II. Pathophysiology
- Slow, indolent infection persisting more than 3 months
- Retrograde infection from distal Urethra to Prostate
- Associated factors
- See Risk Factors below
- Recurrent Urinary Tract Infection
- Asymptomatic bacteruria despite antibiotics
- Causative organisms are the same as in Acute Prostatitis
- Enterobacteriaceae, especially Escherichia coli (80%)
- Enterococcus (15%)
- Pseudomonas aeruginosa
- Burkholderia pseudomallei
III. Risk Factors
- Urethritis due to Sexually Transmitted Infection (STI)
- Urethral Stricture
- Benign Prostatic Hyperplasia
- Urethral instrumentation (including Urethral Catheterization)
- Uncircumsized men (intact foreskin)
- Retrograde ejaculation
IV. Symptoms (sudden onset)
- Irritative urinary symptoms (Mild to Moderate)
- Dysuria
- Urinary Frequency
- Urinary urgency
- Ejaculatory pain
- Hematospermia
- Referred pain
- Low pack pain
- Perineal pain
- Lower Abdominal Pain
- Scrotal Pain
- Pain in penis
- Pain in inner thighs
- Absent Symptoms (Contrast with Acute Prostatitis)
- Systemic symptoms rare
- Obstructive urinary symptoms uncommon
V. Exam
- Abdominal exam including Pelvis and flank
- Genitourinary exam (scrotal exam and penis exam)
-
Digital Rectal Exam
- Avoid Prostatic Massage in suspected Acute Bacterial Prostatitis
- Obtain Urinalysis and Urine Culture before and after Prostatic Massage
- Findings in Chronic Prostatitis
VI. Labs
-
Urinalysis
- Urine White Blood Cells >10/hpf
- Urine Culture
-
Segmented Urine Culture before and after Prostatic Massage (rarely done)
- See Prostatic Massage
- Request lab to report all growth on cultures
- STD Screening (if risk factors or in men under age 35 years old)
- Consider Prostate Specific Antigen (PSA)
- See Prostate Specific Antigen for caveats to testing
- Consider if significant Prostate Cancer risk factors (e.g. Family History at younger age)
- Avoid performing after Prostatic Massage (falsely elevated)
VII. Differential Diagnosis
- Genitourinary
- Acute Bacterial Prostatitis
- Prostate Abscess
- Sexually Transmitted Infection
- Chronic Noninfectious Prostatitis
- Benign Prostatic Hyperplasia
- Urinary Tract Stone (e.g. Prostate calculus, Nephrolithiasis)
- Bladder Cancer
- Urinary tract foreign body
- Enterovesical fistula
- Gastrointestinal
- Musculoskeletal
- Pelvic Floor Dysfunction
- Pelvic injury or Trauma
- Neurologic
- Neurogenic Bladder
- Pudendal neuralgia
VIII. Management
- See Prostatitis General Measures
-
General
- Antibiotics penetrate Chronic Prostatitis poorly
- Prolonged antibiotic regimens are required (however, avoid chronic antibiotic use)
- Antibiotics until Segmented Urine Culture sterile
- Urine Culture sensitivity may best direct antibiotic therapy
- Expect 6 point decrease after treatment in International Prostate Symptom Score
- Course
- Treat for 4-6 weeks
- May require a second 4-6 week course (total of 8-12 weeks)
- Add Selective Alpha Adrenergic Antagonist (e.g. Tamsulosin, Alfuzosin)
- Antibiotics: First-Line (caution regarding prolonged Fluoroquinolone use)
- Levofloxacin 750 mg orally daily (best efficacy)
- Ciprofloxacin 500 orally twice daily
- Norfloxacin 400 mg twice daily
- Trimethoprim-sulfamethoxazole (Bactrim, Septra) DS 160 mg/800 mg one tablet orally twice daily
- Antibiotics: Alternative agents (esp. Chlamydia)
- Doxycycline 100 mg twice daily
- Azithromycin 500 mg daily
- Clarithromycin 500 mg twice daily
- Refractory Cases
- Consider Chronic Noninfectious Prostatitis
- Urology Referral Indications
- Severe or atypical symptoms (severe Dysuria, Hematuria)
- Pre-Prostatic MassageUrine Culture
- Suspected Prostate Cancer (e.g. ProstateNodule, increased PSA)
- Refractory course despite two courses of antibiotics and Alpha Adrenergic Antagonist
IX. References
- Cooner (1994) Prostate Disease, AAFP, p. 9-15
- (2018) Sanford Guide, accessed on IOS, 10/16/2019
- Krieger (Summer, 1998) Patient Care Suppl.: Prostatitis
- Holt (2016) Am Fam Physician 93(4):290-6 [PubMed]
- Pontari (2007) J Urol 177(6): 2050-7 [PubMed]
- Schwager (1991) Am Fam Physician, 44(6): 2137-41 [PubMed]
- Sharp (2010) Am Fam Physician 82(4): 397-406 [PubMed]