Acute bacterial prostatitis

Acute bacterial prostatitis refers to a an infection involving the prostate that may cause significant systemic upset.

It tends to present with urinary symptoms, lower back or pelvic pain +/- symptoms of systemic infection.

Urinary pathogens are often implicated, commonly Escherichia coli. Less commonly sexually transmitted infections are isolated as the cause.

E.coli is the most commonly isolated pathogen in acute bacterial prostatitis.

Pseudomonas aeruginosa, Klebsiella, Enterococcus and Proteus may all be causes. Sexually transmitted infections, Chlamydia trachomatis and Neisseria gonorrhoea, are less commonly isolated.

There are a number of specific scenarios to consider:

• Recent urethral or prostatic instrumentation (e.g. urethral catheterisation, cystoscopy or transrectal prostate biopsy): rarely acute bacterial prostatitis may follow instrumentation of the urethra or prostatic interventions. Multiple or uncommon pathogens are more likely to be isolated in these cases.
• Disseminated infection: acute bacterial prostatitis may also occur secondary to disseminated infection with a distant source. Bacteria like S.aureus may exhibit ‘metastatic’ spread to multiple locations throughout the body including the prostate.

Acute bacterial prostatitis often presents with urinary symptoms, pain and features of systemic infection.

Pain is common but its nature varies and it can be poorly localised. Patients may describe lower abdominal, rectal or perineal pain. Signs of systemic infection are common.

Symptoms

• Dysuria
• Urinary frequency
• Perineal, rectal or pelvic pain
• Back pain
• Urinary retention
• Fevers
• Myalgia
• Malaise

Signs

• Tender, hot, swollen prostate (on DRE)
• Palpable bladder (if in urinary retention)
• Tachycardia
• Pyrexia

Investigations are aimed at isolating the causative organism.

Bloods

• FBC
• U&Es
• CRP

Cultures

• Mid-stream urine
• Semen culture
• Blood culture

STIs

Men should be evaluated for sexually transmitted infections. Routine screening for blood-borne viruses may also be organised.

Imaging

MRI prostate: allows assessment of the prostate and to screen for the development of an abscess.

Most cases will respond to appropriate antibiotics.

Patients presenting with sepsis must be managed with the principles outlined by the ‘sepsis six’ and receive an urgent senior review.

Patients with significant co-morbidities, signs of systemic infection or another cause for concern should be admitted for inpatient therapy and monitoring.

Antibiotics

Antibiotics courses are typically 14 days. IV antibiotics should be reserved for patients with a significant infection under microbiology guidance.

• First line: Oral ciprofloxacin 500 mg twice daily or ofloxacin 200 mg twice daily
• Second line: Oral levofloxacin 500 mg once daily, or co-trimoxazole 960 mg twice daily

NOTE: All patients being prescribed fluoroquinolones (e.g. ciprofloxacin, ofloxacin or levofloxacin) should be counseled on the risk of fluoroquinolone-induced tendon rupture. They should be avoided in patients with a history of tendon rupture related to quinolones or seizures.

Further investigations

Patients require further urological review after the acute episode is treated to evaluate for pre-disposing structural abnormalities in the urinary tract.

The majority of patients will respond well to appropriate antibiotic therapy.

Prostatic abscess occurs in 2-3% of patients whilst 1 in 10 patients will experience a recurrent episode.

Complications of acute bacterial prostatitis include:

• Acute urinary retention
• Epididymitis
• Chronic prostatitis
• Prostatic abscess