Acute and Chronic Prostatitis - Primary Care

Publication: 30/09/2010  --
Last review: 08/10/2020  
Next review: 08/10/2025  
Clinical Guideline
CURRENT 
ID: 2248 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (MHRA advice November 2018).

Acute and Chronic Prostatitis in  Primary Care

See NICE visual summary [link to image at bottom of page] acute prostatitis NG110

Prostatitis is common but <10% cases have proven bacterial infection. Prostatitis-like symptoms have a lifetime prevalence of up to 8.2% in men.  The differential diagnosis in men with prostatitis-like symptoms includes BPH (which may present with acute urinary retention), UTI, epididymo-orchitis, prostate cancer/bladder cancer.

Acute bacterial prostatitis (ABP):

  • is a bacterial infection of the prostate, usually caused by urinary pathogens (e.g. enterobacteriaceae, especially E coli,  or Pseudomonas aeruginosa)
  • rarely occurs secondary to STI e.g. N gonorrhoea, chlamydia trachomatis
  • is usually caused by bacteria entering the prostate from the urinary tract either spontaneously or after medical procedures such as prostate biopsy (despite antimicrobial prophylaxis)
  • characterized by recent onset of symptoms, which may last several weeks
  • may cause complications such as acute urinary retention (approx 10% patients with ABP), prostatic abscess (2.7% patients with ABP), chronic prostatitis (1 in 9 patients with ABP), bacteraemia, epididymitis, pyelonephritis.
  • fever or systemic symptoms in men with urinary symptoms suggests prostatitis or pyelonephritis.
  • 50% recurrent UTI’s and 90% of febrile UTI’s in adult men have prostatic involvement - if symptoms recur or fail to respond to treatment consider referral to a specialist.

Presentation

  • Usually presents with acute onset of feverish illness, symptoms of prostatitis (e.g. low back/suprapubic/perineal/rectal pain), symptoms of lower UTI (dysuria, frequency, urgency, retention) and tender prostate on PR examination.

Investigations:

  • MSU
  • urine dipstick testing (only if prostatitis suspected, not for UTI diagnosis alone) for nitrite and leukocytes have a positive predictive value of 95% and a negative predictive value of 70%
    • Therefore other conditions with similar presentations should also be considered when making a diagnosis of acute prostatitis, such as sexually transmitted infections, prostatic abscess, chronic prostatitis (if the symptoms have been present for several weeks or months), lower or upper urinary tract infection (if there are no symptoms suggesting that the prostate is affected).
  • imaging studies can detect a suspected prostatic abscess.
  • prostatic massage should be avoided as it can induce bacteraemia and sepsis.
  • screen for STI if at risk. First-void urine is the preferred specimen for the diagnosis of urogenital C. trachomatis infection in men by NAATs.

Acute bacterial prostatitis - treatment

NICE visual summary Prostatitis (acute): antimicrobial prescribing

Admit if systemically unwell/complications

Seek urgent advice or consider urgent referral for patients who are immuno-compromised, including diabetics, or have a pre-existing urological condition.

See separate guidelines for treatment of STI associated prostatitis.  GUM referral (contact tracing and partner screening may be indicated).

Following recovery, refer for investigation to exclude structural abnormality of the urinary tract.

 Preferred Option

Alternative Option

Notes

Ciprofloxacin PO 500mg 12-hourly for 14 days then review

See MHRA advice for restrictions and precautions for using fluoroquinolones due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019).

Encourage oral fluids
Offer advice on analgesia
Advise on potential side-effects of antibiotics

Use if ciprofloxacin not appropriate, guided by sensitivities:
Trimethoprim PO 200mg 12-hourly for 14 days then review

 

 

 

 

Check any previous urine culture and susceptibility results and previous antibiotics and choose antibiotics accordingly.
Send MSU before antibiotics are taken.
Follow up at 48hrs to assess response and culture results
Reassess if symptoms worsen/do not improve after 48hours of antibiotic.
Admit for IV antibiotics if become systemically unwell and/or develop complications.
Empiric therapy should be modified to targeted therapy based on culture and sensitivity results.
Use narrow-spectrum where possible.
Review treatment after 14 days and either stop the antibiotic or continue for a further 14 days if needed based on clinical assessment (history, symptoms, exam, urine and blood tests).

