B-QuiCK: Bacterial prostatitis
Acute bacterial prostatitis
Assessment and diagnosis
Symptoms consistent with acute bacterial prostatitis include: pelvic or genitourinary pain (e.g. perineal pain, rectal pain, pain during or after ejaculation), and lower urinary tract symptoms such as urgency, dysuria, hesitancy, incomplete bladder emptying. Systemic symptoms may also be reported, e.g. nausea and vomiting with fever.
Physical examination and relevant investigations include:
- Assessment of temperature, heart rate, blood pressure and other observations, depending on the patient’s clinical condition, an abdominal examination and an examination of the external genitalia for features such as discharge, swelling, tenderness
- A digital rectal exam (DRE) can be considered (a tender, enlarged and “boggy” prostate gland is common)
- Mid-stream urine (MSU) for culture and susceptibility testing to support the diagnosis and guide antibiotic selection
- First void urine sample if a STI pathogen is suspected
- Investigating PSA is not recommended during acute infection as levels may be temporarily elevated
Differential diagnoses include: UTI, STI, acute pyelonephritis, epididymitis and/or orchitis, benign prostatic hyperplasia (BPH), urinary obstruction, e.g. cancer or calculi, proctitis, prostate cancer.
Red flags for emergency department or acute urology referral:
- Severe systemic symptoms and signs indicative of sepsis
- Acute urinary retention
Management
Empiric antibiotic treatment is recommended for all patients with suspected acute bacterial prostatitis:
- Trimethoprim, alone or in combination with sulfamethoxazole, is first-line treatment and should be prescribed for at least 14 days
- Review the patient within 48 hours and then 14 days after initiating treatment
- Consider switching to ciprofloxacin if MSU results indicate the causative pathogen is not sensitive to the prescribed antibiotic
- Stop antibiotic treatment after 14 days if symptoms have resolved, or consider an additional 14 days of treatment depending on the patient’s symptoms, signs and any additional test results, if applicable
- Tailor symptomatic treatment to the individual patient, e.g. paracetamol or NSAIDs for genitourinary pain or doxazosin for obstructive lower urinary tract symptoms
- Monitor patients with significant co-morbidities, e.g. diabetes or immunocompromise, closely to confirm their symptoms are improving, and have a lower threshold for referral
- Patients who experience a recurrence of symptoms following initial treatment may require an extended course of antibiotics, i.e. more than four weeks
- Repeat urine culture to confirm presence of the same organism and use susceptibility testing to guide any changes to antibiotic choice
Oral antibiotic options for the management of patients with mild to moderate acute bacterial prostatitis in primary care
| Antibiotic choice |
Dose |
| First-line: |
|
| Trimethoprim; OR |
300 mg, once daily, for two to four weeks |
| Trimethoprim + sulfamethoxazole |
960 mg, twice daily, for two to four weeks |
| Second-line: |
|
| Ciprofloxacin (only if known to be susceptible) |
500 mg, twice daily, for four weeks |
N.B. Some regional guidelines differ in antibiotic recommendations for acute bacterial prostatitis (e.g. cefalexin as a first-line option). This may be due to local resistance and sensitivity patterns and choices should not be routinely used in other regions. Check for local advice (e.g. HealthPathways) and follow corresponding empiric treatment recommendations, if available.
Chronic bacterial prostatitis
Assessment and diagnosis
Symptoms are similar to acute bacterial prostatitis, but continue for three months or longer, and are often milder and more variable:
- People may be asymptomatic between episodes
- Some level of genitourinary pain is expected
- Systemic symptoms are rare but possible
- Sexual dysfunction or psychological symptoms, e.g. anxiety or depression, can develop
Recommended examination and investigations are the same as for evaluating a patient with acute bacterial prostatitis, however, findings are frequently normal.
Management
- Antibiotic options recommended for chronic bacterial prostatitis are the same as those used for acute infection but should be prescribed for four to six weeks (see above)
- A longer duration (e.g. up to 12 weeks) may be necessary in some patients if symptoms do not completely resolve
- Symptom specific treatments should also be prescribed as necessary, e.g. paracetamol, NSAIDs, doxazosin
- Effective symptom management and reassurance that their condition can be managed may help to reduce or alleviate symptoms of anxiety and depression
- Repeat the urine culture before prescribing another course of antibiotics if relapse or recurrence of symptoms occurs
- Consider prescribing a longer duration of treatment, e.g. six weeks instead of four weeks, if the previous antibiotic was initially effective or change the antibiotic (according to susceptibility testing)
- Patients who remain symptomatic following two courses of antibiotics should be discussed with a urologist
