Acute Bacterial Prostatitis
Acute infection of the prostate gland that causes UTI symptoms and pelvic pain
ETIOLOGY / RISK FACTORS
- BPH
- GU infections – epididymitis, orchitis, urethritis, UTI
- HIgh sexual behavior
- STDs, HIV (immunocompromised)
- Phimosis
- Invasive prostate manipulations – cystoscopy, transrectal biopsy, transurethral surgery, catheterization, urodynamic studies
Common Pathogens: E.coli, Pseudomonas, Klebsiella, Enterococcus, Enterobacter, Proteus, Serratia Others – Chlamydia, Gonorrhea, Staph, Strep, trichomonas, Fungal
CLINICAL FEATURES
- Dysuria, Urinary frequency, Urinary urgency
- Hesitancy, Incomplete voiding, straining to urinate, weak stream
- Suprapubic or perineal pain
- Painful ejaculation, Hematospermia
- Painful defecation
- Fever, chill, nausea, emesis and malaise
- Abdominal exam – distended bladder?, CVA tenderness (hydronephrosis/nephritis)
- DRE and genital exam / DRE should be gentle to void bacteremia or abscess
- Prostate will be tender, enlarged and/or boggy
- Ultrasound for post void residual urine volume
DIAGNOSIS
- UA, midstream urine culture
- Blood cultures if Fever 101.1 to r/o hematogenous source such as endocarditis
- Gram stains of urethral cultures if present
- Evaluate for chlamydia and gonorrhea (DNA amplification test, urine)
- Transrectal ultrasound / CT to r/o prostate abscess if febrile for 36hrs after ABx
*PSA → not indicated, may remain elevated for 1-2 months after treatment. If elevated for 2 months, think prostate cancer
DIFFERENTIAL DIAGNOSIS
- BPH → non tender enlarged prostate, negative Urine cultures
- Chronic bacterial prostatitis → recurring symptoms for at 3 months, positive culture with each episode
- Cystitis → irritative voiding symptoms with normal prostate
- Epididymitis → irritative voiding, tenderness to palpation on scrotum
- Orchitis → Swelling, pain, tenderness to palpation in one or both testes
- Proctitis → tenesmus, rectal bleeding, feeling of rectal fullness, passage of mucus from rectum
- Prostate cancer → constitutional symptoms, nodules on rectal exam
MANAGEMENT
Is patient not severely ill and no resistance risk factors
- Ciprofloxacin 400mg IV q12H (or) Levofloxacin 500-750mg IV Q24H
- Alternatively: Ceftriaxone 1-2g IV q24H + Levofloxacin 500-750mg IV q24H
Treat till patient is afebrile, then switch to oral antibiotics for an additional 2-4 weeks
If patient is severely ill and no resistance risk factors
- Zosyn 3.375g IV q6H + Aminoglycoside
- Alternatively: Cefotaxime 2g IV q4H + Aminoglycosides
Treat till patient is afebrile then switch to oral antibiotics for an additional 2-4 weeks
If patient has resistance risk factors regardless of severity resistance factors → recent fluoroquinolone use, manipulations;
H/O transurethral manipulation, Fluoroquinolone resistant – E.coli
- Zosyn 3.375g IV q6H + Aminoglycoside
H/O transurethral manipulation, Fluoroquinolone resistant – Pseudomonas
- Zosyn 3.375g IV q6H (or) Cefepime 2g IV q12H
Treat till patient is afebrile then switch to oral antibiotics for an additional 2-4 weeks
Alternatively: Meropenem 500mg gIV q8H (or) Ertapenem 1g IV q24H
COMPLICATIONS
Prostate abscess – in 2.7%, risk factors include catheterizations, manipulations, immunocompromised state. Order – transrectal ultrasound or CT for diagnosis
