1034 Prostatitis
• Hematuria may be a presenting complaint. LABORATORY TESTS
BASIC INFORMATION
DEFINITION
Prostatitis refers to inflammation of the prostate
gland. There are four major categories:
1. Acute bacterial prostatitis (type I).
2. Chronic bacterial prostatitis (type II).
3. Chronic prostatitis/pelvic pain syndrome (CP/
CPPS) (type III): subdivided into type IIIA (in-
flammatory) and IIIB (noninflammatory).
4. Asymptomatic inflammatory prostatitis (type IV).
ICD-9CM CODES
601.0  Prostatitis (acute)
601.1  Prostatitis (chronic)
ICD-10CM CODES
N41.0  Acute prostatitis
N41.1  Chronic prostatitis
EPIDEMIOLOGY &
DEMOGRAPHICS
• 50% of men will have symptoms of prostati-
tis in their lifetime.
• Prostatitis accounts for >8% of visits to
urologists and 1% of visits to primary care
physicians.
• The prevalence of chronic bacterial prostati-
tis is 5% to 10%.
• CP/CPPS is the most common of the clinically
defined prostatitis syndromes, with preva-
lence ranging from 9% to 12% of men.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
1. Acute bacterial prostatitis:
• Sudden or rapidly progressive onset of:
○ Dysuria.
○ Frequency.
○ Urgency.
○ Nocturia.
○ Perineal pain that may radiate to the
back, rectum, or penis.
• Hematuria or a purulent urethral discharge
may occur.
• Occasionally urinary retention complicates
the course.
• Fever, chills, and signs of sepsis can also
be part of the clinical picture.
• On rectal examination the prostate is typi-
cally tender.
2. Chronic bacterial prostatitis:
•  Characterized by positive culture of
expressed prostatic secretions. May cause
symptoms such as suprapubic, low back,
or perineal pain; mild urgency, frequency,
and dysuria with urination; and possibly
recurrent urinary tract infections.
• May be asymptomatic when the infection
is confined to the prostate.
• May present as an increase in severity of
baseline symptoms of benign prostatic
hypertrophy (BPH).
•  When cystitis is also present, urinary
frequency, urgency, and burning may be
reported.
• In elderly men, new onset of urinary incon-
tinence may be noted.
3. CP/CPPS:
• Presents similarly with pain in the pelvic
region lasting >3 mo. Symptoms also can
include pain in the suprapubic region, low
back, penis, testes, or scrotum.
• The symptoms can be of variable severity
and may include lower urinary tract symp-
toms, sexual dysfunction, and reduced
quality of life.
ETIOLOGY
1. Acute bacterial prostatitis:
• Acute, usually gram-negative infection of
the prostate gland. E. coli is the most com-
monly isolated organism.
○ Generally associated with cystitis.
○ Results from the ascent of bacteria into
the urethra.
•  Occasionally the route of infection is
hematogenous or a lymphatogenous
spread of rectal bacteria.
• Consider Neisseria gonorrhoeae or
Chlamydia trachomatis in young patients
(age <35 yr) with risk of sexually transmit-
ted disease (STD).
2. Chronic bacterial prostatitis:
• Often asymptomatic. E. coli is the most
commonly isolated organism.
• Exacerbation of symptoms of BPH caused
by the same mechanism as in acute bac-
terial prostatitis.
3. CP/CPPS:
• Type IIIA: refers to symptoms of prostatic
inflammation associated with the pres-
ence of white blood cells in prostatic
secretions with no identifiable bacterial
organism.
• Chlamydia infection may be etiologically
implicated in some cases.
• Type IIIB: refers to symptoms of prostatic
inflammation with no or few white blood
cells in the prostatic secretion.
• Its cause is unknown. Spasm in the blad-
der neck or urethra may be responsible for
the symptoms.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• BPH with lower urinary tract symptoms
• Prostate cancer
WORKUP
• Rectal examination:
1. Tender prostate most suggestive of acute
bacterial prostatitis.
2.  Enlarged prostate common in chronic
bacterial prostatitis.
3. Normal prostate is consistent with chronic
bacterial prostatitis and CP/CPPS.
• Expression of prostatic secretions by prostate
massage is contraindicated in acute bacte-
rial prostatitis but is appropriate in the other
three situations.
• Urinalysis.
• Urine culture and sensitivity.
• Bacterial localization studies can be per-
formed but are cumbersome and impractical
in most clinical settings.
• Cell count and culture of expressed prostatic
secretions.
• Prostate-specific antigen (PSA) is not used to
diagnose prostatitis and is not recommended
unless a nodule is present on digital exami-
nation. A rapid rise over baseline should
raise the possibility of prostatitis even in
the absence of symptoms. In such cases, a
follow-up PSA after treatment of prostatitis is
appropriate.
• Complete blood count and blood cultures if
fever, chills, or signs of sepsis exist.
TREATMENT
1. Acute bacterial prostatitis:
• Uncomplicated (with risk of STD, age <35
yr): ceftriaxone 250 mg IM × 1 dose or
cefixime 400 mg PO × 1 then doxycycline
100 mg bid × 10 days.
• Uncomplicated with low risk of STD: levo-
floxacin 500 mg qd or ciprofloxacin 500
mg bid × 10-14 days.
2. Chronic bacterial prostatitis:
• First-line choice is a quinolone (ciprofloxa-
cin or levofloxacin) for 4 wk.
• Trimethoprim-sulfamethoxazole (TMP-SMX)
is second-line choice for 1-3 mo if the
organism is sensitive. Tissue penetration for
TMP-SMX is not as good as quinolones, and
there is evidence of increasing uropatho-
genic resistance.
3. CP/CPPS:
• No specific treatment. A brief course of
NSAIDs may be tried until urine localiza-
tion cultures are completed. Alfuzosin may
reduce symptoms in men who have not
received prior therapy with an alpha-
blocker.
• Recent trials have shown modest improve-
ment with quinolones (possibly secondary
to their anti-inflammatory and analgesic
effects), but antibiotics are not generally
effective and should be avoided in patients
who are afebrile and have normal urinaly-
sis results.
SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Prostatitis (Patient Information)
AUTHOR: FRED F. FERRI, M.D.
Prostatitis 1034.e1

SUGGESTED READINGS
Anothaisintawee T et al.: Management of chronic prostatitis/chronic pelvic pain
syndrome, JAMA 305(1):78–86, 2011.
Nickel JC et al.: Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain
syndrome, N Engl J Med 359(25):2663–2673, 2008.
Shoskes DA et al.: Phenotypically directed multimodal therapy for chronic prosta-
titis/chronic pain syndrome, Urology 75(6):1249–1253, 2010.