Physical Exam: DRE reveals an exquisitely tender, warm, swollen, boggy prostate.
Chronic Bacterial Prostatitis (CBP):
Presentation: Recurrent UTIs with the same organism, subacute/relapsing irritative voiding symptoms, pain with ejaculation, pelvic/perineal discomfort. c
Systemic: Fever and chills are typically absent.
Physical Exam: DRE is often normal or shows mild tenderness/induration. c
Chronic pelvic/perineal/genital pain for ≥3 months + irritative voiding symptoms without demonstrable bacterial infection on culture.
Diagnosis
Acute Bacterial Prostatitis (ABP):
Initial / Key Labs: Midstream UA (pyuria, bacteriuria, hematuria) and Urine Culture (UCx).
Contraindication: Avoid vigorous prostatic massage (risk of severe bacteremia and urosepsis).
STI Evaluation: Urine NAAT for C. trachomatis and N. gonorrhoeae in sexually active males <35 yo or high-risk individuals.
Other Labs: CBC (leukocytosis with left shift), blood cultures (if febrile/hemodynamically unstable), transiently elevated PSA (do not test in acute setting).
Imaging: Transrectal Ultrasound (TRUS) or pelvic CT with contrast indicated only if persistent fever/symptoms >48–72h despite Abx to evaluate for prostatic abscess.
Chronic Bacterial Prostatitis (CBP):
Confirmatory / Gold Standard: Meares-Stamey 4-glass test (or simplified 2-glass pre- and post-massage test):
Diagnostic finding: >10-fold increase in bacterial colony count and WBCs in expressed prostatic secretions (EPS) or post-massage urine (VB3) compared to pre-massage urine (VB1/VB2).
Differential Diagnostics
Acute Cystitis / Pyelonephritis:
Differentiating features: Cystitis presents without severe perineal pain or boggy/tender prostate; Pyelonephritis presents with prominent CVA tenderness and flank pain.
Prostatic Abscess:
Differentiating features: Suspect when ABP fails to improve after 48–72 hours of appropriate Abx; DRE may show a fluctuant prostate mass; confirmed via pelvic CT or TRUS.
Benign Prostatic Hyperplasia (BPH):
Differentiating features: Chronic, slowly progressive obstructive voiding symptoms; absence of pyuria, bacteriuria, fever, or acute prostate tenderness.
Acute Epididymo-orchitis:
Differentiating features: Unilateral scrotal swelling and pain; positive Prehn sign (pain relief with scrotal elevation); prostate may be non-tender unless concomitant prostatitis is present.
Chronic Pelvic Pain Syndrome (CP/CPPS):
Differentiating features: Symptoms mimic CBP, but UCx and EPS cultures are persistently sterile (<10 WBCs/HPF in non-inflammatory CPPS, >10 WBCs/HPF in inflammatory CPPS without bacterial growth).
Management
Acute Bacterial Prostatitis (ABP):
Initial Stabilization: IV fluids and antipyretics if septic/unstable.
Urinary Retention: Perform suprapubic catheterization (transurethral Foley catheterization is contraindicated due to risk of urethral trauma and urosepsis).
Antimicrobial Therapy:
Age <35 yo / High STI risk:
Ceftriaxone 500 mg IM single dose (covers N. gonorrhoeae) + Doxycycline 100 mg PO BID x 10–14 days (covers C. trachomatis).
Age >35 yo / Low STI risk (Enteric gram-negative rods):
Outpatient (Mild): Oral Fluoroquinolone (Ciprofloxacin 500 mg BID or Levofloxacin 500 mg daily) OR TMP-SMX (1 DS tab BID) for 4–6 weeks (prolonged duration required due to poor prostate tissue penetration).
Inpatient (Severe / Sepsis / Intolerant of PO): IV Fluoroquinolone OR IV 3rd-gen Cephalosporin (e.g., Ceftriaxone) +/- Aminoglycoside (e.g., Gentamicin). Transition to oral FQ/TMP-SMX once afebrile for 48 hours to complete a 4–6 week total course.
Chronic Bacterial Prostatitis (CBP):
First-line: Oral Fluoroquinolone (Ciprofloxacin or Levofloxacin) for 6–12 weeks.
Second-line: TMP-SMX for 6–12 weeks (if culture shows susceptibility or FQ contraindicated).
Adjunctive: Alpha-1 blockers (e.g., Tamsulosin) to reduce urinary outflow resistance and recurrence risk.