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Acute Prostatitis

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Overview

Acute prostatitis is a severe, potentially life-threatening bacterial infection of the prostate. It is most commonly due to pathogens implicated in urinary tract infections (UTIs), with Escherichia coli being the most common cause. These bacteria enter the prostate gland via the urethra.

Acute prostatitis can occur after:

  • Urethral trauma/instrumentation (e.g. catheterisation)
  • Prostate biopsies
  • Bladder outflow obstruction
  • Sexually transmitted infections (STIs) such as Chlamydia and gonorrhoea (rare)

Epidemiology

  • The risk of prostatitis is 3 times higher in people aged 50-60 years old compared to those who are 20-40 years old
  • Bacterial prostatitis is the most common form of prostatitis in people <35 years old

Presentation

Overview

Features of acute prostatitis include:

  • Prostate features:
    • Pain that may be referred to the perineum, penis, rectum, or back
      • Ejaculation may be painful as well
    • Obstructive voiding symptoms may be seen (e.g. acute urinary retention, weak stream, straining etc.)
  • UTI features:
    • Features of UTI are often present (e.g. dysuria, urgency, frequency)
  • Bacteraemia features:
    • Fever, rigours
    • Myalgia and joint pain may be present
  • Digital rectal exam – may identify a tender, boggy prostate (it feels like it has fluid in it) which may be enlarged. 

Differential Diagnoses

Chronic prostatitis

  • In chronic prostatitis, symptoms persist for >3 months and tend to present less acutely. They may have a history of acute prostatitis that was treated but symptoms remained

Investigations

Overview

Key investigations include:

  • Mid-stream urinary sample for dipstick, culture, and sensitivity:
    • May identify features of UTI such as leukocytes, nitrites, and blood
    • Identifies causative pathogen
  • Full blood count (FBC):
    • May show leukocytosis suggesting infection
  • Blood cultures:
    • May identify causative pathogen

Consider screening for STIs in people who are at an increased risk. 

Management

Referral

Admit to hospital if any of the following apply:

  • Unable to take oral antibiotics
  • Severe symptoms
  • Features of a more serious condition (e.g. sepsis, acute urinary retention, or prostatic abscess)

Consider hospital referral if any of the following apply:

  • Immunosuppressed or has diabetes mellitus
  • Has a pre-existing urological condition including benign prostatic hyperplasia or an indwelling catheter – these people may require specialist urological management 

Treatment

For people that do not require hospital admission:

  • 1st-line: 14-day course of an oral quinolone antibiotic (ciprofloxacin or levofloxacin)
  • Arrange follow up at 48 hours to check for treatment response and review urine culture results

After recovery, refer for investigations to screen for structural abnormalities of the urinary tract.

Complications

  • Acute urinary retention – common and may be the presenting feature:
    • Inflammation and oedema of the prostate can obstruct the flow of urine
  • Bacteraemia:
    • This can lead to sepsis and shock
  • Chronic prostatitis:
    • May be likely if symptoms such as dysuria, frequency, and pain/discomfort persist after treatment and culture results are normal
  • Prostatic abscess – rare and may require surgery:
    • The risk is higher in people who are have long-term catheterisation, recent urethral instrumentation/surgery, and an immunocompromised state
  • Epididymo-orchitis
  • Pyelonephritis

Prognosis

  • If treated early and adequately, acute prostatitis generally resolves without any long-term complications in most cases
  • Around 1 in 9 people with acute prostatitis will develop chronic bacterial prostatitis

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