Overview
Prostatitis
1. Clinical Overview
Summary
Prostatitis refers to inflammation of the prostate gland, encompassing a spectrum of conditions from life-threatening Acute Bacterial Prostatitis to the common but poorly understood Chronic Pelvic Pain Syndrome (CPPS). The NIH classification divides prostatitis into 4 categories: Type I (Acute Bacterial), Type II (Chronic Bacterial), Type III (Chronic Pelvic Pain Syndrome - most common, 90%), and Type IV (Asymptomatic Inflammatory). Acute Bacterial Prostatitis is a urological emergency requiring IV antibiotics. CPPS is frustrating for patients and clinicians alike, with multifactorial aetiology and limited treatment success. [1,2]
Clinical Pearls
Acute Bacterial Prostatitis is a Medical Emergency: Fever, rigors, perineal pain, acutely tender prostate. Requires IV antibiotics. Risk of sepsis and prostatic abscess.
Do NOT Massage the Prostate in Acute Prostatitis: Prostatic massage (for EPS) is contraindicated in acute prostatitis – risk of bacteraemia. DRE is gentle palpation only.
CPPS is Most Common (90%): Most men presenting with "prostatitis" symptoms have Chronic Pelvic Pain Syndrome (Type III). No bacteria found. Treatment is challenging.
4-6 Week Antibiotics for Bacterial Prostatitis: Due to poor antibiotic penetration into prostate, prolonged courses are required. Fluoroquinolones are first-line.
2. Epidemiology
Incidence
- Lifetime Prevalence: 5-10% of men will experience prostatitis symptoms.
- Age: All ages. Peak 30-50 years.
- Distribution by Type: CPPS (90%), Chronic Bacterial (5-10%), Acute Bacterial (1-5%), Asymptomatic Inflammatory (less than 5%).
Risk Factors
| Factor | Notes |
|---|---|
| Urinary Tract Infection | Ascending infection from urethra. |
| Sexually Transmitted Infections | Chlamydia, Gonorrhoea → rare cause of prostatitis. |
| Benign Prostatic Hyperplasia (BPH) | Urinary stasis. |
| Urinary Catheterisation | Introduction of bacteria. |
| Urological Procedures | Prostate biopsy, Cystoscopy. |
| Immunosuppression | Diabetes, HIV. |
| Previous Prostatitis | Recurrence common. |
3. NIH Classification of Prostatitis
| Type | Name | Features |
|---|---|---|
| I | Acute Bacterial Prostatitis | Acute infection. Fever, rigors, perineal pain, LUTS. Tender prostate. Positive cultures. Medical emergency. |
| II | Chronic Bacterial Prostatitis | Recurrent UTIs. Same organism. Bacteria in Expressed Prostatic Secretions (EPS) or post-massage urine. |
| III | Chronic Pelvic Pain Syndrome (CPPS) | Pain >3 months. No bacteria. Most common (90%). A: Inflammatory (WBCs in EPS). B: Non-inflammatory (No WBCs). |
| IV | Asymptomatic Inflammatory Prostatitis | Incidental finding (WBCs in EPS or semen, or prostate biopsy). No symptoms. No treatment needed. |
4. Pathophysiology
Mechanisms by Type
Acute Bacterial Prostatitis (Type I)
- Ascending Infection: Bacteria ascend from urethra to prostatic ducts.
- Organisms: E. coli (80%), Pseudomonas, Klebsiella, Enterococcus. STIs (Chlamydia, Gonorrhoea) in young sexually active men.
- Intraprostatic Reflux: Infected urine refluxes into prostatic ducts.
- Acute Inflammation: Prostate becomes oedematous, tender, enlarged.
- Complications: Bacteraemia, Sepsis, Prostatic Abscess.
Chronic Bacterial Prostatitis (Type II)
- Persistent low-grade bacterial infection.
- Bacteria sequestered in prostate (protected niche). Poor antibiotic penetration.
- Relapsing UTIs with same organism.
Chronic Pelvic Pain Syndrome (CPPS) (Type III)
- Poorly Understood. No bacteria identified.
- Theories: Autoimmune, Neurogenic (chronic pain sensitisation), Muscular (Pelvic Floor Dysfunction), Post-infectious.
- Aetiology Likely Multifactorial.
