II. Pathophysiology

  1. Slow, indolent infection persisting more than 3 months
  2. Retrograde infection from distal Urethra to Prostate
  3. Associated factors
    1. See Risk Factors below
    2. Recurrent Urinary Tract Infection
    3. Asymptomatic bacteruria despite antibiotics
  4. Causative organisms are the same as in Acute Prostatitis
    1. Enterobacteriaceae, especially Escherichia coli (80%)
    2. Enterococcus (15%)
    3. Pseudomonas aeruginosa
    4. Burkholderia pseudomallei

III. Risk Factors

  1. Urethritis due to Sexually Transmitted Infection (STI)
  2. Urethral Stricture
  3. Benign Prostatic Hyperplasia
  4. Urethral instrumentation (including Urethral Catheterization)
  5. Uncircumsized men (intact foreskin)
  6. Retrograde ejaculation

IV. Symptoms (sudden onset)

  1. Irritative urinary symptoms (Mild to Moderate)
    1. Dysuria
    2. Urinary Frequency
    3. Urinary urgency
    4. Ejaculatory pain
    5. Hematospermia
  2. Referred pain
    1. Low pack pain
    2. Perineal pain
    3. Lower Abdominal Pain
    4. Scrotal Pain
    5. Pain in penis
    6. Pain in inner thighs
  3. Absent Symptoms (Contrast with Acute Prostatitis)
    1. Systemic symptoms rare
    2. Obstructive urinary symptoms uncommon

V. Exam

  1. Abdominal exam including Pelvis and flank
  2. Genitourinary exam (scrotal exam and penis exam)
  3. Digital Rectal Exam
    1. Avoid Prostatic Massage in suspected Acute Bacterial Prostatitis
    2. Obtain Urinalysis and Urine Culture before and after Prostatic Massage
    3. Findings in Chronic Prostatitis
      1. Prostate often normal on exam
      2. Prostate may be tender to palpation, boggy or indurated
      3. Prostatic calculi or crepitation may be present

VI. Labs

  1. Urinalysis
    1. Urine White Blood Cells >10/hpf
  2. Urine Culture
  3. Segmented Urine Culture before and after Prostatic Massage (rarely done)
    1. See Prostatic Massage
    2. Request lab to report all growth on cultures
  4. STD Screening (if risk factors or in men under age 35 years old)
    1. Neisseria gonorrhoeae PCR
    2. Chlamydia Trachomatis PCR
  5. Consider Prostate Specific Antigen (PSA)
    1. See Prostate Specific Antigen for caveats to testing
    2. Consider if significant Prostate Cancer risk factors (e.g. Family History at younger age)
    3. Avoid performing after Prostatic Massage (falsely elevated)

VII. Differential Diagnosis

  1. Genitourinary
    1. Acute Bacterial Prostatitis
    2. Prostate Abscess
    3. Sexually Transmitted Infection
    4. Chronic Noninfectious Prostatitis
    5. Benign Prostatic Hyperplasia
    6. Urinary Tract Stone (e.g. Prostate calculus, Nephrolithiasis)
    7. Bladder Cancer
    8. Urinary tract foreign body
    9. Enterovesical fistula
  2. Gastrointestinal
    1. Irritable Bowel Syndrome
  3. Musculoskeletal
    1. Pelvic Floor Dysfunction
    2. Pelvic injury or Trauma
  4. Neurologic
    1. Neurogenic Bladder
    2. Pudendal neuralgia

VIII. Management

  1. See Prostatitis General Measures
  2. General
    1. Antibiotics penetrate Chronic Prostatitis poorly
    2. Prolonged antibiotic regimens are required (however, avoid chronic antibiotic use)
    3. Antibiotics until Segmented Urine Culture sterile
    4. Urine Culture sensitivity may best direct antibiotic therapy
    5. Expect 6 point decrease after treatment in International Prostate Symptom Score
  3. Course
    1. Treat for 4-6 weeks
    2. May require a second 4-6 week course (total of 8-12 weeks)
      1. Add Selective Alpha Adrenergic Antagonist (e.g. Tamsulosin, Alfuzosin)
  4. Antibiotics: First-Line (caution regarding prolonged Fluoroquinolone use)
    1. Levofloxacin 750 mg orally daily (best efficacy)
    2. Ciprofloxacin 500 orally twice daily
    3. Norfloxacin 400 mg twice daily
    4. Trimethoprim-sulfamethoxazole (Bactrim, Septra) DS 160 mg/800 mg one tablet orally twice daily
  5. Antibiotics: Alternative agents (esp. Chlamydia)
    1. Doxycycline 100 mg twice daily
    2. Azithromycin 500 mg daily
    3. Clarithromycin 500 mg twice daily
  6. Refractory Cases
    1. Consider Chronic Noninfectious Prostatitis
  7. Urology Referral Indications
    1. Severe or atypical symptoms (severe Dysuria, Hematuria)
    2. Pre-Prostatic MassageUrine Culture
    3. Suspected Prostate Cancer (e.g. ProstateNodule, increased PSA)
    4. Refractory course despite two courses of antibiotics and Alpha Adrenergic Antagonist

IX. References

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