Prostatitis

Background

• E. coli involved in 80% of cases

Risk Factors

• Urinary Tract Obstruction
• Epididymitis
• Urethritis
• Unprotected rectal intercourse
• Phimosis
• Indwelling urethral catheter

Evaluation

Acute Prostatitis

• Clinical diagnosis (UA and Urine culture may be normal)
  • Dysuria/urgency/frequency, perineal pain/low back pain, fever
  • Rectal exam: Exquisitely tender and boggy prostate

Chronic Prostatitis

• Similar to acute prostatitis with exception of fever/chills
• Rectal exam is often unremarkable

Work-Up

• Urinalysis, urine culture

Differential Diagnosis

Dysuria

• Genitourinary infection
  • Acute cystitis ("UTI")
  • Pyelonephritis
  • Urethritis
  • Chronic cystitis
  • Infected nephrolithiasis
  • Prostatitis
  • Epididymitis
  • Renal abscess/perinephric abscess
  • Emphysematous pyelonephritis
• Nephrolithiasis
• Urethral issue
  • Urethritis
  • Urolithiasis
  • Urethral foreign body
  • Urethral diverticulum
  • Allergic reaction (contact dermatitis)
  • Chemical irritation
  • Urethral stricture or obstruction
  • Trauma to vagina, urethra, or bladder
• Gynecologic
  • Vaginitis/cervicitis
  • PID
  • Genital herpes
  • Uterine/bladder/vaginal prolapse
  • Fistula
  • Cystocele
• Other
  • Diverticulitis
  • Behavioral symptom without detectable pathology

Management

Antibiotics

Target organisms are E.coli, and STDs (GC)

Associated with STD

• Doxycycline 100mg PO q12 hrs x14 days + Ceftriaxone 250mg IM x1
• Ciprofloxacin no longer recommended to treat gonorrhea in US

No Associated STD and Chronic Bacterial Prostatitis

• Aimed at Enterobacteriaceae, enterococci, Pseudomonas
• Ciprofloxacin 500mg PO q12hrs x 28 days OR
• Levofloxacin 500mg PO daily x 28 days OR
• TMP/SMX 1 DS tablet PO q12hrs x 28 days
• Consider extension to 6 wks of empiric therapy

Septic

• Gentamycin 7mg/kg IV daily + Ceftriaxone 1g IV q12hrs

Supportive Measures

• If severe obstruction suspected, may pass a Foley gently
• If Foley does not pass easily, insert punch suprapubic catheter, to be removed 24-36 hrs later
• Consider alpha-blocker for outflow obstruction and urinary reflux
  • Terazosin 5mg/d PO for 4 wks or long-term
  • OR tamsulosin
• Prostatic abscesses frequently require surgical aspiration

Disposition

• Admit toxic patients or patients with Urinary Retention
• Urology follow up

References

Authors

Kevin Lu, Ross Donaldson, Jordan Swartz, Neil Young, Daniel Ostermayer