History and Examination

Symptoms characteristic of acute prostatitis include:

• A feverish illness of sudden onset
• Irritative urinary voiding symptoms (dysuria, frequency, urgency) or acute urinary retention
• Perineal or suprapubic pain (low back pain, pain on ejaculation, and pain during bowel movements can also occur)

Examination

• A focused physical examination is important so that abnormalities of the abdomen and external genitalia are not missed and left untreated
• Urine dipstick test suggesting that there are white blood cells and bacteria in the urine

Signs of acute prostatitis include:

• Signs localised to the prostate:
  • an extremely tender, swollen and tense, smooth-textured prostate gland which is warm to the touch
• DRE may not be possible because of extreme discomfort

Signs of the bacteraemia:

• Patients with acute bacterial prostatitis are usually systemically unwell
  • pyrexia and tachycardia

Signs of chronic prostatitis:

• Apyrexial, no systemic signs
• The patient may have a diffusely tender prostate during acute episodes otherwise no objective clinical signs

Differential Diagnoses

• Acute bacterial prostatitis in uncommon.
• True chronic prostatitis is also uncommon and is usually a manifestation of chronic pelvic pain syndrome.
• Consider acute prostatitis as an STI in younger adults.
• Does the patient have symptoms of UTI with signs of prostatism?

• Consider PSA as a baseline

Management in primary care

No evidence of dehydration or haemodynamic instability.

Patients with acute bacterial prostatitis are often acutely unwell or may become so. Urgent referral to secondary care should be considered.

Advise patients on the following:

• Adequate hydration should be maintained
• Encourage rest
• Analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) can be taken if required

Send MSU and check microbiology advice

Treat accordingly:

• Analgesia for pain
• Start antibiotic treatment immediately
• Stool softener (If defecation is painful, offer a stool softener)
  • The following are not recommended:
    • Bulk-forming agents − may not ease defecation, and it will be several days before they take effect
    • Stimulant agents − will not soften the stool
    • Enemas and rectal preparations − likely to be painful to insert

Reassess after 24-48 hours

• Review the culture results and ensure that an appropriate antibiotic is being used.
• Many antibiotics used to treat UTIs have unpredictable penetration into the prostate. Trimethoprim, ciprofloxacin and doxycycline are generally considered as first line choices according to sensitivities.

Adequate response to treatment

• If sure of diagnosis refer all men when they have recovered. Investigation of the urinary tract is required to exclude structural abnormality.

Inadequate response to treatment after appropriate antibiotic treatment:

• Refer to Urology.
• Discuss with microbiologist
• Complications such as prostatic abscess should be assessed for, and this may require transrectal ultrasound (TRUS) examination or CT scan of the prostate
• If present, perineal or transurethral drainage may be necessary

Joint Formulary – Chapter 5

Referral Criteria

Admit to hospital

If the patient:

• Is unable to take oral antibiotics − parenteral therapy should be arranged
• Is severely ill
• Shows symptoms of acute urinary retention − suprapubic catheterization is required (inserting a urethral catheter may spread the infection through the blood)
• Has deteriorating symptoms despite appropriate antibiotic treatment

Refer to Urology urgently

• If the patient has pre-existing urological conditions (such as benign prostatic hypertrophy or an indwelling catheter) specialist urological management may be required
• Any patient who is immunocompromised or has diabetes
• If the infection is not responding adequately to treatment

Refer to urology

• All men when they have recovered. Investigation of the urinary tract is required to exclude structural abnormality.

Referral Information

Referral to Urology

• e-Referrals selection
  • Service: Urology
  • Clinic type: Not otherwise specified
  • Service: DRSS-Western-Urology-Devon ICB-15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: November 2017