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Prostatitis describes a combination of infectious diseases ( acute or bacterial prostatitis ) chronic pelvic pain syndrome and asymptomatic inflammation ( Krieger et al 2008 )


Prevalence is high , comparable to rates of IHD and diabetes Third most important condition of the prostate AAFP reports prevalence of 8.2 % ( range from 2.2 to 9.7 % ) Rosebud et al quote a prevalence of 5 % to 9 % among unselected men in the community The lifetime probability of a man being diagnosed as prostatitis exceeds 25 % and prostatitis accounts for about ~ 25 % of men seeking medical attention for genitourinary complaints.


Type 1 or Acute bacterial prostatitis acute infection of the prostate / urinary tract infection can be medical emergency with severe symptoms , systemic upset true incidence is not known but it is estimated that this may constitute about
10 % of all cases of prostatitis.


Type II Chronic bacterial prostatitis persistent bacterial infection of the prostate gland causing recurrent UTI’s caused by the same strain of bacteria duration > 3 months.


Type IIIChronic prostatitis/chronic pelvic pain syndrome most common subtype no identifiable infection further subdivided into
○ Type A : inflammatory CPS previously known as chronic non bacterial prostatitis
○ Type B non inflammatory CPS previously called prostatodynia


Type IV asymptomatic inflammatory prostatitis no symptoms but documented inflammation in prostatic tissue abnormal semen analysis , elevated PSA or incidental finding of prostatitis on examination of a biopsy specimen


What causes prostatitis is a matter of ongoing debate Multiple etiologies both infectious & non infectious Some cases clearly infectious Majority of cases have no evidence of genitourinary infection and the cause is usually not known Risk factors include
○ genetic , behavioural and environmental factors
○ inflammatory mediators
○ urinary tract instrumentation
○ men with chronic indwelling catheters
○ diabetes
○ cirrhosis
○ a h/o sexually transmitted infections
○ having a urethral stricture


Acute bacterial prostatitis –Acute prostatitis is used interchangeably with acute acute bacterial prostatitis ( ABP ) in literature NICE in its draft for consultation ( May 2018 ) mentions that
○ acute prostatitis is a bacterial infection of the prostate needing treatment with antibiotics
○ usually caused by bacteria which enter the prostate from the urinary tract
○ ABP can happen spontaneously or after medical procedures as prostate biopsy 
○ it can last for several weeks
○ complications include urinary retention & prostatic abscess ABP can be a life threatening event – requires prompt recognition and treatment.


Presentation -Systemic symptoms as -fever / chills / malaise / tachycardia dysuria , frequency , urinary retention
( edema of prostate can cause lower
urinary tract obstruction ) pelvic / lower back / rectal / perineal pain tender , enlarged or boggy prostate painful ejaculation , haematospermia and 
painful defecation may also be reported.


Cause -most are community acquired Escherichia coli is a common cause ( Gram negative uropathogen ) other pathogens may include Pseudomonas aeruginosa and Enterococcus species some episodes may be seen after transurethral manipulation procedures such as urethral catheterization and cystoscopy or after 
TRUS ( transrectal prostate biopsy )


Tests -Urine dipstick NICE recommends that a MSU should be sent before starting antibiotic Examine 
○ abdominal ( e.g distended bladder )
○ genital
○ DRE ( consider a gentle examination as vigorous prostatic examination can induce bacteremia ) Consider STI screen You may consider additional lab tests based on risk factors & severity of illness.


Differentials -sexually transmitted infections prostatic abscess chronic prostatitis Lower or upper urinary tract infection Benign prostatic hypertrophy ( hyperplasia ) Chronic pelvic pain syndrome Cystitis Diverticulitis Epididymitis Orchitis Proctitis Prostate cancer.


Admit -Urinary retention systemically unwell Unable to tolerate oral medications Immunocompromised Complexities for e.g pre-existing urological condition Symptoms do no improve after 48 hrs of starting antibiotic Risk factors for antibiotic resistance.


Antibiotic treatment -Most cases are managed in primary care Diagnosis is made based on history and physical examination ( helped by urinalysis ) Treatment is with antibiotic & supportive measures Adjust the antibiotic choice based on culture & sensitivity results when available Consider the severity , risk of complications , treatment failure , previous antibiotic use & local antibiotic resistance data.


First choice -Ciprofloxacin 500 mg bd X 14 days Ofloxacin 200 mg bd x 14 days


Alternative 1st choice -Trimethoprim 200 mg bd x 14 days

Second choice -Following discussion with specialist
 Levofloxacin 500 mg od x 14 days Co-trimoxazole 960 mg bd x 14 days.


