What is the recommended workup for an adult male presenting with pelvic or perineal discomfort, dysuria, urinary frequency, urgency, hesitancy, painful ejaculation, or fever suggestive of prostatitis?

Workup for Prostatitis

The workup for prostatitis begins with history, physical examination including digital rectal exam (DRE), urinalysis, and urine culture—with the specific diagnostic approach determined by whether the presentation suggests acute bacterial, chronic bacterial, or chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). 1, 2, 3

Initial Clinical Assessment

History Taking

• Document the nature, duration, and severity of genitourinary symptoms including pelvic/perineal pain, dysuria, urinary frequency, urgency, hesitancy, painful ejaculation, and presence of fever or chills 4, 1, 2
• Assess for pain location specifically: perineum, suprapubic region, testicles, or tip of penis—pain at the penile tip during urination is characteristic of CP/CPPS 1
• Determine if pain is exacerbated by urination or ejaculation, and whether patients describe "pressure" rather than "pain" (common in CP/CPPS) 1
• Inquire about symptom duration: acute bacterial prostatitis presents with sudden onset, while CP/CPPS requires ≥3 months of pelvic pain or discomfort 1, 2
• Review sexual history and recent urological procedures (catheterization, cystoscopy, transrectal biopsy) as these increase risk for bacterial prostatitis 2, 3
• Document previous surgical procedures affecting the genitourinary tract, as prior pelvic surgery is common in CP/CPPS patients 4, 1

Physical Examination

• Assess the suprapubic area to rule out bladder distention 4
• Evaluate overall motor and sensory function focused on the perineum and lower limbs 4, 1
• Check anal sphincter tone during digital rectal examination 1
• Perform DRE to evaluate the prostate for approximate size, consistency, shape, tenderness, and abnormalities suggestive of cancer 4, 3
• In acute bacterial prostatitis, the prostate will be tender, enlarged, or boggy 3
• DRE may reveal pelvic floor muscle spasm in CP/CPPS 1

Critical Pitfall: Do NOT perform prostatic massage in acute bacterial prostatitis due to risk of bacteremia 1

Essential Laboratory Testing

Urinalysis and Culture

• Obtain urinalysis using dipstick tests to check for hematuria, proteinuria, pyuria, glucosuria, ketonuria, and positive nitrite 4, 1
• Urine culture and susceptibility testing is mandatory in all male patients with suspected prostatitis, as men represent complicated UTIs with broader microbial spectrum and higher antimicrobial resistance 5, 2, 3
• For chronic bacterial prostatitis diagnosis, use the Meares and Stamey four-glass test to confirm prostatic localization of infection 6

Additional Diagnostic Studies

• Measure post-void residual (PVR) to rule out urinary retention, as incomplete bladder emptying is a common complicating factor in men 4, 5
• Consider frequency-volume charts (voiding diary) for 3 consecutive 24-hour periods, particularly when nocturia is the dominant symptom 4
• Obtain serum PSA only if life expectancy is >10 years and prostate cancer detection would modify management 4, 1
• Consider urine cytology in men with predominantly irritative symptoms 1

Specialized Testing for Urethritis (if suspected)

• Obtain Gram-stained smear of urethral exudate or intraurethral swab (>5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1
• Perform culture or nucleic acid amplification test on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1

Categorization by Prostatitis Type

Acute Bacterial Prostatitis

• Diagnosis is predominantly clinical based on sudden onset of fever/chills, pelvic pain, and urinary symptoms with tender prostate on DRE 2, 3
• Urine culture identifies causative organism (80-97% gram-negative bacteria: E. coli, Klebsiella, Pseudomonas) 2, 3
• Additional labs based on severity: complete blood count, blood cultures if systemically ill, basic metabolic panel 3
• Radiography typically unnecessary unless complications suspected 3

Chronic Bacterial Prostatitis

• Defined as persistent bacterial infection presenting as recurrent UTIs from the same strain 2
• Requires documentation of prostatic localization via Meares and Stamey technique 6
• Up to 74% due to gram-negative organisms, particularly E. coli 2
• Test for atypical pathogens including Chlamydia trachomatis and Mycoplasma species 1

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

• Diagnosis of exclusion when evaluation does not identify infection, cancer, urinary obstruction, or retention 2
• Requires ≥3 months of pelvic pain/discomfort with negative urine cultures 1, 2
• Use NIH Chronic Prostatitis Symptom Index (NIH-CPSI) to measure symptom severity (scale 0-43, with 6-point change clinically meaningful) 2
• Strongly consider interstitial cystitis/bladder pain syndrome (IC/BPS) as clinical characteristics overlap significantly—some men meet criteria for both conditions 1, 5

When to Perform Cystourethroscopy

• NOT routine for CP/CPPS unless Hunner lesions suspected, hematuria present, history of bladder cancer, urethral stricture, or prior lower urinary tract surgery 5
• Perform before surgical intervention for stress urinary incontinence to assess for urethral and bladder pathology 4

Red Flags Requiring Urgent Evaluation

• Bilateral radicular symptoms or progressive perineal sensory loss warrant emergency MRI to exclude cauda equina syndrome 1
• Systemically ill patients, urinary retention, or inability to tolerate oral intake require hospitalization and broad-spectrum IV antibiotics 3
• Suspected prostate abscess (failure to respond to antibiotics within 48-72 hours) may require imaging and surgical drainage 7