most common form, affecting 10-15% of the male population and accounting for nearly 2 million outpatient visits annually 2

Clinical Presentation

• Pain in the perineum, suprapubic region, testicles, or tip of penis, often exacerbated by urination or ejaculation 4
• Urinary symptoms: frequency, urgency, sense of incomplete emptying 4, 2
• Pain may be described as "pressure" or "discomfort" rather than frank pain—many patients actually deny "pain" when asked directly 4
• Pain often worsens with specific foods/drinks, bladder filling, and improves with urination 4
• Significant sexual dysfunction including dyspareunia and reduced libido 4

Key Distinction

• No culturable bacterial infection distinguishes CP/CPPS from chronic bacterial prostatitis 1, 2
• Up to 50% show signs of urethral inflammation without detectable microorganisms, suggesting prior sexually transmitted infections may trigger persistent inflammatory changes 1

Asymptomatic Inflammatory Prostatitis (NIH Category IV)

• By definition asymptomatic, discovered incidentally during evaluation for infertility or prostate cancer 2, 5
• Characterized by prostatic inflammation on biopsy or elevated white blood cells in prostatic secretions without symptoms 5, 6
• Clinical significance remains unknown and typically left untreated 2, 5

Special Considerations in Men

Overlap with Interstitial Cystitis/Bladder Pain Syndrome

• Men with bladder-perceived pain should be strongly considered for IC/BPS diagnosis 4
• Some men meet criteria for both CP/CPPS and IC/BPS, requiring combined treatment approaches 4
• Early symptoms may begin with mild dysuria or urgency, progressing to severe frequency, nocturia, and suprapubic pain 4

Age-Related Presentations

• In men under 35 years, consider sexually transmitted pathogens including Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma species 1
• Acute bacterial prostatitis is rare in healthy adult men without underlying disease (benign prostatic hyperplasia, urinary stones, sexually transmitted diseases, or malignancy) 7

Common Pitfalls

• Overlooking acute bacterial prostatitis in non-urologic settings can lead to treatment failure, progression to prostatic abscess requiring surgery, or transition to chronic prostatitis requiring lifelong management 7
• Stopping antibiotics prematurely in acute bacterial prostatitis can result in chronic bacterial prostatitis 1
• Failure to evaluate and treat sexual partners perpetuates recurrent infections 1