Prostatitis is inflammation of the prostate gland, which is most commonly infectious in origin. Prostatitis may be acute or chronic, but this article will focus solely on acute prostatitis.
Prostatitis is very common, accounting for approximately 2 million cases per year. It is more common in young males, ages 30 to 50 and those who are sexually active.
The differential diagnosis of a patient presenting with prostatitis should consider acute cystitis, acute urethritis, urinary tract infection, and epididymitis. Signs, symptoms, and the physical exam will help narrow down the primary diagnosis.
Acute Prostatitis Risk Factors
Risk factors for the development of prostatitis include, quite obviously male sex, age greater than 50 years, urinary tract infection, trauma to the perineal area, and dehydration.
Patients with HIV are much more likely to have an episode of prostatitis. Iatrogenic prostatitis can be caused by previous prostate biopsy, transurethral resection of the prostate, cystoscopy, urethral dilatation procedures, and chronic or frequent self-catheter use.
Etiology of Acute Prostatitis
The most common cause of acute prostatitis is Escherichia coli. Other considerations include Proteus Mirabilis, Klebseilla, and Enterobacter.
It is most commonly caused by gram negative rods. Gonorrhea and chlamydia should be considered in the sexually active patient.
Acute Prostatitis vs Urinary Tract Infection
An important consideration that can help differentiate patients suffering from prostatitis versus other considerations in the differential, such as urinary tract infection, is that patients with prostatitis are acutely ill.
A differentiating factor between prostatitis and other diagnoses is that patients with prostatitis will likely have fever, malaise, myalgias, and other systemic symptoms.
Urinary symptoms such as dysuria, frequency, urgency, and obstructive symptoms can be present. These symptoms are usually accompanied by pelvic and perineal pain, rectal pain, or even signs of bacteremia.
The Digital Rectal Exam
A digital rectal exam can be performed, but should be gentle in nature due to the risk for bacteremia with manipulation or massage of the prostate.
Pain on rectal exam may be present in acute prostatitis. The prostate itself may be tender, boggy, or edematous. It is important to note that in other conditions, the digital rectal exam should be normal/non painful.
Working Up Acute Prostatitis
The work up for a patient suspected of prostatitis should focus on narrowing the differential diagnosis. A good initial test is a urinalysis which should be sent for a confirmatory culture. Urinalysis may show evidence of infection, including pyuria or bacteriuria.
A CBC may show a mild to moderate leukocytosis. A C-reactive protein or erythrocyte sedimentation rate can be elevated in acute disease.
A prostate specific antigen may also be elevated, which can further narrow the differential, as other conditions should not have an elevated PSA.
The presence of a leukocytosis in the setting of an elevated PSA should increase clinical suspicion of prostatitis.
Depending on the patient’s presentation, blood cultures may be indicated to rule out sepsis.
Treating Acute Prostatitis
Acute management of prostatitis should focus both on treatment with antibiotics as well as measures to promote analgesia.
Patients that have signs and symptoms of bacteremia and/or those who may not be able to tolerate oral therapy, should be admitted to the hospital for parenteral antibiotics.
Given that patients may have significant pain, analgesia is extremely important. Analgesics such as Tylenol or ibuprofen may provide pain relief while also providing an anti-pyretic benefit.
Stool softeners can be helpful to ease pain associated with bowel movements. Sitz baths may be helpful to reduce pain as well. Hydration also plays an important role in the management of prostatitis.
Antibiotic choice should be considered once the diagnosis is made and other conditions have been ruled out. Antibiotic choice is somewhat limited in that it can be challenging to attain adequate antibiotic levels to treat prostatitis.
Three potential choices include TMP-SMX, ciprofloxacin, and Levaquin, given that these drugs are associated with higher levels in the prostate.
At a minimum, prostatitis should be treated for at least 30 days. Some sources suggest repeating a urinalysis and subsequent urine culture during or after antibiotic therapy have been completed.
Patients that cannot tolerate oral therapy or that have signs of bacteremia should be treated with parenteral antibiotics.
Complications of untreated or inadequately treated prostatitis include a prostatic abscess, bacteremia, chronic prostatitis, and epididymitis.
Unfortunately, prostatitis is very hard to cure. Approximately 20% of patients initially diagnosed may have a re-infection or suffer from chronic prostatitis. However, prompt recognition and treatment can prevent the progression to life threatening sepsis.