Makindo Medical Notes

In men with acute bacterial prostatitis, the prostate will be tender, enlarged, or boggy. If performed a rectal exam should be performed gently because vigorous prostatic massage can lead to sepsis.

About

• Inflammation of the prostate
• Usually infections from UTI
• Consider STD in the sexually active

Clinical

• UTI: Severe dysuria
• Prostatitis:Perineal, penile, or rectal pain. Acute urinary retention, obstructive voiding symptoms (difficulty voiding, hesitancy, straining to urinate, weak stream). Low back pain, pain on ejaculation. Tender, swollen, warm prostate (on gentle rectal examination). Typically older males
• Bacteraemia: Rigors, arthralgia, or myalgia. Fever, tachycardia.

Investigations

• Urinalysis and Send MSU
• FBC: raised WCC and CRP and send blood cultures if hospitalised
• Exclude distended bladder or costovertebral angle tenderness, a genital examination, and a digital rectal examination (DRE).
• Screen for STD if sexually active referral to GUM

Differentials

• Benign prostatic hyperplasia (BPH): hesitancy, frequency, and nocturia. Acute retention of urine.
• Chronic prostatitis: symptoms for several weeks or months.
• Urinary tract infection
• Acute unilateral or bilateral epididymo-orchitis: scrotum, testis, or epididymis are painful or swollen, there will usually also be symptoms of dysuria and frequency.
• Prostate cancer
• Bladder cancer: haematuria +/- dysuria and urinary frequency
• Colorectal cancer: change in bowel habit and there may be rectal bleeding or weight loss.

Management

• General advice take paracetamol / codeine /ibuprofen as needed. Drink enough fluids to avoid dehydration. Explain the usual course of acute prostatitis can be several weeks.
• Admit to the hospital if unable to take oral antibiotics or has severe symptoms or has signs or symptoms of a more serious condition (for example sepsis, acute urinary retention or prostatic abscess)
• Consider urgent referral for any man who is immunocompromised or has diabetes mellitus. Has a pre-existing urological condition (such as benign prostatic hypertrophy or an indwelling catheter) as specialist urological management may be required.
• Start oral antibiotic treatment, taking into account local antimicrobial resistance data. Prescribe an oral antibiotic for 14 days
  • Ciprofloxacin 500 mg BD or ofloxacin 200 mg BD first line, or if they are unsuitable trimethoprim 200 mg BD. If given fluoroquinolone advise the patient to stop treatment at the first signs of a serious adverse reaction, such as tendonitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and central nervous system effects, and to contact their doctor immediately. Give them the patient information sheet
  • Levofloxacin 500 mg OD, or co-trimoxazole 960 mg BD (when there is bacteriological evidence of sensitivity and good reasons to prefer this combination to a single antibiotic) second-line
• If sexually active consider referral urgently to a genito-urinary medicine (GUM) clinic. If there is likely to be a delay before the person is seen, seek advice from a GUM specialist regarding interim treatment.
• Review antibiotic treatment after 14 days and either stop treatment or continue for an additional 14 days based on an assessment of history, symptoms, clinical examination, urine and blood tests.
• Following recovery, refer for the investigation to exclude structural abnormality of the urinary tract.

References

• NICE Prostatitis - acute Last revised in November 2020