Prostatitis, Acute Bacterial
A man complains of acute onset of malaise, fever, chills, and perineal or low back pain. He also may have dysuria, urinary urgency and frequency, and signs of obstruction to urinary flow, ranging from a weak stream to urinary retention. On gentle examination, the prostate is swollen, hot, and exquisitely tender. The infection may spread from or into the contiguous urogenital tract (epididymis, bladder, urethra) or the bloodstream.
What To Do:
Perform a rectal examination and, only once, gently palpate the prostate to see if it is tender, swollen, edematous, warm, fluctuant, or boggy.
For patients who appear to be toxic with systemic symptoms, consider hospital admission for intravenous antimicrobials. An aminoglycoside and β-lactam combination or a fluoroquinolone may be administered, along with intravenous hydration. Gentamicin (Garamycin), 1 to 1.5 mg/kg IV tid, plus ampicillin (generic), 500 mg IV qid, can be given. Alternatively, give levofloxacin (Levaquin), 750 mg IV qd, or ciprofloxacin, 400 mg IV bid.
Evaluate and treat for possible associated urinary retention (see Chapter 84). In severe cases, a suprapubic catheter may be preferable to a Foley catheter for bladder decompression and urinary drainage, because it avoids trauma to the prostate with resulting pain and hematogenous spread of infection.
Culture the urine to help identify the organism responsible. (This will usually identify the organism involved in acute bacterial prostatitis.) Test for sexually transmitted diseases, such as gonorrhea or chlamydia, with a nucleic acid amplification test.
For the nontoxic patient, empiric therapy should be started. Typical regimens include ciprofloxacin 500 mg PO bid or levofloxacin 500 mg PO qd for 4 to 6 weeks. Alternatively, a less expensive regimen is trimethoprim-sulfamethoxazole PO bid for 4 to 6 weeks. The long duration of treatment is necessary to penetrate deep prostatic tissues.
For pain and fever, prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) if there are no contraindications. If the patient needs narcotics, add stool softeners to prevent constipation.
Arrange for urologic follow-up.
Do not massage or repeatedly palpate the prostate. Rough treatment is unlikely to help drain the infection or produce the responsible organism in the urine but is likely to extend or worsen a bacterial prostatitis or to precipitate bacteremia, urosepsis, or septic shock.
Blood in the ejaculate may be a sign of inflammation in the prostate and epididymis or, especially in younger males, may simply be a self-limiting sequela of vigorous sexual activity.
For the treatment of bacterial prostatitis, only trimethoprim and the fluoroquinolones possess both the appropriate bactericidal activity and the ability to diffuse into the prostate. Levofloxacin shows particularly good penetration into prostatic tissue.
The diagnosis of acute prostatitis largely relies on clinical signs and symptoms and a limited number of laboratory findings. Prostate-specific antigen (PSA) levels may be elevated in both acute and chronic bacterial prostatitis. Men who present with an elevated PSA level and findings of prostatitis should be given a course of antibiotics followed by a repeat PSA measurement before any biopsy is performed.