Prostatitis

Prostatitis is a group of inflammatory and non-inflammatory conditions of the prostate that cause pelvic pain, voiding symptoms and sexual dysfunction. It affects 8 to 10% of men during their lifetime, and it is the commonest urological diagnosis in men under 50 years.

NIH classification

• Category I, acute bacterial prostatitis: acute prostatic infection with systemic features.
• Category II, chronic bacterial prostatitis: recurrent infection with the same organism, with or without symptoms between episodes.
• Category III, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): pelvic pain for at least 3 months with no demonstrable uropathogen. Divided into IIIA (inflammatory, white cells in expressed prostatic secretions, semen or post-massage urine) and IIIB (non-inflammatory).
• Category IV, asymptomatic inflammatory prostatitis: found incidentally during evaluation of infertility, raised PSA or biopsy.
• Proportions: CP/CPPS accounts for about 90% of cases, chronic bacterial prostatitis 5 to 10%, and acute bacterial prostatitis under 5%.

Microbiology of bacterial prostatitis

• E. coli (65 to 80%), other Enterobacterales (Klebsiella, Proteus), Pseudomonas aeruginosa, and Enterococcus faecalis.
• In young sexually active men: Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis.
• In immunosuppressed and HIV-infected men: Staphylococcus aureus, Mycobacterium tuberculosis, Cryptococcus, Candida, and Salmonella.
• Resistance (fluoroquinolone and ESBL producers) is rising, particularly after transrectal prostate biopsy.

Pathogenesis

• Bacterial: ascending urethral infection, intraprostatic reflux of infected urine, bacteraemic spread, and rectal flora introduced by transrectal biopsy or instrumentation. Prostatic stones and biofilms allow persistence.
• CP/CPPS is multifactorial: pelvic floor muscle dysfunction, neurogenic inflammation, central sensitisation, autoimmune mechanisms, urinary reflux, hormonal factors, psychological stress, and prior infection.
• Risk factors: BPH and urinary obstruction, indwelling catheter or instrumentation (biopsy, cystoscopy), unprotected anal intercourse, recent urinary tract infection or epididymitis, urethral stricture, immunosuppression, diabetes, and HIV.
• Complications: urinary retention, prostatic abscess, sepsis, epididymitis, bacteraemia, chronic prostatitis, infertility, sexual dysfunction, and reduced quality of life.

Acute bacterial prostatitis

• Abrupt fever, chills and malaise, perineal, suprapubic or low back pain, dysuria, frequency, urgency, nocturia, and obstructive voiding symptoms (hesitancy, weak stream, retention).
• Arthralgia, myalgia, nausea and vomiting, and rarely septic shock.
• Digital rectal examination shows a swollen, warm, very tender, firm or boggy prostate. Avoid vigorous palpation or massage, which risks bacteraemia.

Chronic bacterial prostatitis

Recurrent urinary tract infections with the same organism, perineal, testicular, penile or suprapubic discomfort, voiding symptoms, painful ejaculation, and haematospermia. Between episodes, symptoms may be minimal. Examination may be normal or show a tender or nodular prostate.

CP/CPPS

• Pain or discomfort in the perineum, suprapubic region, testicles, penile tip or lower back for at least 3 months, aggravated by sitting, ejaculation or bowel movements.
• Lower urinary tract symptoms, sexual dysfunction (painful ejaculation, erectile difficulty, reduced libido), anxiety, depression, catastrophising, and poor quality of life.
• Examination: prostatic tenderness, and tender, tight pelvic floor muscles (levator ani, obturator internus) on digital examination.
• Prostatic abscess (complication, 2 to 10% of acute cases): persistent fever despite 48 to 72 hours of antibiotics, fluctuant prostate on rectal examination, retention, and risk factors such as diabetes and instrumentation.
• Differential diagnosis: urinary tract infection, urethritis, epididymo-orchitis, BPH, interstitial cystitis or bladder pain syndrome, prostate cancer, urethral stricture, bladder stone, anorectal disease, pudendal neuralgia, pelvic floor myalgia, inguinal hernia, and lumbar disc disease.
• Red flags: fever and sepsis, retention, abscess, haematuria, hard or nodular prostate, rising PSA, neurological symptoms, weight loss, and immunosuppression.