5. Differential Diagnosis (Male Pelvic Pain / LUTS)
| Condition | Key Features |
|---|---|
| Prostatitis (Acute Bacterial) | Acute. Fever. Tender boggy prostate. Positive urine culture. |
| Prostatitis (CPPS) | Chronic pelvic/perineal pain. Normal cultures. No fever. |
| Urinary Tract Infection (Cystitis) | Dysuria, Frequency. Positive urine culture. Suprapubic tenderness. Not prostate tenderness. |
| Benign Prostatic Hyperplasia (BPH) | Older men. LUTS (Frequency, Hesitancy, Weak stream). Enlarged prostate on DRE. |
| Prostate Cancer | Usually asymptomatic. Hard irregular nodule on DRE. Raised PSA. |
| Epididymo-Orchitis | Testicular pain/swelling. Often secondary to UTI or STI. |
| Urethritis | Dysuria, Discharge. STI (Chlamydia, Gonorrhoea). |
| Bladder Cancer | Haematuria. Older men. Smoking history. |
| Pelvic Floor Dysfunction | Chronic pelvic pain. Muscle tension. Overlap with CPPS. |
6. Clinical Presentation
Acute Bacterial Prostatitis (Type I) – EMERGENCY
| Symptom/Sign | Notes |
|---|---|
| Systemic Symptoms | Fever, Rigors, Malaise. Sepsis features (Tachycardia, Hypotension). |
| Urinary Symptoms | Dysuria, Frequency, Urgency. Hesitancy. Acute Urinary Retention (severe swelling obstructs urethra). |
| Pain | Perineal pain. Low back pain. Suprapubic pain. Pain on ejaculation. |
| DRE | Exquisitely Tender, Boggy, Swollen Prostate. Gentle palpation only (avoid vigorous massage – bacteraemia risk). |
Chronic Bacterial Prostatitis (Type II)
Chronic Pelvic Pain Syndrome (Type III) – CPPS
Recurrent UTI symptoms (Dysuria, Frequency).
Common presentation.
Perineal/Pelvic pain (between acute episodes).
Common presentation.
May have relapsing episodes with same pathogen.
Common presentation.
7. Investigations
Urine Tests
| Test | Notes |
|---|---|
| Urinalysis (Dipstick) | Leucocytes, Nitrites (bacterial infection). |
| MSU (Midstream Urine Culture) | Positive in Acute Bacterial (E. coli etc). Negative in CPPS. |
| STI Screen (if young/at risk) | Chlamydia and Gonorrhoea NAAT. |
"2-Glass" or "4-Glass" (Meares-Stamey) Test
- 4-Glass Test (Gold Standard, now rarely performed):
- VB1 (Voided Bladder 1): Initial stream – Urethral sample.
- VB2 (Voided Bladder 2): Midstream – Bladder sample.
- EPS (Expressed Prostatic Secretions): After prostatic massage.
- VB3 (Voided Bladder 3): Post-massage urine – Prostatic sample.
- Compare WBC and cultures.
- 2-Glass Test (Simplified, More Common): Pre- and Post-massage urine. Increase in WBC or bacteria in post-massage sample localises to prostate.
Blood Tests
- FBC, CRP: Inflammatory markers (elevated in acute bacterial).
- PSA: Often elevated in prostatitis (acute inflammation). Do NOT use for screening during active prostatitis.
- Blood Cultures: If septic (Acute Bacterial Prostatitis).
Imaging
- Transrectal Ultrasound (TRUS): If prostatic abscess suspected (Acute Bacterial not responding, fluctuant area).
- MRI Prostate: Rarely needed. May show abscess or inflammation.
8. Management
Management Algorithm
MALE WITH PROSTATITIS SYMPTOMS
↓
ASSESS SEVERITY
┌────────────────┴────────────────┐
ACUTE CHRONIC
(Fever, Sepsis, (Pain >3 months,
Acutely Tender Prostate) No Systemic Features)
↓ ↓
ACUTE BACTERIAL URINE CULTURE
PROSTATITIS (Type I) (Midstream)
↓ ┌────────────┴────────────┐
IV ANTIBIOTICS POSITIVE NEGATIVE
(Ciprofloxacin or (Same organism (No bacteria)
Gentamicin + Amoxicillin) on repeat) ↓
↓ ↓ CPPS (Type III)
STEP DOWN TO ORAL CHRONIC BACTERIAL
(4-6 week total course) PROSTATITIS (Type II)
↓ ↓
IMAGING ORAL ANTIBIOTICS
(TRUS if abscess suspected) (Ciprofloxacin/
Trimethoprim 4-6 weeks)
↓
ABSCESS → DRAINAGE
↓
CPPS MANAGEMENT
- Alpha-Blocker (Tamsulosin)
- Analgesia (NSAIDs, Paracetamol)
- Pelvic Floor Physiotherapy
- Psychological Support
- Trial of Antibiotics (limited evidence)
Acute Bacterial Prostatitis (Type I) – Emergency
| Phase | Treatment |
|---|---|
| Initial (IV) | Admit to hospital. IV fluids if septic. IV Ciprofloxacin OR IV Gentamicin + IV Amoxicillin. |
| Step-Down (Oral) | Once afebrile 24-48h: Oral Ciprofloxacin 500mg BD OR Trimethoprim 200mg BD. |
| Duration | 4-6 weeks total (prolonged due to poor prostatic penetration). |
| Catheterisation | Suprapubic Catheter if urinary retention (avoid urethral catheter – trauma to inflamed prostate). |
| Abscess | Suspect if no improvement. TRUS to diagnose. Drainage (Transrectal or Transperineal or TURP). |
Chronic Bacterial Prostatitis (Type II)
- Antibiotics: Fluoroquinolone (Ciprofloxacin) OR Trimethoprim for 4-6 weeks.
