Bacterial Prostatitis

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Prostatitis is inflammation of the prostate gland, which may be bacterial or abacterial. Bacterial prostatitis is more common than abacterial prostatitis. It may present as an acute condition which may either be sexually transmitted or result from urethral reflux of infected urine into the prostatic ducts. Other potential sources may be bacteria spread from rectum or bloodstream.

If inadequately treated this may progress to chronic prostatitis. It is more common in men below below 50 years.

Cause

  • Gram-negative bacterial infections e.g. from E. coli, Pseudomonas, Streptococcus faecalis, Proteus, Klebsiella, Serratia and Enterobacteria.

  • Sexually transmitted infections e.g. from Gonococcus and Chlamydia

Symptoms

Acute

  • Fever
  • Chills and malaise
  • Low back and waist pain
  • Myalgia and arthralgia
  • Rectal /perineal pain
  • Urinary urgency and frequency
  • Nocturia
  • Dysuria
  • Difficulty in urination/retention of urine 
  • Haematuria
  • Haemospermia and loss of libido

Chronic

  • Insiduous onset
  • Relapsing UTI
  • Persistence of bacteria in seminal fluid despite antibiotic treatment
  • Low back and waist pain
  • Urinary urgency and frequency
  • Nocturia
  • Difficulty in urination
  • Haematuria
  • Haemospermia

Signs

Acute

  • Swollen and tender prostate on Digital Rectal Examination (DRE). (Avoid prostatic massage as this could lead to septicaemia).
  • The rectum feels “hot” from the inflammation. 

Chronic

  • Findings on DRE may be normal or a tender prostate occasionally for longstanding disease it may feel very firm or hard as in prostate cancer.

Investigations

  • Urinalysis and culture
  • FBC, ESR
  • PSA
  • Blood culture 
  • Expressed prostatic secretions for culture and sensitivity through DRE. Voided specimen before and after prostate massage compared (in chronic prostatitis only)

TreatmentTreatment Objectives

  • To relieve pain and fever
  • To control infection
  • To relieve lower urinary tract obstruction
  • To prevent chronic prostatitis

Non-pharmacological treatment

  • Bed rest
  • Hydration
  • Hospitalisation may be required in severe cases or when the condition is complicated by acute urinary retention and significant haematuria.
  • Suprapubic cystostomy for acute urinary retention. (Urethral catheterization should be avoided.)

Pharmacological treatment

 See sections below

Referral Criteria

Refer all cases of severe infections or chronic prostatitis for specialist care

Mild to Moderate infections

1st Line Treatment 

Evidence Rating: [B]

  • Ciprofloxacin, oral, 500 mg 12 hourly for 4-6 weeks

And

  • Doxycycline, oral, 100 mg 12 hourly for 4-6 weeks

2nd Line Treatment 

  • Levofloxacin, oral, 500 mg daily for 4-6 weeks

And

  • Doxycycline, oral, 100 mg 12 hourly for 4-6 weeks

Severe infections

  • Ciprofloxacin, IV, 400 mg 8-12 hourly (to be administered over 60 minutes)

Or

  • Levofloxacin, IV, 500 mg 12 hourly 

Or

  • Ceftriaxone, IV, 1-2g Daily 

And

  • Gentamicin, IV, 80 mg 12 Hourly

Note: Initial therapy with parenteral antibiotics is indicated in severe cases. Follow up  should be for at least 4 months 

For improvement of urinary flow 

  • Tamsulosin, 400 micrograms daily (at night)

Or

  • Alfuzosin, 10 mg daily

Or

  • Terazosin, 2-5 mg daily (at night)

Adjunct treatment in severe presentations

Evidence Rating: [C]

  • Sodium chloride 0.9%, IV, as required in severe systemic infections.

And

  • Ibuprofen, oral, 400 mg 8 hourly when required

Or 

  • Diclofenac, oral, 75 mg 12 hourly when required

And

  • Lactulose, oral, 10-15 ml 12 hourly and adjust dose accordingly