Chronic Bacterial Prostatitis

Chronic bacterial prostatitis is a persistent or relapsing bacterial infection of the prostate, with symptoms lasting over 3 months and recurrent urinary infections with the same organism. It accounts for about 5 to 10% of prostatitis syndromes.

It is difficult to eradicate, and relapse is common. Treatment needs an antibiotic that penetrates prostatic tissue, given for long courses.

Pathophysiology. Organisms enter by reflux of infected urine into the prostatic ducts, by ascent from the urethra, or through the rectum. Prostatic calculi and obstruction harbour bacteria and protect them from antibiotics.

Organisms:

• Escherichia coli in about 75 to 80%, then Klebsiella, Proteus, Enterococcus faecalis and Pseudomonas.
• Chlamydia trachomatis, Ureaplasma and Mycoplasma, with a less certain role.

Risk factors are bladder outlet obstruction, urethral stricture, catheterisation or instrumentation, prostate biopsy, unprotected sex with infection, and diabetes or immunosuppression.

Recurrent cystitis with the same organism, perineal, suprapubic, testicular or penile pain, dysuria, frequency, weak stream, painful ejaculation, haemospermia and sexual dysfunction. Fever is usually absent between flares. The prostate may be normal, or slightly tender, boggy or indurated. Prostatic abscess or acute flare needs urgent treatment.

• Urinalysis and midstream culture, and first void urine nucleic acid tests for Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium.
• Meares-Stamey four glass test (or the simpler two glass pre- and post-massage test): first void (VB1), midstream (VB2), expressed prostatic secretion (EPS) and post-massage urine (VB3). Bacterial count at least 10 times higher in EPS or VB3 than in VB1 and VB2, with leucocytes in the EPS (over 10 in each high power field), confirms prostatic infection. Do not perform massage during an acute flare.
• PSA may be raised during infection. Repeat at 6 to 8 weeks after treatment before judging cancer risk.
• Transrectal ultrasound for calculi, abscess and cysts. Uroflowmetry and post-void residual, and cystoscopy or urethrography for stricture or obstruction.
• Chronic Prostatitis Symptom Index (score 0 to 43) to grade symptoms and follow response.

Differential diagnosis.

• Chronic prostatitis chronic pelvic pain syndrome
• Benign prostatic enlargement with recurrent infection
• Urethral stricture
• Bladder stone or tumour
• Epididymo orchitis
• Prostatic abscess or tuberculosis
• Prostate cancer

• Antibiotic with prostatic penetration, chosen by culture, for 4 to 6 weeks (up to 12 weeks for a relapse):
  • Ciprofloxacin 500 mg orally twice daily, with the dose reduced to 250 to 500 mg every 12 hours when eGFR is 30 to 50, and every 24 hours when under 30.
  • Levofloxacin 500 mg orally once daily, with the dose reduced when eGFR is under 50.
  • Co-trimoxazole 960 mg orally twice daily, halved when eGFR is 15 to 30 and avoided when under 15.
  • Doxycycline 100 mg orally twice daily for 2 to 4 weeks when Chlamydia or Ureaplasma is found.
  • Resistant organisms: specialist directed therapy with infectious disease.
• Fluoroquinolone cautions: tendon rupture (more with corticosteroids, transplant and age over 60), QT prolongation, dysglycaemia, aortic aneurysm and neuropsychiatric effects. Use only when alternatives are unsuitable.
• Tamsulosin 400 micrograms orally once daily after a meal for 3 to 6 months for voiding symptoms. NSAIDs for short courses: ibuprofen 400 mg every 8 hours for up to 2 weeks with food.
• Relapse is common (about 25 to 50%). Options: repeat a longer course, or suppression with nitrofurantoin 50 to 100 mg orally at night (eGFR over 45) or trimethoprim 100 mg at night, or co-trimoxazole 480 mg at night, reviewed every 3 to 6 months.
• Surgery: transurethral resection or laser removal of infected calculi or obstructing tissue, for persistent infection with calculi or obstruction. Radical prostatectomy is rarely justified.
• Treat partners when a sexually transmitted organism is found.
• Avoid prostatic massage as therapy, and correct obstruction and stricture.

Monitoring. Urine culture at 1 week and 4 weeks after treatment, and symptom index at 6 and 12 weeks. PSA 6 to 8 weeks after treatment if it was raised. Review for relapse at 3 and 6 months.

Referral and escalation. Refer to urology for relapse, calculi, obstruction, resistant organisms or a raised PSA that does not fall. Urgent referral for retention, sepsis, abscess or a suspicious nodule.