Prostatitis

Question 1

What is it? Difference between acute and chronic ?

Answer 1

Prostatitis refers to inflammation of the prostate. It can be classed as:

Acute bacterial prostatitis – acute infection in the prostate, presenting with a more rapid onset of symptoms
Chronic prostatitis – symptoms lasting for at least 3 months

Chronic prostatitis may be sub-divided into:

Chronic prostatitis or chronic pelvic pain syndrome (no infection)
Chronic bacterial prostatitis (infection)

The cause of inflammation and pain in chronic prostatitis is unclear. It may be initially triggered by an infection, with inflammation persisting after the infection has resolved.

Question 2

Presentation for acute and chronic

Answer 2

Chronic prostatitis presents with at least 3 months of:

Pelvic pain, which may affect the perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area
Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention
Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen)
Pain with bowel movements
Tender and enlarged prostate on examination (although examination may be normal)

Acute bacterial prostatitis presents with a more acute presentation of similar symptoms to chronic prostatitis. There may also be systemic symptoms of infection, such as:

Fever
Myalgia
Nausea
Fatigue
Sepsis

Question 3

Investigations

Answer 3

Urine dipstick testing can confirm evidence of infection.

Urine microscopy, culture and sensitivities (MC&S) can identify the causative organism and the antibiotic sensitivities.

Chlamydia and gonorrhoea NAAT testing on a first pass urine, if sexually transmitted infection is considered.

Question 4

Management?

Answer 4

Management of acute bacterial prostatitis:

Hospital admission for systemically unwell or septic patients (for bloods, blood cultures and IV antibiotics)
Oral antibiotics, typically for 2-4 weeks (e.g., ciprofloxacin, ofloxacin or trimethoprim)
Analgesia (paracetamol or NSAIDs)
Laxatives for pain during bowel movements

Management of chronic prostatitis (adapted from NICE CKS, updated 2019):

Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
Analgesia (paracetamol or NSAIDs)
Psychological treatment, where indicated (e.g., cognitive behavioural therapy and / or antidepressants)
Antibiotics if less than 6 months of symptoms or a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks)
Laxatives for pain during bowel movements

Question 5

Complications

Answer 5

The complications of acute bacterial prostatitis are:

Sepsis
Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
Acute urinary retention
Chronic prostatitis