- Repeat Culture: Confirm eradication.
- Consider Low-Dose Suppressive Antibiotics: If recurrent despite treatment.
Chronic Pelvic Pain Syndrome (Type III) – CPPS
| Modality | Treatment |
|---|---|
| Alpha-Blockers | Tamsulosin 400mcg OD. Relaxes prostate/bladder neck. Some evidence of benefit. |
| Analgesia | NSAIDs (Ibuprofen). Paracetamol. Amitriptyline (Neuropathic pain component). |
| Antibiotics | Trial of 4-6 weeks Fluoroquinolone sometimes attempted (limited evidence, may help subset). |
| Pelvic Floor Physiotherapy | Relaxation of pelvic floor muscles. Biofeedback. Good evidence for muscular component. |
| Psychological Support | CBT. Address anxiety, depression. Multidisciplinary Pain Service. |
| Other | 5-Alpha Reductase Inhibitors (Finasteride – limited evidence). Quercetin (supplement – some trials). Acupuncture (some evidence). |
- Key Message: CPPS is difficult to treat. Multimodal approach. Manage expectations.
9. Complications
Acute Bacterial Prostatitis
| Complication | Notes |
|---|---|
| Urosepsis | Systemic infection. Requires aggressive treatment. |
| Prostatic Abscess | Suspect if persistent fever despite antibiotics. Needs drainage. |
| Acute Urinary Retention | Prostatic oedema obstructs urethra. Suprapubic catheter. |
| Chronic Bacterial Prostatitis | May develop if acute not fully treated. |
CPPS
- Chronic Pain.
- Psychological Morbidity (Depression, Anxiety).
- Sexual Dysfunction.
- Impact on Quality of Life.
10. Prognosis and Outcomes
- Acute Bacterial: Excellent with prompt treatment. Risk of abscess/sepsis if delayed.
- Chronic Bacterial: Often responds to prolonged antibiotics but recurrence common.
- CPPS: Chronic, relapsing course. Symptom management rather than cure. Quality of life significantly affected.
11. Evidence and Guidelines
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Prostatitis Guidelines | EAU (European Association of Urology) | NIH classification. Fluoroquinolones for bacterial. Multimodal for CPPS. |
| NICE UTI Guidelines | NICE | Antibiotic recommendations. |
12. Patient and Layperson Explanation
What is Prostatitis?
Prostatitis means inflammation of the prostate gland (a walnut-sized gland below the bladder in men). It can be caused by a bacterial infection (which we treat with antibiotics) or it can cause pain without infection (called Chronic Pelvic Pain Syndrome).
Is it serious?
Acute bacterial prostatitis with fever is serious and needs urgent hospital treatment with IV antibiotics. Chronic prostatitis/pelvic pain syndrome is not dangerous but can significantly affect quality of life.
How is it treated?
- Bacterial: Antibiotics for 4-6 weeks.
- Chronic Pelvic Pain Syndrome: A combination of medication (to relax the prostate), painkillers, physiotherapy, and sometimes psychological support. It can be difficult to treat and may take time.
Does it mean I have cancer?
No. Prostatitis is inflammation, not cancer. However, your PSA blood test may be elevated during inflammation, which can be confusing. We interpret PSA carefully.
13. References
Primary Sources
- Krieger JN, et al. NIH Consensus Definition and Classification of Prostatitis. JAMA. 1999;282(3):236-237.
- EAU Guidelines on Urological Infections. 2023.
14. Examination Focus
Common Exam Questions
- Classification: "Most common type of prostatitis?"
- Answer: Chronic Pelvic Pain Syndrome (CPPS – Type III). ~90%.
- Acute Presentation: "Fever + Perineal Pain + Tender Boggy Prostate. Diagnosis?"
- Answer: Acute Bacterial Prostatitis.
- DRE Warning: "Why avoid vigorous prostatic massage in acute prostatitis?"
- Answer: Risk of bacteraemia/sepsis.
- Treatment Duration: "Duration of antibiotics for bacterial prostatitis?"
- Answer: 4-6 weeks (poor prostatic penetration).
Viva Points
- Catheterisation in Acute Retention: Use Suprapubic (not urethral) to avoid trauma to inflamed prostate.
- CPPS Aetiology: Explain it is poorly understood – neurogenic, muscular, autoimmune, post-infectious theories.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.