Acute bacterial prostatitis

• Midstream urine for urinalysis and culture before antibiotics (pyuria, bacteriuria). Blood cultures when febrile. CBC, CRP, creatinine, glucose, and lactate.
• NAAT for chlamydia and gonorrhoea in men under 35, and HIV and syphilis testing when indicated.
• PSA is often markedly raised and is not useful for cancer detection during infection. Repeat 6 to 8 weeks after resolution.
• Measure post-void residual by bladder scan. Suprapubic catheter is preferred if retention occurs (avoid urethral catheter where possible).
• Imaging if no improvement in 48 to 72 hours or suspected abscess: transrectal or transperineal ultrasound (gentle), CT or MRI of the pelvis.

Chronic bacterial prostatitis and CP/CPPS

• Meares-Stamey four-glass test: VB1 (first 10 mL of urine, urethra), VB2 (midstream, bladder), EPS (expressed prostatic secretions after massage), and VB3 (first 10 mL of urine after massage).
  • Bacterial prostatitis: bacterial counts in EPS or VB3 at least 10-fold higher than VB1 and VB2 (with VB2 sterile).
  • Inflammation: more than 10 white cells per high power field in EPS.
  • CP/CPPS: negative cultures.
• A simplified two-glass test (pre- and post-massage urine) is used in practice. Perform a urine culture before any test.
• NIH Chronic Prostatitis Symptom Index (NIH-CPSI, 0 to 43 points: mild 0 to 14, moderate 15 to 29, severe 30 to 43) to quantify pain, urinary symptoms and quality of life, and to track response.
• UPOINT phenotyping (Urinary, Psychosocial, Organ-specific, Infection, Neurological/systemic, Tenderness of pelvic floor muscles) to direct therapy.
• Uroflowmetry, post-void residual, urine cytology, and cystoscopy for haematuria, voiding abnormalities, or persistent symptoms.
• Transrectal ultrasound for prostatic calculi, abscess and cysts. MRI of the pelvis for pelvic floor pathology and to exclude other causes.
• Semen culture and analysis for infertility, STI testing, tuberculosis tests where relevant, and PSA interpreted in context.

Acute bacterial prostatitis

• Admit for sepsis, retention, vomiting, diabetes, immunosuppression, or suspected resistant organism. Mild cases can be treated as outpatients.
• IV empirical therapy:
  • Ceftriaxone 1 to 2 g daily, or piperacillin-tazobactam 4.5 g every 6 to 8 hours, or ciprofloxacin 400 mg every 12 hours.
  • Add gentamicin 5 mg/kg daily (renal adjusted) for sepsis, and use meropenem 1 g every 8 hours for ESBL risk.
  • Men under 35 with STI risk: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg twice daily for 14 days.
• Step down to oral therapy when afebrile for 24 to 48 hours: ciprofloxacin 500 mg twice daily, levofloxacin 500 to 750 mg daily, or trimethoprim-sulfamethoxazole 160/800 mg twice daily, guided by susceptibility. Total duration 2 to 4 weeks (4 weeks reduces progression to chronic disease).
• Supportive: hydration, paracetamol 1 g every 6 hours, NSAIDs (naproxen 500 mg twice daily), stool softeners, and tamsulosin 0.4 mg daily to improve voiding.
• Retention: suprapubic catheter. Avoid prostatic massage and urethral instrumentation.
• Prostatic abscess: transperineal or transrectal ultrasound-guided drainage, or transurethral unroofing for large or multiloculated abscesses. Continue antibiotics for 4 to 6 weeks.
• Reassess at 48 to 72 hours. Failure to improve warrants imaging for abscess and review of antibiotic choice.

