Prostatitis

Types

1. Acute Bacterial Prostatitis

   • Sudden onset, systemic symptoms (fever, chills)

   • Positive urine culture (typical pathogens: E. coli, other Enterobacteriaceae)

2. Chronic Bacterial Prostatitis

   • Recurrent UTIs, often fewer systemic symptoms

   • Positive prostatic fluid culture; may have normal or mildly elevated WBC in urine

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

   • Pelvic pain >3 months, no bacterial growth on culture

   • Inflammatory (white cells in semen/prostatic fluid) or non-inflammatory

4. Asymptomatic Inflammatory Prostatitis

   • No symptoms

   • Incidental finding of prostatic inflammation (e.g. on biopsy)

Symptoms (General)

• LUTS: Dysuria, frequency, urgency, weak stream, hesitancy, dribbling

• Systemic: Fevers, chills, sweats (mainly in acute cases)

• Pain: Perineal, pelvic, lower back pain, painful ejaculation

• Tender Prostate on DRE (digital rectal exam)

• Haematospermia / Haematuria occasionally

• Acute urinary retention if severe swelling or pain

Examination

• DRE: Prostate is very tender in acute bacterial prostatitis (avoid vigorous palpation to prevent bacteraemia).

• Abdomen: Check for suprapubic tenderness if concern for urinary retention.

Investigations

1. Urinalysis & Urine Culture: Essential to identify bacterial cause, especially in acute/chronic bacterial prostatitis.

2. Blood Cultures: If systemic infection or sepsis suspected.

3. PSA: May be elevated; best avoided during acute infection due to transient elevation.

4. Imaging: TRUS (transrectal ultrasound), CT, or MRI if prostatic abscess suspected.

5. Two-Glass Test (Pre- and Post-Prostate Massage Urine Culture): Used in chronic bacterial prostatitis to identify pathogens in post-massage urine.

Management

Acute Bacterial Prostatitis

• Non-Severe (Outpatient)

  • Trimethoprim 300 mg daily for 2 weeks (first-line)

  • Cephalexin 500 mg QID for 2 weeks (alternative)

  • Fluoroquinolones (ciprofloxacin 500 mg BD / norfloxacin 400 mg BD) if resistant or culture-sensitive

  • Confirm resolution with repeat urine culture 1 week post-treatment

• Severe (Fever >38°C, sepsis features)

  • IV Therapy: Gentamicin + amoxicillin 2 g IV Q6H (or ampicillin)

  • If gentamicin is contraindicated: Ceftriaxone 1 g IV daily or cefotaxime 1 g IV Q8H

  • Step down to oral therapy once stable; total duration ~4 weeks

Chronic Bacterial Prostatitis

• First-Line:

  • Ciprofloxacin 500 mg BD or Norfloxacin 400 mg BD for 4 weeks

• Alternative:

  • Trimethoprim 300 mg daily for 4 weeks

• Avoid repeat antibiotic courses if asymptomatic with no positive culture.

Complications

• Acute Urinary Retention

• Chronic Bacterial Prostatitis

• Prostatic Abscess (requires imaging ± drainage)

• Sepsis / Bacteraemia

• Fistula formation (rare)

• Osteomyelitis (spread to spine or SI joints)

Acute vs. Chronic Prostatitis

Treatment Approach

• Acute: Empirical antibiotics; IV if severe or septic.

• Chronic: Longer duration oral antibiotics (4 weeks); only treat if symptomatic with positive culture.

Note

• Haematuria or haematospermia are symptoms, not complications.

• PSA doubling in 12 months may indicate cancer or prostatitis.

• Prostatic Abscess: Imaging confirmation, may require drainage.