Acute Bacterial Prostatitis

Aka: Acute Bacterial Prostatitis, Acute Prostatitis

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II. Epidemiology

  1. Uncommon type of Prostatitis, accounting for only 10% of cases
  2. Peak onset age 20-40 years old, and over age 70 years old

III. Pathophysiology: Mechanisms

  1. Ascending infection from infected Urethra or intraprostatic reflux (most cases)
    1. Bacterial Prostatitis and Pyelonephritis share the same Bladder source of infection
  2. Instrumentation (transrectal Prostate biopsy, Urinary Catheterization, cystoscopy)
  3. Direct or lymphatic spread from Rectum
  4. Hematogenous spread (Sepsis)

IV. Causes: Organisms

  1. Aerobic Gram Negative Rods (Enterobacteriaceae, most common)
    1. Escherichia coli (80%)
    2. Klebsiella
    3. Enterobacter
    4. Proteus
    5. Serratia
  2. Gram Positive Bacteria
    1. Enterococcus (common)
    2. Streptococcus faecalis (uncommon)
    3. Staphylococcus aureus (uncommon)
  3. After instrumentation or in hospitalized patients (up to 2% of cases)
    1. Pseudomonas
    2. Resistant organisms (ESBL e coli and Fluoroquinolone resistant)
  4. Sexually Transmitted Infection (typically age <35 years old)
    1. Neisseria gonorrhoeae
    2. Chlamydia trachomatis
  5. Immunocompromised patients
    1. Salmonella
    2. Candida
    3. Cryptococcus
  6. Other uncommon organisms
    1. Tuberculous Prostatitis (Tuberculosis)
    2. Parasitic Prostatitis (e.g. Trichomonas vaginalis)
    3. Mycotic Prostatitis (Fungal organisms - Aspergillus, Candida, Cryptococcus, Histoplasma)
    4. Burkholderia pseudomallei

V. Risk Factors

  1. Benign Prostatic Hyperplasia
  2. Other genitourinary infection
    1. Epididymitis or Orchitis
    2. Urethritis
    3. Urinary Tract Infection
  3. Urinary tract manipulation or instrumentation
    1. Urinary Catheterization or Indwelling Urethral catheter
    2. Condom Catheter Drainage
    3. Transrectal Prostate biopsy
    4. Transurethral surgery
  4. Infected sexual contact, STD History or high risk behavior
  5. Immunocompromised patients (e.g. HIV or AIDS, Diabetes Mellitus)
  6. Anatomic abnormalities
    1. Phimosis
    2. Urethral strcture

VI. Symptoms (sudden onset)

  1. Systemic symptoms
    1. Fever and chills
    2. Malaise
    3. Joint Pain (Arthralgia)
    4. Muscle pain (myalgia)
    5. Nausea or Vomiting
  2. Referred pain
    1. Low Back Pain
    2. Perineal pain or Rectal Pain
    3. Suprapubic Pain
  3. Irritative urinary symptoms
    1. Dysuria
    2. Urinary Frequency
    3. Urinary urgency
  4. Obstructive urinary symptoms
    1. Decreased urine caliber and force
    2. Urinary hesitancy
    3. Postvoid dribbling
    4. Incomplete Bladder emptying Sensation
    5. Urine retention
  5. Other
    1. Painful ejaculation
    2. Hematospermia
    3. Difficulty stooling (Dyschezia)

VII. Signs

  1. Ill, toxic appearing patient
  2. Abdominal exam
    1. Suprapubic tenderness if obstruction
  3. Genitourinary exam
    1. Examine the Scrotum and penis to exclude other causes (e.g. Epididymitis)
  4. Digital Rectal Exam
    1. Avoid vigorous exam or Prostatic Massage (risk of bacteremia)
      1. Gentle exam is safe, and helps to identify source of infection
    2. Prostate is warm, boggy, tender on palpation
      1. Prostate is tender out of proportion to what would be expected
      2. Prostate palpation may reproduce Prostatitis symptoms of urgency and pressure
      3. Normal Prostate exam makes Acute Prostatitis diagnosis much less likely

VIII. Differential Diagnosis

  1. See Prostatitis
  2. Epididymitis (and Orchitis)
  3. Urethritis (Chlamydia, Gonorrhea)
  4. Urinary tract cancer
  5. Ureterolithiasis (including infected Ureteral Stone)
  6. Acute Pyelonephritis
    1. Flank Pain seen in Pyelonephritis is typically absent in Acute Prostatitis
  7. Urinary Tract Infection
    1. Uncommon in males unless Bladder outlet obstruction (e.g. BPH, neurologic disorder)

