What is the appropriate evaluation and management of prostatitis?

Evaluation and Management of Prostatitis

Initial Diagnostic Approach

The evaluation of prostatitis begins with classifying the condition into one of four categories—acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), or asymptomatic—because each requires distinct diagnostic and therapeutic strategies. 1, 2

Essential History Components

• Duration and character of symptoms: Acute onset with fever/chills suggests acute bacterial prostatitis; pelvic pain ≥3 months with urinary symptoms indicates CP/CPPS 1, 2
• Urinary symptoms: Frequency, urgency, dysuria, incomplete emptying, weak stream 3
• Systemic symptoms: Fever, chills, malaise (present in acute bacterial prostatitis) 1
• Sexual function and pain: Ejaculatory pain, erectile dysfunction 3
• Recurrent urinary tract infections: Suggests chronic bacterial prostatitis 1
• Previous genitourinary surgeries or instrumentation 3

Physical Examination Findings

• Digital rectal examination (DRE): Assess for prostate tenderness, warmth, boggy texture (acute bacterial), firmness, or nodularity 3, 2
• Caution: Vigorous prostatic massage is contraindicated in acute bacterial prostatitis due to risk of bacteremia 2
• Suprapubic examination: Palpable bladder suggests urinary retention 4

Laboratory Evaluation

For suspected bacterial prostatitis (acute or chronic):

• Midstream urine culture before antibiotics: Essential for identifying causative organism 2, 5
• Complete urinalysis with microscopy: Detect pyuria, hematuria 3
• Pre- and post-prostatic massage urine specimens (Meares-Stamey technique): For chronic bacterial prostatitis diagnosis, comparing bacterial counts before and after massage 5
• Post-void residual measurement: Rule out urinary retention 1

For CP/CPPS:

• Urine culture to exclude infection 1
• Post-void residual to exclude retention 1
• NIH Chronic Prostatitis Symptom Index (NIH-CPSI): Baseline score (0-43 scale) to track treatment response; 6-point change is clinically meaningful 1

Management by Classification

Acute Bacterial Prostatitis

First-line therapy is broad-spectrum antibiotics for 2-4 weeks, with 92-97% success rate. 1

Antibiotic selection:

• Febrile or systemically ill patients: Intravenous piperacillin-tazobactam OR ceftriaxone initially 1
• Mild-moderate cases: Oral ciprofloxacin 500mg twice daily OR levofloxacin 500-750mg daily 1
• Duration: Minimum 2-4 weeks 1, 5

Causative organisms: Gram-negative bacteria (E. coli, Klebsiella, Pseudomonas) in 80-97% of cases 1

Critical pitfall: Failure to recognize acute bacterial prostatitis can lead to prostate abscess requiring surgical drainage, progression to chronic bacterial prostatitis, or overlooking underlying conditions (benign prostatic hyperplasia, urinary stones, malignancy) 6

Chronic Bacterial Prostatitis

First-line therapy is fluoroquinolones for minimum 4 weeks. 1, 5

Antibiotic regimen:

• Levofloxacin 500mg daily OR ciprofloxacin 500mg twice daily for ≥4 weeks 1, 5
• Ofloxacin is an alternative due to favorable prostatic penetration 5
• If improvement occurs at 2-4 weeks, continue for additional 2-4 weeks to achieve eradication 5
• If no improvement by 2-4 weeks, stop and reconsider diagnosis 5

Causative organisms: Up to 74% are gram-negative (E. coli most common) 1

Diagnostic confirmation: Meares-Stamey technique showing persistent same-strain bacteria in post-prostatic massage specimens 5

Important caveat: Do not treat empirically for 6-8 weeks without assessing effectiveness at 2-4 weeks 5

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

CP/CPPS is a diagnosis of exclusion requiring pelvic pain ≥3 months with negative urine cultures and no evidence of infection, cancer, obstruction, or retention. 1, 2

First-line therapy for patients with urinary symptoms:

• α-blockers (tamsulosin 0.4mg daily OR alfuzosin 10mg daily): Most effective treatment with NIH-CPSI score improvement of 4.8-10.8 points versus placebo 1

Second-line therapies (modest benefit):

• NSAIDs (ibuprofen): NIH-CPSI improvement 1.7-2.5 points 1
• Pregabalin: NIH-CPSI improvement 2.4 points 1
• Pollen extract: NIH-CPSI improvement 2.49 points 1

Treatment duration: Assess response at 2-4 weeks for α-blockers 4

Key distinction: Unlike bacterial prostatitis, antibiotics are not indicated unless there is clinical, bacteriological, or immunological evidence of infection 5

Asymptomatic Prostatitis

No treatment required; typically an incidental finding during evaluation for other urologic conditions 2, 7

When to Refer to Urology

Immediate urologic referral is indicated for: 4

• DRE suspicious for prostate cancer
• Hematuria (gross or microscopic)
• Abnormal PSA (if obtained and patient has >10-year life expectancy)
• Recurrent infections despite appropriate antibiotic therapy
• Palpable bladder or urinary retention
• Neurological disease affecting voiding
• Pain unresponsive to initial management
• Suspected prostate abscess (fluctuance on DRE, persistent fever despite antibiotics)

Common Pitfalls to Avoid

• Do not perform vigorous prostatic massage in acute bacterial prostatitis—risk of bacteremia 2
• Do not initiate antibiotics before obtaining urine culture in non-febrile patients 5
• Do not continue antibiotics beyond 2-4 weeks without documented improvement 5
• Do not prescribe antibiotics for CP/CPPS without evidence of infection—α-blockers are first-line 1
• Do not overlook underlying urologic pathology (stones, obstruction, malignancy) that may predispose to prostatitis 6
• Do not obtain PSA during acute prostatitis—it will be falsely elevated 3