Chronic Bacterial Prostatitis

Aka: Chronic Bacterial Prostatitis, Chronic Prostatitis

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II. Pathophysiology

  1. Slow, indolent infection persisting more than 3 months
  2. Retrograde infection from distal Urethra to Prostate
  3. Complication of Acute Bacterial Prostatitis in 8% of patients (remainder are primary infections)
  4. Associated factors
    1. See Risk Factors below
    2. Recurrent Urinary Tract Infection
    3. Asymptomatic bacteruria despite Antibiotics
  5. 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

  1. Often presents as Recurrent Urinary Tract Infections despite prior adequate Antibiotic management
    1. Typically Urine Culture repeatedly grows the same organism despite prior treatment
  2. Sudden onset, but more subacute severity and development than with Acute Bacterial Prostatitis
    1. Systemic symptoms (e.g. fever, chills, Vomiting) are typically absent (unlike Acute Bacterial Prostatitis)
  3. Irritative urinary symptoms (Mild to Moderate)
    1. Dysuria
    2. Urinary Frequency
    3. Urinary urgency
    4. Ejaculatory pain
    5. Hematospermia
  4. Referred pain
    1. Low pack pain
    2. Perineal pain
    3. Lower Abdominal Pain
    4. Scrotal Pain or Testicular Pain
    5. Pain in penis
    6. Pain in inner thighs
  5. 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
      1. In Chronic Bacterial Prostatitis, Prostatic Massage may be used in the Two Glass Test
    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
    1. Typically Urine Culture repeatedly grows the same organism despite prior treatment
    2. Persistent single organisms are also seen in obstructive lesions (e.g. urinary tract stones)
  3. Segmented Urine Culture before and after Prostatic Massage (rarely done)
    1. See Expressed Prostatic Secretion (Two Glass Test, Four Glass Test)
    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. Imaging

  1. CT Abdomen and Pelvis indications
    1. Relapsing Chronic Bacterial Prostatitis despite appropriate treatment
    2. Suspected prostatic abscess
    3. Suspected obstructive urinary tract lesions

VIII. 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)
      1. As with Chronic Bacterial Prostatitis, Urine Culture typically grows the same organism
    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

IX. Management

  1. See Prostatitis General Measures
  2. Precautions
    1. Evaluate for Urinary Retention (e.g. BPH, neurogenic Bladder) for patients with Chronic Bacterial Prostatitis
  3. 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
  4. Course
    1. Treat for 4 to 6 weeks
    2. May require a second 4 to 6 week course (total of 8-12 weeks)
      1. Add Selective Alpha Adrenergic Antagonist (e.g. Tamsulosin, Alfuzosin)
  5. Antibiotics: Flouroquinolones (First-Line)
    1. Caution regarding prolonged Fluoroquinolone use (but excellent spectrum and Prostate penetration)
    2. Levofloxacin 750 mg orally daily (best efficacy)
    3. Ciprofloxacin 500 orally twice daily
    4. Norfloxacin 400 mg twice daily
  6. Alternative Agents (esp. if based on culture sensitivities)
    1. Trimethoprim-sulfamethoxazole (Bactrim, Septra) DS 160 mg/800 mg one tablet orally twice daily
    2. Beta lactams may be considered if susceptible by antibiogram but consult local infectious disease
  7. Specific Organism Management
    1. ESBL E. coli Bacterial Prostatitis
      1. Fosfomycin 3 g orally every 1 to 3 days
    2. Chlamydia trachomatis
      1. Doxycycline 100 mg twice daily for 4 weeks
      2. Azithromycin 500 mg daily (or for 3 consecutive days each week) for 3 weeks
      3. Clarithromycin 500 mg twice daily
  8. Refractory Cases
    1. Consider Chronic Noninfectious Prostatitis
  9. 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

X. References

  1. Cooner (1994) Prostate Disease, AAFP, p. 9-15
  2. (2018) Sanford Guide, accessed on IOS, 10/16/2019
  3. Krieger (Summer, 1998) Patient Care Suppl.: Prostatitis
  4. Holt (2016) Am Fam Physician 93(4):290-6 [PubMed]
  5. Lam (2024) Am Fam Physician 110(1): 45-51 [PubMed]
  6. Pontari (2007) J Urol 177(6): 2050-7 [PubMed]
  7. Schwager (1991) Am Fam Physician, 44(6): 2137-41 [PubMed]
  8. Sharp (2010) Am Fam Physician 82(4): 397-406 [PubMed]

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