IX. Labs: Standard

  1. Urinalysis
  2. Urine Culture (negative in 35% of acute prostatis cases)
  3. STD Screening (if risk factors or in men under age 35 years old)
    1. Neisseria gonorrhoeae PCR
    2. Chlamydia Trachomatis PCR

X. Labs: Severe cases

  1. Indications
    1. Indications for hospitalization (see below)
    2. Fever >101
    3. SIRS Criteria for Sepsis or increased serum Lactic Acid
    4. Hematogenous source of infection suspected
  2. Tests
    1. Complete Blood Count with differential (>18k in severe cases)
    2. Basic metabolic panel (BUN >19 in severe cases)
    3. Lactic Acid
    4. Blood Cultures x2
      1. Bacteremia present in 20% of inpatient cases
  3. Labs to avoid
    1. Avoid CRP or ESR (unlikely to direct care)
    2. Avoid PSA
      1. Expect PSA elevation for 2 months after acute infection

XI. Imaging

  1. Bedside Ultrasound
    1. Evaluate for post-void residual Urine Volume (Urinary Retention)
  2. Other imaging for prostatic abscess (indicated in severe, refractory cases or fever >36 hours)
    1. Transrectal Ultrasound
    2. CT Pelvis
    3. MRI Pelvis

XII. Management: Indications for Hospitalization (<16% of Acute Prostatitis cases)

  1. Signs of bacteremia or Sepsis (fever>100.4, rigors)
  2. Urinary Retention
  3. Failed outpatient management (e.g. need for ParenteralAntibiotics)
  4. Significant Dehydration and inability to take oral fluids
  5. Post-instrumentation (e.g. status post transurethral catheterization)
  6. Older age (>65 years old) is associated with worse outcomes (but no formal age criteria for admission)

XIII. Management: Outpatient

  1. See Prostatitis General Measures
  2. Indicated for mild to moderate illness not meeting inpatient criteria above
  3. For mild Acute Prostatitis, 10 day Antibiotic course is sufficient
  4. Consider treatment of Gonorrhea and Chlamydia (esp. age <35 years old)
    1. Obtain baseline labs to include a dirty urine for Gonorrhea PCR and Chlamydia PCR
    2. Gonorrhea management
      1. Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
      2. Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
      3. Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
    3. Chlamydia management
      1. Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
      2. Azithromycin 1 g orally for 1 dose
    4. References
      1. Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6 [PubMed]
        1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  5. Standard Antibiotic protocol (esp. age >35 years old, depending on local Antibiotic Resistance)
    1. May also use Antibiotics as listed under Chronic Prostatitis
    2. Longer courses may be required in more severe cases (up to 6 weeks)
    3. First-line medications
      1. Ciprofloxacin (Cipro) 500 mg orally twice daily for 10-14 days
      2. Levofloxacin (Levaquin) 500-750 mg orally daily for 10-14 days
    4. Alternative medications (Consider as first-line given risks of Fluoroquinolones)
      1. Trimethoprim Sulfamethoxazole (Septra, Bactrim) DS one orally twice daily for 10-14 days
  6. AIDS Considerations
    1. Consider Cryptococcus neoformans as causative organism
  7. Other measures
    1. Consider Tamsulosin (Flomax) if obstructive symptoms (e.g. decreased urinary stream, double voiding)

