Acute bacterial prostatitis

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

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

Urinary pathogens are commonly 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.

Urethral instrumentation

Rarely acute bacterial prostatitis may follow instrumentation of the urethra. Multiple pathogens and more uncommon pathogens are more likely to be isolated in these cases.

Disseminated infections

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.

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

Pain is common but its nature varies and may 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
• UE
• CRP

Cultures

• Mid-stream urine
• Semen culture
• Blood culture

STIs

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

Imaging

MRI prostate: Allows assessment prostate and for the development of 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 urgent senior review.

Patients with significant co-morbidities, signs of systemic infection or other 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 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 

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 and around one in ten patients will experience a recurrent episode.

Complications of acute bacterial prostatitis include:

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