Acute Bacterial Prostatitis: Diagnosis and Management

 

Am Fam Physician. 2016 Jan 15;93(2):114-120.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/prostatitis.html.

Author disclosure: No relevant financial affiliations.

Acute bacterial prostatitis is an acute infection of the prostate gland that causes pelvic pain and urinary tract symptoms, such as dysuria, urinary frequency, and urinary retention, and may lead to systemic symptoms, such as fevers, chills, nausea, emesis, and malaise. Although the true incidence is unknown, acute bacterial prostatitis is estimated to comprise approximately 10% of all cases of prostatitis. Most acute bacterial prostatitis infections are community acquired, but some occur after transurethral manipulation procedures, such as urethral catheterization and cystoscopy, or after transrectal prostate biopsy. The physical examination should include abdominal, genital, and digital rectal examination to assess for a tender, enlarged, or boggy prostate. Diagnosis is predominantly made based on history and physical examination, but may be aided by urinalysis. Urine cultures should be obtained in all patients who are suspected of having acute bacterial prostatitis to determine the responsible bacteria and its antibiotic sensitivity pattern. Additional laboratory studies can be obtained based on risk factors and severity of illness. Radiography is typically unnecessary. Most patients can be treated as outpatients with oral antibiotics and supportive measures. Hospitalization and broad-spectrum intravenous antibiotics should be considered in patients who are systemically ill, unable to voluntarily urinate, unable to tolerate oral intake, or have risk factors for antibiotic resistance. Typical antibiotic regimens include ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam. The risk of nosocomial bacterial prostatitis can be reduced by using antibiotics, such as ciprofloxacin, before transrectal prostate biopsy.

Acute bacterial prostatitis is an acute infection of the prostate gland that causes urinary tract symptoms and pelvic pain in men.1 It is estimated to comprise up to 10% of all prostatitis diagnoses, and its incidence peaks in persons 20 to 40 years of age and in persons older than 70 years.2 Most cases can be diagnosed with a convincing history and physical examination.3 Although prostatitis-like symptoms have a combined prevalence of 8.2% in men, the incidence and prevalence of acute bacterial prostatitis are unknown.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Prostatic massage should be avoided in patients suspected of having acute bacterial prostatitis.

C

11, 12, 20, 22

Expert consensus

Midstream urine culture should be used to guide antibiotic therapy for acute bacterial prostatitis.

C

3, 10, 11

Prospective cohort study, retrospective cohort study

Blood cultures are indicated in patients with a body temperature greater than 101.1°F (38.4°C), a possible hematogenous source of infection (e.g., endocarditis with Staphylococcus aureus), or complicated infections (e.g., sepsis), and in patients who are immunocompromised.

C

21

Prospective cohort study

Prostate-specific antigen testing is not indicated in the evaluation of acute bacterial prostatitis.

C

11, 12, 20

Prospective cohort study

Fevers that persist for longer than 36 hours should be evaluated with imaging to rule out prostatic abscess.

C

27

Expert opinion

Acute bacterial prostatitis occurring after a transrectal prostate biopsy should be treated with broad-spectrum antibiotics to cover fluoroquinolone-resistant bacteria and extended spectrum beta-lactamase–producing Escherichia coli.

C

1518, 24

Multiple retrospective cohort studies and one prospective cohort study


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Prostatic massage should be avoided in patients suspected of having acute bacterial prostatitis.

C

11, 12, 20, 22

Expert consensus

Midstream urine culture should be used to guide antibiotic therapy for acute bacterial prostatitis.

C

3, 10, 11

Prospective cohort study, retrospective cohort study

Blood cultures are indicated in patients with a body temperature greater than 101.1°F (38.4°C), a possible hematogenous source of infection (e.g., endocarditis with Staphylococcus aureus), or complicated infections (e.g., sepsis), and in patients who are immunocompromised.

C

21

Prospective cohort study

Prostate-specific antigen testing is not indicated in the evaluation of acute bacterial prostatitis.

C

11, 12, 20

Prospective cohort study

Fevers that persist for longer than 36 hours should be evaluated with imaging to rule out prostatic abscess.

C

27

Expert opinion

Acute bacterial prostatitis occurring after a transrectal prostate biopsy should be treated with broad-spectrum antibiotics to cover fluoroquinolone-resistant bacteria and extended spectrum beta-lactamas

The Authors

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TIMOTHY J. COKER, MD, FAAFP, is associate program director at the Ehrling Bergquist Family Medicine Residency Program, Offutt Air Force Base, Neb. He is also an assistant professor at the Uniformed Services University of the Health Sciences, Bethesda, Md....

DANIEL M. DIERFELDT, DO, is an assistant professor at the Uniformed Services University of the Health Sciences. He is also an attending physician at the Offutt Family Medicine Residency, Offutt Air Force Base, Neb.

Address correspondence to Timothy J. Coker, MD, Ehrling Bergquist Family Medicine Residency Program, 2501 Capehart Rd., Offutt Air Force Base, NE 68113 (e-mail: t.j.coker@hotmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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