XIV. Management: Inpatient

  1. Precautions
    1. Avoid Foley Catheter or Prostate massage (may place suprapubic drain as needed)
  2. Indicated if inpatient criteria met (see above)
  3. Step 0: Obtain labs
    1. Includes Urine Culture in all patients prior to Antibiotics (and consider Blood Culture)
  4. Step 1a: Antibiotics for non-seriously ill patients and no Antibiotic Resistance risk factors
    1. First-line: Fluoroquinolone (choose one)
      1. Ciprofloxacin 400 mg IV every 12 hours
      2. Levofloxacin 500-750 mg IV every 24 hours
    2. Alternative
      1. Piperacillin/tazobactam (Zosyn) 3.375 g IV every 6 hours OR
      2. Ceftriaxone 1-2 g IV every 24 hours AND Levofloxacin 500-750 mg IV every 24 hours
  5. Step 1b: Antibiotics for seriously ill patients but no Antibiotic Resistance risk factors
    1. First-line (dual coverage)
      1. Antibiotic 1: Aminoglycoside (choose one)
        1. Gentamicin 7 mg/kg every 24 hours (peak 16-24 mcg/ml, trough <1 mcg/ml)
        2. Amikacin 15 mg/kg IV every 24 hours (peak 56-64 mcg/ml, trough <1 mcg/ml)
      2. Antibiotic 2 (choose one)
        1. Piperacillin/tazobactam (Zosyn) 3.375 g IV every 6 hours OR
        2. Cefotaxime (Claforan) 2 g IV every 4 hours OR
        3. Ceftazidime (Fortaz) 2 g IV every 8 hours
    2. Alternative
      1. Fluoroquinolone (Ciprofloxacin or Levofloxacin) AND Aminoglycoside (Gentamicin or Amikacin) OR
      2. Ertapenem (Invanz) 1 g IV every 24 hours OR
      3. Imipenem/cilastin (Primaxin) 500 mg IV every 6 hours OR
      4. Meropenem (Merrem) 500 mg IV every 8 hours
  6. Step 1c: Antibiotics for resistance risks factors
    1. Transrectal instrumentation (Fluoroquinolone resistance and ESBL e coli risk)
      1. First-line (dual coverage)
        1. Piperacillin/tazobactam (Zosyn) 3.375 g IV every 6 hours AND
        2. Aminoglycoside (Gentamicin or Amikacin)
      2. Alternative
        1. Ertapenem (Invanz) 1 g IV every 24 hours OR
        2. Imipenem/cilastin (Primaxin) 500 mg IV every 6 hours
    2. Transurethral instrumentation (Pseudomonas risk)
      1. First-line
        1. Piperacillin/tazobactam (Zosyn) 3.375 g IV every 6 hours OR
        2. Ceftazidime (Fortaz) 2 g IV every 8 hours OR
        3. Cefepime 2 g IV every 12 hours
      2. Alternative
        1. Fluoroquinolone (Ciprofloxacin or Levofloxacin) OR
        2. Imipenem/cilastin (Primaxin) 500 mg IV every 6 hours
        3. Meropenem (Merrem) 500 mg IV every 8 hours
    3. Fluoroquinolone exposure (Fluoroquinolone resistance suspected)
      1. First-line
        1. Piperacillin/tazobactam (Zosyn) 3.375 g IV every 6 hours OR
        2. Ceftazidime (Fortaz) 2 g IV every 8 hours OR
        3. Cefepime 2 g IV every 12 hours
      2. Alternative
        1. Ceftriaxone 1-2 g IV every 24 hours OR
        2. Ertapenem (Invanz) 1 g IV every 24 hours
  7. Step 2: Lack of improvement or persistent fever
    1. Obtain Prostate imaging typically with CT Pelvis
      1. Other imaging options include transrectal Ultrasound or MRI Pelvis
    2. Imaging demonstrates Prostate abscess
      1. Urology consult for drainage
    3. Imaging negative
      1. Adjust Antibiotics based on Urine Culture results
  8. Step 3: When affebrile
    1. Switch to oral Antibiotics as described above
    2. Antibiotics may need to be extended for a total of 2-4 weeks

XV. Complications

  1. Prostate abscess (3 to 6% of cases)
    1. Identified on CT Pelvis or transrectal Ultrasound
    2. Requires surgical drainage and prolonged Antibiotic course
    3. Consider CT imaging in patients at higher risk of abscess
      1. Prolonged catheterization
      2. Recent instrumentation (Prostate biopsy, cystoscopy)
      3. Immunocompromised
      4. Ongoing fever >48 hours despite Antibiotics
      5. Ill, hospitalized patients
      6. Infection relapse despite adequate Antibiotic course
  2. Chronic Prostatitis >3 months (10% of cases)
  3. Recurrent Acute Prostatitis (13% of cases)
  4. Pyelonephritis
  5. Epididymitis
  6. Sepsis
  7. Acute urinary obstruction (10% cases)

XVI. Prevention

  1. Avoid Urethral Catheterization or transrectal biopsy if possible
  2. Prophylactic Antibiotics prior to transrectal biopsy (e.g. cipro 500 mg taken 12 hours before procedure)

XVII. References

  1. Cooner (1994) Prostate Disease, AAFP, p. 9-15
  2. (2018) Sanford Guide, IOS app, accessed 10/16/2019
  3. Krieger (Summer, 1998) Prostatitis, Patient Care Suppl.
  4. Spangler, Weinstock and Carmack in Herbert (2016) EM:Rap 16(11): 15-6
  5. Coker (2016) Am Fam Physician 93(2): 114-20 [PubMed]
  6. Holt (2016) Am Fam Physician 93(4):290-6 [PubMed]
  7. Lam (2024) Am Fam Physician 110(1): 45-51 [PubMed]
  8. Nickel (2005) Urology 66(1): 2-8 [PubMed]
  9. Pontari (2007) J Urol 177(6): 2050-7 [PubMed]
  10. Schwager (1991) Am Fam Physician, 44(6): 2137-41 [PubMed]
  11. Sharp (2010) Am Fam Physician 82(4): 397-406 [PubMed]

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