Prostatitis Category I: Acute prostatitis (bacterial)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Category I: Acute Prostatitis (Bacterial)

Acute prostatitis is any inflammation of the prostate gland that is caused by a sudden infection, usually by bacteria that get into the prostate by traveling up into the body through the urethra. Some of these bacteria are the normal germs that live on and inside your body. Other infections are transmitted through sexual contact.

Most men who will develop prostatitis have a normal prostate gland, although the infection may be more common in older men as the gland gets larger with age. There is no known link between prostatitis and prostate cancer.

Prostatitis is more common in men with AIDS, but many men who develop this infection have a normal immune system.

Signs and Symptoms

• Pain between the scrotum & rectum.
• Frequent but low amount of urination (pollakiuria).
• The sensation of burning or pain during urination (dysuria), dribbling with urination.
• Difficulty starting the urine stream or total inability to pass urine.
• Blood or pus in the urine.
• Sometimes accompanied by fever and chills and/or IBS symptoms, nausea and vomiting, muscle aches, and fatigue or flu-like symptoms.
• The desire to urinate more at night.
• There may be discharge from the penis.
• Demonstrable infection of the urinary tract, as evidenced by white blood cells and bacteria in the urine.

Diagnosis

Acute prostatitis is relatively easy to diagnose due to its symptoms that suggest infection. Common bacteria are Escherichia coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Serratia, and Staphylococcus aureus. This can be a medical emergency in some patients and hospitalization with intravenous antibiotics may be required. A full blood count reveals increased white blood cells. Sepsis from prostatitis is very rare, but may occur in immunocompromised patients; high fever and malaise generally prompt blood cultures, which are often positive in sepsis. A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis. Since bacteria causing the prostatitis is easily recoverable from the urine, prostate massage is not required to make the diagnosis.

Treatment

Antibiotics are the first line of treatment in acute prostatitis (Cat. I). Antibiotics usually resolve acute prostatitis infections in a very short time. Appropriate antibiotics should be used, based on the microbe causing the infection. Some antibiotics have very poor penetration of the prostatic capsule, others, such as ciprofloxacin, co-trimoxazole, and tetracyclines penetrate well. In acute prostatitis, penetration of the prostate is not as important as for category II because the intense inflammation disrupts the prostate-blood barrier. It is more important to choose a bacteriocidal antibiotic (kills bacteria, e.g. quinolones) rather than a bacteriostatic antibiotic (slows bacterial growth, e.g. tetracycline) for acute potentially life threatening infections. Severely ill patients may need hospitalization, while nontoxic patients can be treated at home with bed rest, analgesics, stool softeners, and hydration. Patients in urinary retention are best managed with a suprapubic catheter or intermittent catheterization. Lack of clinical response to antibiotics should raise the suspicion of an abscess and prompt an imaging study such as a transrectal ultrasound (TRUS).

Acute Uncomplicated Prostatitis Risk of STD(Age<35) ▸ Ceftriaxone 250 mg IM x 1 dose OR ▸Cefixime 400 mg po x 1dose THEN ▸ Doxycycline100 mg po bid x 10 days Low risk of STD ▸ Fluoroquinolones for 10-14 days Levofloxacin 500-750 mg IV/PO once daily OR Ciprofloxacin 500-750 mg po or 400 mg IV bid OR ▸ TMP-SMX 2.5 mg/kg IV q8h 500-750 mg po or 400 mg IV for 10-14 days Alternative Regimen(Resistant organisms) ▸Resistant enterobacteriaceae Ertapenem 1 gm IV qd for 2-4 weeks ▸Resistant Pseudomonas Imipenem 500 mg IV q6h for 4 weeks' OR Meropenem 500 mg IV q8h for 4 weeks

Prognosis

Full recovery without sequelae is usual.