Fluoroquinolones – consider restrictions and precautions as per MHRA advice
○ rare reports of disabling & potentially long-lasting irreversible SEs of musculoskeletal and nervous systems
○ advice to stop at 1st sign of serious adverse reaction such as tendonitis
○ prescribe with special caution in over 60s
○ avoid co-administration with a corticosteroid
 Co-trimoxazole – only use if there is bacteriological evidence of sensitivity & good reasons to prefer this combination.


Review if symptoms worsen and consider
○ alternative diagnoses
○ complications as acute urinary retention , prostatic abscess or sepsis
○ antibiotic resistance
 Following 2 week antibiotic use
○ stop or continue for additional 14 days if needed based on history , symptoms , clinical examination , urine and blood tests.


Chronic bacterial prostatitis -Symptoms persist > 3 months CBP – most common presentation is recurrent urinary tract infection from the same organism Rees et al report that the pain is a predominant symptom of both CBP and CP/ CPPS with the four main symptoms domains of CBP & Cp/ CPPS being
○ urogenital pain (perineal , inguinal , suprapubic , scrotum , testis , penile tip , lower back , rectum )
○ lower urinary tract symptoms ( LUTS )
○ psychological issues
○ sexual dysfunction
 CBP can be a complication of ABP in about 5 % of men About 10 % of CP have a bacterial cause.


Cause -ascending urethral infection lymphogenous spread of rectal bacteria hematogenous spread of bacteria from a remote source undertreated acute bacterial prostatitis recurrent UTI with prostatic reflux.


Pathogens -similar to ABP E Coli responsible for majority of cases other identified pathogens include Chlamydia trachomatis , Ureaplasma species , Trichomonas vaginalis and Mycobacterium tuberculosis.


Diagnosis -Can be challenging as history and examination can be highly variable.


Meares-Stamey ( 1968 ) four glass test- finds mention in most papers as being gold standard but nor rarely used Urinalysis Expressed prostatic secretions culture Semen culture Further testing based on clinical suspicion for e.g PSA , STI screen , cystometric studies.


Treatment -can be difficult includes trial of antibiotics , alpha adrenergic agents for refractory cases options tried include
○ alternative agents as fosfomycin
○ direct antimicrobial injections into the prostate
○ surgical removal of infected prostate tissue
○ chronic oral antibiotic suppression
○ novel therapies as utilizing bacteriophages to target antibiotic resistant bacteria.


Complex condition of largely unknown cause – usually diagnosis of exclusion.


Urology Care Foundation has a section for patients with diagrams which can be useful when explaining the condition

Excellent collection of resource both for the patient and the professional from Prostate Cancer UK

Brigham and Women’s Hospital has a FAQ like a section for patients who wish to know more

Prostate Scotland has a section for the patient with explainer videos



  1. Krieger JN, Lee SW, Jeon J, Cheah PY, Liong ML, Riley DE. Epidemiology of prostatitis. Int J Antimicrob Agents. 2008 Feb;31 Suppl 1(Suppl 1):S85-90. doi: 10.1016/j.ijantimicag.2007.08.028. Epub 2007 Dec 31. PMID: 18164907; PMCID: PMC2292121. ( Abstract )
  2. Roberts, R.O., Jacobsen, S.J. Epidemiology of Prostatitis. Curr Urol Rep 1, 135–141 (2000). ( Abstract )
  3. Benjamin A. Lipsky, Ivor Byren, Christopher T. Hoey, Treatment of Bacterial Prostatitis, Clinical Infectious Diseases, Volume 50, Issue 12, 15 June 2010, Pages 1641–1652,
  4. Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010 Aug 15;82(4):397-406. PMID: 20704171
  5. Prostatitis Infectious Disease Antimicrobial agents Dierdre L Church MD PhD FRCPC Prostatitis – Infectious Disease and Antimicrobial Agents (
  6. Prostatitis Diagnosis and treatment RACGP Volume 42 , No 4 , April 2013 RACGP – Prostatitis – diagnosis and treatment
  7. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic
    pain syndrome: a consensus guideline Jon Rees, Mark Abrahams*, Andrew Doble† and Alison Cooper‡ for the Prostatitis Expert Reference Group (PERG)
    Backwell and Nailsea Medical Group, Bristol, *Department of Pain Medicine, †
    Department of Urology, Addenbrooke’s Hospital, Cambridge, and ‡
    Evidence Team, Prostate Cancer UK, London, UK
  8. CKS NHS Chronic Prostatitis
  9. Virtual Mentor. 2006;8(11):748-751. doi: 10.1001/virtualmentor.2006.8.11.cprl1-0611.
  10. Leeds NHS Trust Acute and Chronic Prostatitis – Primary Care Acute and Chronic Prostatitis (
  11. Prostatitis (acute): antimicrobial prescribing NICE guideline [NG110]Published date: 

  12. Su, Z.T., Zenilman, J.M., Sfanos, K.S. et al. Management of Chronic Bacterial Prostatitis. Curr Urol Rep 21, 29 (2020).


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