Prostatitis

Prostatitis refers to inflammation or infection of the prostate gland, commonly caused by urinary tract pathogens or sexually transmitted organisms. It is a frequent urological condition affecting men of all age groups and may present as an acute bacterial infection, chronic infection, or chronic pelvic pain syndrome.

Prostatitis significantly affects quality of life due to urinary, sexual, and pain-related symptoms. Early recognition and appropriate antimicrobial therapy are essential to prevent complications such as prostatic abscess, urinary retention, or chronic prostatitis.

Classification

Prostatitis is clinically classified into four categories:

1. Acute bacterial prostatitis

2. Chronic bacterial prostatitis

3. Chronic prostatitis / Chronic pelvic pain syndrome

4. Asymptomatic inflammatory prostatitis

This guideline mainly addresses acute bacterial prostatitis, the most urgent clinical form.

Risk Factors

Infectious Risk Factors

• Urinary tract infection

• Sexually transmitted infections (STIs)

• Unprotected sexual intercourse

• Multiple sexual partners

Urological Risk Factors

• Recent urinary catheterization

• Instrumentation (cystoscopy)

• Prostate biopsy

• Bladder outlet obstruction

• Benign prostatic hyperplasia (BPH)

Patient-Related Factors

• Diabetes mellitus

• Immunosuppression

• Dehydration

• History of prostatitis

• Prolonged sitting (drivers, office workers)

Etiological Organisms

Men <35 years (STI related)

• Neisseria gonorrhoeae

• Chlamydia trachomatis

Men >35 years (Urinary pathogens)

• Escherichia coli (most common)

• Klebsiella species

• Proteus species

• Pseudomonas aeruginosa

Signs and Symptoms

Local Symptoms

• Perineal pain

• Sacral or lower back pain

• Suprapubic discomfort

• Painful ejaculation

• Pelvic pressure

Urinary Symptoms

• Dysuria

• Frequency

• Urgency

• Nocturia

• Weak urinary stream

• Urinary retention

Systemic Symptoms

• Fever

• Chills

• Malaise

• Myalgia

Diagnostic Criteria

Diagnosis is based on clinical findings supported by laboratory investigations:

• Perineal, sacral or suprapubic pain

• Dysuria and urinary frequency

• Obstructive urinary symptoms

• Possible acute urinary retention

• Fever may be present

Physical Examination

• Tender, swollen prostate on digital rectal examination⚠️ Avoid vigorous prostate massage in acute prostatitis due to risk of bacteremia and sepsis.

Investigations

Laboratory Tests

• Urinalysis (pyuria, bacteriuria)

• Urine culture and sensitivity

• Full blood count (leukocytosis)

• C-reactive protein (CRP)

• Blood cultures (if febrile/septic)

Imaging (When Indicated)

• Ultrasound KUB

• Transrectal ultrasound (TRUS)

• CT scan pelvis (suspected prostatic abscess)

Management

Management depends on severity and patient stability.

Acute Bacterial Prostatitis

Pharmacological Management

Men <35 years or STI suspected

Cefixime 400 mg orally single dose

Followed by:

• Doxycycline 100 mg orally every 12 hours for 7 days

Men >35 years or associated cystitis

• Ciprofloxacin 500 mg orally every 12 hours for 14 days

Treatment duration may extend to 4 weeks depending on clinical response.

Supportive Pharmacological Therapy

• NSAIDs for pain relief (e.g., Ibuprofen)

• Antipyretics for fever

• Alpha blockers (e.g., Tamsulosin) for voiding difficulty when indicated

Non-Pharmacological Management

• Adequate hydration

• Bed rest during acute illness

• Avoid alcohol and caffeine

• Avoid prolonged sitting

• Warm sitz baths for pelvic pain relief

• Temporary urinary catheterization if retention occurs(Prefer suprapubic catheter when possible)

Referral to Urologist

Immediate referral required if:

• No response to antibiotics

• Urinary retention

• High persistent fever or sepsis

• Suspected prostatic abscess

• Chronic or recurrent prostatitis

• Immunocompromised patient

Complications

• Prostatic abscess

• Chronic bacterial prostatitis

• Septicemia

• Epididymo-orchitis

• Acute urinary retention

• Infertility (rare)

Prevention

Primary Prevention

• Safe sexual practices

• Early treatment of STIs

• Adequate hydration

• Good genital hygiene

Secondary Prevention

• Prompt treatment of urinary tract infections

• Avoid unnecessary catheterization

• Proper aseptic technique during urological procedures

Patient Education

Patients should be advised that:

• Completion of antibiotic therapy is essential.

• Symptoms may improve slowly despite treatment.

• Recurrence may occur if treatment is incomplete.

• Fever with urinary symptoms requires urgent medical care.

• Avoid sexual activity until infection resolves.

Prognosis

Acute bacterial prostatitis generally has an excellent prognosis with early antibiotic therapy. Delayed treatment increases risk of chronic infection and complications.