Chronic bacterial prostatitis

Background

Microbiology

• Enterobacterales
• Pseudomonas
• Occasionally, Enterococcus

Clinical Manifestations

• Mild to moderate pelvic pain symptoms with recurrent urinary tract infections, typically with the same organism
• Prostate is usually normal on physical or endoscopic assessment

Diagnosis

• The gold standard is the 4-glass test
  • Sample 1: first void (5-10 mL)
  • Sample 2: midstream
  • Sample 3: expressed prostatic secretions
  • Sample 4: first void after prostatic massage (5-10 mL)
  • Positive if sample 4 has ≥10 times the colony count of sample 1
• Can also do 2-glass pre- and post-massage test
  • Sample 1: midstream urine (10 mL)
  • Sample 2: first void after prostate massage (10 mL)
  • Positive if sample 2 has ≥10 times the colony count of sample 1
• Semen cultures are not recommended
• Prostatic ultrasonography is not recommended

Management

• First-line treatment is fluoroquinolones for 4 to 6 weeks
  • Ciprofloxacin 500 mg p.o. twice daily
  • Levofloxacin 500 to 750 mg p.o. daily
• Alternatives include, in order of preference:
  • TMP-SMX DS 1 tablet p.o. twice daily for 6 weeks
  • Doxycycline 100 mg p.o. twice daily for 6 weeks
  • Fosfomycin 3 g p.o. every 1 to 3 days for 6 weeks
• For chlamydial prostatitis, azithromycin 500 mg p.o. daily (or for 3 consecutive days every week) for 3 weeks
• Acutely ill patients should be treated with a third-generation cephalosporin or carbapenem
• Test-of-cure generally not needed