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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