Clinical Notes : Urology

100. Acute Bacterial Prostatitis 

 

NIH consensus definition and classification of prostatitis (1)

Prevalence :

International studies show approximately

  • Bacterial prostatitis (acute and chronic) : 10%

  • Nonbacterial prostatitis (Chronic Pelvic Pain Syndrome)  : 90%

 
 

Etiology of Acute Bacterial Prostatitis :

The most common means of infection are :

  • Intraprostatic urinary reflux

    • UTI

    • Nursing home patients with indwelling urethral catheters may also be at increased risk of acute bacterial prostatitis.

    • Approximately 80% of the pathogens are gram-negative organisms (eg, Escherichia coli, Enterobacter, Serratia, Pseudomonas, Enterococcus, and Proteus species) (2)

    • Mixed bacterial infections are uncommon

  • Ascending urethral infection

    • Consider Neisseria gonorrhoeae and Chlamydia trachomatis infection in any male younger than 35 years presenting with urinary tract symptoms. (3)

    • Consider following penetrative anal intercourse

  • Direct invasion or lymphogenous spread from the rectum

    • Sclerotherapy for rectal prolapse may also increase risk. (4)

    • Recent transrectal ultrasound-guided prostate needle biopsy

  • Direct hematogenous infection

    • Specific blood groups (5)

Presentation

  • Typically presents as

    • acute onset of fever, chills, malaise

    • dysuria

    • perineal or rectal pain

  • 96% of patients present with a triad of pain, prostate enlargement, and failure to void (6)

  • 92% present with fever. (6) 

Diagnosis

  • Based largely on presentation

  • In most cases, perineal tenderness alone is sufficient for a diagnosis.

  • Investigations NOT recommended include

    • digital rectal examination (DRE) 

      • can be very painful, and is best avoided or deferred to the post recovery period (looking for other pathologies)

    • prostatic massage

      • Although prostatic secretions in patients with acute bacterial prostatitis contain large numbers of leukocytes and fat-laden macrophages, prostatic massage to obtain secretions should not be performed as it is rarely necessary for diagnosis.

    • urodynamic studies

      • other primary causes of irritative and obstructive voiding symptoms may possibly be excluded by urodynamic studies. However, this is more the situation in chronic prostatitis. in acute prostatitis, this should not be necessary

    • blood culture

      • only occasionally positive and reserved for cases requiring referral and admission​

 
 

Treatment

The intense inflammation in acute bacterial prostatitis (ABP) makes the prostate gland highly responsive to antibiotics, which otherwise penetrate poorly into the prostate. 

  • Antibiotic therapy

    • Initial therapy should be directed at gram-negative enteric bacteria.

    • Useful agents include

      • fluoroquinolones

        • ciprofloxacin 500mg BD for 28 days, is the usual first choice

        • gemifloxacin 

        • levofloxacin 

        • moxifloxacin

        • norfloxacin

        • ofloxacin

      • trimethoprim-sulfamethoxazole

      • ampicillin with gentamicin

  • Supportive therapy

    • antipyretics

    • analgesics

    • stool softeners

    • bed rest

    • increased fluid intake 

  • Alpha-blocker therapy

    • Because the bladder neck and prostate are rich in alpha-receptors, alpha blockade may improve outflow obstruction and diminish intraprostatic urinary reflux

      • terazosin, 5 mg/d orally for 4-52 weeks, is the usual first choice. (7)

      • tamsulosin

      • alfuzosin

      • doxazosin

Urgent referral to A+E

  • Acute urinary retention 

    • requires catheterisation for 24 to 36 hours, with IV antibiotics

  • Sepsis

  • Prostatic abscess

    • suspected when worsening clinical symptoms follow an initial favorable response to treatment

    • confirmed with transrectal ultrasonography and noncontrast computed tomography (CT) scanning of the pelvis

    • may require surgical drainage

 
 
 
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journals.png

1. Krieger JN, Nyberg L Jr, Nickel JC.

NIH consensus definition and classification of prostatitis. 

JAMA. 1999. 282:236-7. 

View/Access

2. Krieger JN, Dobrindt U, Riley DE, Oswald E.

Acute Escherichia coli prostatitis in previously health young men: bacterial virulence factors, antimicrobial resistance, and clinical outcomes.

 Urology. 2011 Jun. 77(6):1420-5. 

View/Access

3. Brede CM, Shoskes DA.

The etiology and management of acute prostatitis. 

Nat Rev Urol. 2011 Apr. 8(4):207-12. 

View/Access

4. Feneley M, Kirby RS, Parkinson C.

Clinico-pathological findings simulating prostatic malignancy following sclerotherapy: a diagnostic pitfall. 

Br J Urol. 1996 Jan. 77(1):157-8. 

View/Access

5. Lomberg H, Cedergren B, Leffler H, Nilsson B, Carlström AS, Svanborg-Edén C.

Influence of blood group on the availability of receptors for attachment of uropathogenic Escherichia coli.

 Infect Immun. 1986 Mar. 51(3):919-26.

View/Access

6. Nagy V, Kubej D.

Acute bacterial prostatitis in humans: current microbiological spectrum, sensitivity to antibiotics and clinical findings. 

Urologia Internationalis. October/2012. 89 (4):445-450.

View/Access

7. Barbalias GA, Nikiforidis G, Liatsikos EN.

Alpha-blockers for the treatment of chronic prostatitis in combination with antibiotics. 

J Urol. 1998 Mar. 159(3):883-7. 

View/Access

Urological Infections

European Association of Urology

EAU Guidelines. Edn. presented at the EAU Annual Congress Barcelona 2019. 

G. Bonkat (Chair), R.R. Bartoletti, F. Bruyère, T. Cai, S.E. Geerlings, B. Köves, S. Schubert, F. Wagenlehner

View/Access

Acute bacterial prostatitis: diagnosis and management

American Academy of Family Physicians

January 2016

View/Access

Ireland notes.png

The following are available in Ireland :

ciprofloxacin (Cifloxager, Cifox, Ciplox, Ciprofloxacin Teva, Ciproxin, Profloxin, Truoxin)

levofloxacin (Tavanic)

moxifloxacin (Avelox)

ofloxacin (Biravid,Tarivid)

trimethoprim-sulfamethoxazole (Septrin)

terazosin (Hytrin)

tamsulosin (Omnelex, Tamnaxyl XL, Tamnic, Tamsu)

alfuzosin (Alfu, Tevax, Xatger, Xatral)

doxazosin (Cardura, Carsem XL, Doxacar, Doxane XL, Doxatan, Raporsin)

The following are N/A available in Ireland :

gemifloxacin 

norfloxacin

 

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