Chronic bacterial prostatitis

• Prolonged antibiotics with good prostatic penetration for 4 to 6 weeks (up to 12 weeks in selected patients):
  • Ciprofloxacin 500 mg twice daily, or levofloxacin 500 mg daily.
  • Trimethoprim-sulfamethoxazole 160/800 mg twice daily.
  • Doxycycline 100 mg twice daily for 4 weeks or more (chlamydia, Ureaplasma), or azithromycin 500 mg daily for 3 days weekly for 3 weeks.
  • Fosfomycin 3 g every 48 to 72 hours for 6 weeks for ESBL organisms.
• Alpha blocker (tamsulosin 0.4 mg daily, alfuzosin 10 mg daily) for 3 months. Treat associated BPH.
• Recurrence is common (up to 50%). Options include repeat prolonged courses, low-dose suppressive therapy, and transurethral resection of infected prostatic calculi in carefully chosen cases.
• Counsel about fluoroquinolone adverse effects (tendon rupture, neuropathy, QT prolongation, CNS effects, aortic aneurysm) and use alternatives when possible.

CP/CPPS (multimodal, phenotype-directed)

• Education, reassurance that the condition is not cancer and not contagious, and realistic goals (symptom control).
• Urinary: alpha blockers (tamsulosin 0.4 mg or silodosin 8 mg daily for 6 to 12 weeks), antimuscarinics or mirabegron 25 to 50 mg for overactive bladder symptoms.
• Infection: a single 4 to 6 week trial of an antibiotic (ciprofloxacin 500 mg twice daily or levofloxacin 500 mg daily) in treatment-naive men, stopped if no improvement within 2 weeks. Do not repeat empirically.
• Organ-specific: quercetin 500 mg twice daily, pollen extract (Cernilton) 2 tablets three times daily, pentosan polysulfate 100 mg three times daily, and finasteride 5 mg daily for coexisting BPH.
• Neurological and pain: NSAIDs (naproxen 500 mg twice daily, celecoxib 200 mg daily) for short courses, gabapentin 300 mg at night titrated to 1800 to 2400 mg/day, pregabalin 75 to 150 mg twice daily, amitriptyline 10 to 75 mg at night, and duloxetine 30 to 60 mg daily. Avoid opioids.
• Pelvic floor tenderness: pelvic floor physiotherapy with myofascial release, trigger point therapy, biofeedback and relaxation training, warm baths, and botulinum toxin A injection (100 to 200 units) into pelvic floor muscles in refractory cases. Low-intensity extracorporeal shockwave therapy has moderate evidence.
• Psychosocial: cognitive behavioural therapy, stress management, sleep optimisation, and treatment of depression and anxiety (sertraline 50 to 100 mg daily).
• Sexual dysfunction: tadalafil 5 mg daily or on demand, and sexual counselling.
• Lifestyle: avoid prolonged sitting and cycling, use a cushion, limit caffeine, alcohol and spicy foods, exercise regularly, and regular ejaculation may help.
• Refractory cases: pain clinic referral, neuromodulation (tibial or sacral), and rarely surgery. Prostatectomy and radical interventions are not recommended.
• Expect partial improvement in about half of patients over months. Use the NIH-CPSI every 6 to 12 weeks to guide continuation.

Asymptomatic inflammatory prostatitis

• No treatment is required unless found during infertility or raised PSA evaluation. Consider an antibiotic course and repeat PSA after 6 to 8 weeks before biopsy.

Prevention

• Transrectal prostate biopsy: targeted antimicrobial prophylaxis (rectal swab-guided, or fosfomycin 3 g before and after), povidone-iodine rectal preparation, and preference for the transperineal route to lower infection risk.
• Safe sex practices, early treatment of urinary infection and urethritis, and appropriate catheter care.

Follow-up

• Acute: review at 48 to 72 hours, then at the end of treatment with repeat urine culture 1 to 2 weeks after completion. Repeat PSA at 6 to 8 weeks.
• Chronic: review every 4 to 12 weeks while adjusting therapy, with the NIH-CPSI to measure response. Refer to urology or a pain service for refractory disease or if red flags develop.