Prostatitis

Background

Prostate anatomy

• E. coli involved in 80% of cases
• Other: Pseudomonas, Klebsiella, Enterobacter, Serratia, Staph

Risk Factors

• Urinary Tract Obstruction
• Epididymitis
• Urethritis
• Unprotected rectal intercourse
• Phimosis
• Indwelling urethral catheter

Genitourinary infection

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

• Renal/perirenal
  • Pyelonephritis
    • Emphysematous pyelonephritis
  • Renal abscess
  • Perinephric abscess
• Ureteral
  • Infected urolithiasis
• Bladder
  • Acute cystitis ("UTI")
  • Chronic cystitis
• Urethra/periurethra
  • Urethritis
  • Prostatitis

Clinical Features

Acute

• Dysuria/urgency/frequency, perineal pain/low back pain, pain with ejaculation, fever
• Rectal exam: Exquisitely tender and boggy prostate

Chronic

• Similar to acute prostatitis with exception of fever/chills
• Rectal exam is often unremarkable

Differential Diagnosis

Dysuria

• Genitourinary infection
  • Acute cystitis ("UTI")
  • Pyelonephritis
  • Urethritis
  • Chronic cystitis
  • Infected nephrolithiasis
  • Prostatitis
  • Epididymitis
  • Renal abscess/perinephric abscess
  • Emphysematous pyelonephritis
• Nephrolithiasis
• Urethral issue
  • Urethritis
  • Urolithiasis
  • Urethral foreign body
  • Urethral diverticulum
  • Allergic reaction (contact dermatitis)
  • Chemical irritation
  • Urethral stricture or obstruction
  • Trauma to vagina, urethra, or bladder
• Gynecologic
  • Vaginitis/cervicitis
  • PID
  • Genital herpes
  • Pelvic organ prolapse
  • Fistula
  • Cystocele
• Other
  • Diverticulitis
  • Interstitial cystitis
  • Behavioral symptom without detectable pathology

Evaluation

Work-Up

• Urinalysis, urine culture

Diagnosis

• Clinical diagnosis (UA and Urine culture may be normal)

Management

Antibiotics

Associated with STD

Target organisms are E. coli, and STDs (GC)

• Doxycycline 100mg PO q12 hrs x14 days + Ceftriaxone 500mg IM x1
• Ciprofloxacin no longer recommended to treat gonorrhea in US

No Associated STD and Chronic Bacterial Prostatitis

Aimed at Enterobacteriaceae, enterococci, Pseudomonas

• Ciprofloxacin 500mg PO q12hrs x 28 days OR
• Levofloxacin 500mg PO daily x 28 days OR
• TMP/SMX 1 DS tablet PO q12hrs x 28 days
• Consider extension to 6 wks of empiric therapy

Septic

• Gentamycin 7mg/kg IV daily + Ceftriaxone 1g IV q12hrs

Supportive Measures

• If severe obstruction suspected, may pass a Foley gently
• If Foley does not pass easily, insert punch suprapubic catheter, to be removed 24-36 hrs later
• Consider α-blocker for outflow obstruction and urinary reflux
  • Terazosin 5mg/d PO for 4 weeks or long-term
  • OR tamsulosin
• Prostatic abscesses frequently require surgical aspiration

Disposition

• Admit toxic patients or patients with Urinary Retention
• Urology follow up
  • Should obtain repeat Urinalysis and urine culture in 7 days
  • Ensure follow up to tailor therapy to urine culture and sensitivities
  • Counsel patients on importance of adhering to full course of prolonged therapy