Doctors Revision

Renal & Urinary System

Prostatitis

Inflammation or infection of the prostate gland. Can be acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), or asymptomatic inflammatory prostatitis.

Also known as: Prostate Infection

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Referral and warning signs

When to refer

Referral to hospital (HC4/H) for suspected acute bacterial prostatitis requiring IV antibiotics/supportive care, or acute urinary retention. Referral to Urology specialist for: Chronic prostatitis refractory to treatment. Suspected prostatic abscess. Need for specialized diagnostic tests (TRUS, urodynamics). Consideration for surgical management (rare).

Red flags

  • High fever, chills, signs of sepsis
  • Acute urinary retention
  • Severe pelvic or perineal pain
  • Fluctuant prostate on DRE (suggests abscess)
  • Failure to improve on appropriate antibiotics

Signs and symptoms

  • Acute Bacterial Prostatitis:
  • - Sudden onset fever, chills, malaise.
  • - Perineal, rectal, sacral, or low back pain.
  • - Urinary symptoms: Dysuria, frequency, urgency, hesitancy, weak stream.
  • - Painful ejaculation.
  • - May cause acute urinary retention.
  • - Prostate tender, swollen, warm on DRE (perform gently).
  • Chronic Bacterial Prostatitis:
  • - Recurrent UTIs.
  • - Persistent or intermittent pelvic/perineal pain.
  • - Voiding symptoms (frequency, urgency, dysuria).
  • - Prostate may be normal or boggy/tender on DRE.
  • Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS):
  • - Chronic pelvic/perineal/genital pain (>3 months) is hallmark.
  • - Voiding symptoms often present.
  • - Pain during or after ejaculation.
  • - No demonstrable bacterial infection.
  • - Prostate exam often normal.

Risk factors

  • Recent UTI or urethritis
  • Urinary catheterization or instrumentation
  • Benign Prostatic Hyperplasia (BPH)
  • Phimosis
  • High-risk sexual behaviour (for infectious causes)
  • Epididymitis
  • History of prostatitis

Diagnosis

Clinical assessment

Suspect acute bacterial prostatitis with fever, pelvic pain, voiding symptoms, and tender prostate on DRE. Suspect chronic forms with persistent/recurrent symptoms. CP/CPPS is diagnosis of exclusion. Differential diagnosis: UTI (cystitis/pyelo), Epididymitis, Urethritis, BPH, Prostate cancer, Interstitial cystitis, Anal fissure/haemorrhoids.

Investigations

  • Urinalysis and Urine Culture (Midstream Urine - MSU): Essential. Pyuria/bacteriuria common in acute bacterial prostatitis. Culture confirms pathogen.
  • Prostatic Massage / Expressed Prostatic Secretions (EPS) / Post-Massage Urine (VB3): Part of '4-glass test' (or simpler 2-glass test: pre/post massage urine) used for diagnosing chronic bacterial prostatitis (shows higher bacterial count/WBCs in post-massage samples). Massage CONTRAINDICATED in acute bacterial prostatitis (risk of bacteraemia).
  • Blood tests: CBC (leucocytosis in acute), PSA (may be elevated non-specifically due to inflammation - check after resolution), Blood cultures (if sepsis suspected).
  • STI testing (if urethritis/risk factors present).
  • Transrectal Ultrasound (TRUS) or MRI: If prostatic abscess suspected.

Diagnostic criteria

Acute Bacterial: Clinical syndrome + positive urine culture. Chronic Bacterial: Recurrent UTI + positive post-prostatic massage culture. CP/CPPS: Chronic symptoms + negative cultures.

Management

Non-pharmacological management

  • Acute Bacterial Prostatitis:
  • - Hospitalization often needed if severe/septic.
  • - Bed rest.
  • - Adequate hydration (oral/IV).
  • - Avoid prostatic massage.
  • - Stool softeners to prevent straining.
  • - Suprapubic catheterization if acute urinary retention (avoid urethral catheter if possible).
  • Chronic Prostatitis / CPPS:
  • - Sitz baths.
  • - Regular ejaculation.
  • - Avoid bladder irritants (caffeine, alcohol, spicy foods).
  • - Pelvic floor physical therapy.
  • - Stress management / Psychological support.

Pharmacological treatment

  • Acute Bacterial Prostatitis:
  • - IV Antibiotics initially if severe/hospitalized: e.g., Fluoroquinolone (Ciprofloxacin, Levofloxacin) OR Ampicillin + Gentamicin OR Ceftriaxone. Tailor to sensitivities.
  • - Switch to Oral Antibiotics when afebrile/improving: Fluoroquinolones OR TMP-SMX. Total duration 4-6 weeks (to ensure prostate penetration).
  • Chronic Bacterial Prostatitis:
  • - Prolonged course (4-12 weeks) of antibiotics that penetrate prostate well: Fluoroquinolones (Ciprofloxacin, Levofloxacin) OR TMP-SMX.
  • Chronic Prostatitis / CPPS:
  • - Trial of antibiotics (4-6 weeks) sometimes given initially.
  • - Alpha-blockers (e.g., Tamsulosin, Alfuzosin): Relax prostate/bladder neck smooth muscle, improve voiding symptoms.
  • - NSAIDs or Paracetamol for pain.
  • - Neuropathic pain agents (Amitriptyline, Gabapentin) for chronic pain.
  • - 5-alpha-reductase inhibitors (Finasteride) - limited role.
  • Analgesia/Antipyretics for acute symptoms.

Monitoring

Monitor clinical response (fever, pain, voiding symptoms). Monitor urine culture results. Long-term follow-up often needed for chronic forms.

Complications

  • Acute: Bacteraemia/Sepsis, Prostatic abscess, Acute urinary retention, Epididymitis, Chronic prostatitis.
  • Chronic: Recurrent UTIs, Chronic pain, Sexual dysfunction, Infertility (rare).

Prevention

  • Prompt treatment of UTIs/urethritis.
  • Safe sex practices.
  • Manage BPH effectively.

Patient education

  • Explain type of prostatitis.
  • Importance of completing prolonged antibiotic course (if bacterial).
  • Symptomatic relief measures.
  • Avoid prostatic massage in acute phase.
  • Chronic nature of CP/CPPS and focus on symptom management.
  • Lifestyle modifications for CP/CPPS.

Uganda-specific notes

Acute bacterial prostatitis needs prompt treatment. Chronic prostatitis symptoms common but often managed empirically due to limited diagnostics (EPS culture, TRUS). Ciprofloxacin commonly used but resistance is a concern.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 7, Section 7.2.3

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