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Bacterial Prostatitis

Definitions

Acute bacterial prostatitis is characterized by sudden fever, perineal and suprapubic pain and voiding symptoms. Chronic bacterial prostatitis refers to persistent or recurrent bacterial prostatitis for more than three months (Benway and Moon, 2008). EAU guidelines: (Bonkat u.a., 2020)

Etiology of Acute Prostatitis

Acute prostatitis is a bacterial infection of the prostate, caused by ascension of bacteria from the urinary tract, please see section urinary tract infection. Risk factors for acute bacterial prostatitis: intraprostatic reflux, phimosis, anal sex, urinary tract infections, epididymitis, bladder catheterization, prostate biopsy or transurethral resections.

Chronic bacterial infection: among other Enterobacteria, Chlamydia trachomatis, Ureaplasma urealyticum. The detection of pathogens responsible for prostatitis is difficult, since contamination from the urethra as well as non-pathogenic bacteria in the prostate are common.

Intraprostatic reflux: urine and bacteria may enter via reflux into the prostate and lead to inflammation. This theory is supported by urinous components of prostate stones\index{prostate stones}. In the biofilm of the prostate stones, bacteria can persist despite adequate antibiotic treatment or inflammatory response and maintain a chronic infection.

Pathology of Acute Prostatitis

Macroscopic Pathology

• Enlarged prostate
• Hyperemia and edema
• Abscess formation

Microscopic Pathology

• Infiltration by neutrophils in acinar and stromal tissue
• Microabscesses

Signs and Symptoms

General complaints:

• Fever, chills
• Lumbar and perineal pain

Lower Urinary Tract Symptoms:

• Urinary frequency and urgency
• Dysuria
• Weak urinary stream and urinary retention

Rectal Examination

Painful prostate exam: prostate of soft consistency, possibly with fluctuation as a sign of a prostate abscess.

Diagnostic Work-Up of Bacterial Prostatitis

Urine Analysis

• Pyuria
• Bacteriuria
• Microhematuria

Urine Culture

Urine culture usually identifies the pathogen and is mandatory before antibiotic treatment.

Blood culture

Blood culture can identify the pathogen, if a high fever or signs of urosepsis are present.

Blood Tests

• Leukocytosis
• CRP ↑
• PSA ↑

Ultrasound Imaging

Urinary retention or residual urine?

Transrectal ultrasound imaging

After initiating the antibiotic treatment, transrectal imaging can be safely performed and may reveal an abscess of the prostate [fig. prostatic abscess]. Alternative imaging: computed tomography.

Prostatic abscess (left): hypoechoic area in transrectal ultrasound (TRUS). Center and right: transperineal puncture, advancing a guide wire and drainage of the prostatic abscess

Treatment of Acute Prostatitis

Antibiotic therapy

Until the results of urine culture and blood culture are available, treatment is started with e.g. ofloxacin 200–400 mg p.o. 1-0-1 or ciprofloxacin 500 mg p.o. 1-0-1.

In severe cases, intravenous treatment is started with ampicillin/clavulanic acid 2.2 g 1-1-1 i.v. or cephalosporin i.v. combined with gentamicin 3 mg/kg i.v. 1-0-0.

Duration of Antibiotic Therapy

Antibiotic treatment is given parenterally for 3–7 days. Afterwards, treatment is switched to a full-dose oral antibiotic treatment for 2–4 weeks. Prospective studies of acute prostatitis are lacking.

Symptomatic Treatment

• Suprapubic catheter drainage is necessary in urinary retention or refractory fever.
• Bed rest
• Rehydration
• Treatment of fever and pain with NSAID, e.g. diclofenac or metamizol
• Lactulose for stool softening

Prostatic Abscess

• Needle aspiration is sufficient in a small prostatic abscess
• Perineal drainage (Pigtail 8–12 CH) for large prostate abscess formation [fig. prostatic abscess]
• Transurethral resection and unroofing of central prostate abscess formation

Chronic bacterial prostatitis:

oral long term antibiotic therapy for 4--6 weeks, the antibiotic is chosen depending on results of the bacterial culture of urine or expressed prostate secretions.

Gramnegative bacteria:

fluoroquinolones like ofloxacin 200--400~mg 1-0-1 or ciprofloxacin 250--500~mg 1-0-1.

Chlamydia trachomatis:

azithromycin (1~g once a week), doxycyclin 100~mg 1-0-1.

Ureaplasma urealyticum:

erythromycin 500~mg 1-1-1-1, fluoroquinolones.

Lack of improvement or recurrence:

low-dose long-term antibiotics for prophylaxis in case of recurrence. Possibly TURP in refractory cases, controlled studies are lacking. Acute or chronic bacterial prostatitis may be the trigger for chronic pelvic pain syndrome (CPPS), see below.

References

Benway, B. M. & Moon, T. D.

Bacterial prostatitis.
Urol Clin North Am, 2008, 35, 23-32;

  Deutsche Version: Akute bakterielle Prostatitis