Inadequately treated ABP may progress to chronic bacterial prostatitis. Approx. 13% men with ABP have recurrence and require further antibiotic course.
Consider prostatic abscess if failure to respond:  USS +/- drainage

Second line options:

 

 

Levofloxacin 500mg od for 14 days then review
See MHRA advice for restrictions and precautions for using fluoroquinolones due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding co-administration with a corticosteroid (March 2019).

Co-trimoxazole (contains trimethoprim and suxamethoxazole) at 960mg PO 12-hourly for 14 days then review.

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole can be used instead of Trimethoprim if known sensitivity and a reason why preferred to a single agent.

Chronic prostatitis:

  • is defined as at least 3 months of urogenital pain (perineal, suprapubic, inguinal, rectal, testicular, or penile)
  • is often associated with lower urinary tract symptoms (e.g. dysuria, frequency, hesitancy, and urgency) and sexual dysfunction (erectile dysfunction, painful ejaculation, or postcoital pelvic discomfort)
  • the risk of chronic prostatitis is thought to increase with age; men aged between 50–59 years old have a three-fold increased risk of having prostatitis than men aged between 20–39 years old
  • the exact incidence and prevalence of chronic prostatitis is unknown, as there is significant overlap with symptoms of other conditions such as benign prostate hyperplasia and prostatic cancer

Chronic prostatitis can be further classified as:

a) Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (also called abacterial prostatitis or prostate pain syndrome)

  • no proven bacterial infection
  • accounts for over 90% of men with chronic prostatitis
  • exact cause of CP/CPPS is unknown but is thought to be multifactorial, Infection and inflammation have been implicated as possible triggers
  • there is some evidence that the pain associated with CP/CPPS may be neuropathic in nature   

b) Chronic bacterial prostatitis (CBP) — less than 10% of men with chronic prostatitis. 

  • caused by
    • an ascending urethral infection, or
    • lymphogenous spread of rectal bacteria, or
    • undertreated acute bacterial prostatitis, or
    • recurrent urinary tract infection with prostatic reflux.
  • a wide range of pathogens, including atypical microorganisms, are responsible, including enterobacteriaceae,  Enterococcus faecalis, and Pseudomonas aeruginosa  
  • men who have HIV or who are immunocompromised are more susceptible to prostate infection with Mycoplasma , M. tuberculosisCandida species, Coccidioides immitisBlastomyces dermatitidis, and Histoplasma capsulatum
  • rarely, CBP can occur secondary to a sexually transmitted infection such as chlamydia, gonorrhoea or trichomoniasis

Investigations may include:

  • MSU for culture and sensitivity
  • Urine NAAT for STI
  • Urine for AAFB :symptoms of CBP or CPPS can mask prostate tuberculosis. Pyospermia and hematospermia in men in endemic regions or with a history of tuberculosis should trigger investigation for urogenital tuberculosis.
  • Ultrasound for prostatic abscesses, calcification in the prostate, and dilatation of the seminal vesicles
  • Bladder outflow and urethral obstruction should always be considered and investigated for if appropriate e.g. endoscopy.

Semen culture sensitivity is approximately 50%; therefore, it is not routinely part of the diagnostic assessment of CBP.

Prostate specific antigen levels may be elevated during active prostatitis (increased in about 60% and 20% of men with ABP and CBP, respectively) therefore, PSA testing should be avoided. The PSA level decreases after antibiotic therapy and correlates with clinical and microbiological improvement.
Treatment of Chronic Bacterial Prostatitis

  • Specialist referral to urology (use clinical judgement to determine the urgency of referral).
  • Antibiotics can usually be delayed until culture and susceptibility results are available. Options include:
    • Trimethoprim 200 mg twice a day for 4-6 weeks, or
    • Doxycycline 100 mg twice daily for 4–6 weeks.
  • treatment of bacterial prostatitis may be impaired by lack of antibiotic penetration into infected prostate tissue and fluids.
  • Fluoroquinolones e.g. ciprofloxacin, are not recommended as first-line empirical treatment of CBP, due to safety concerns with long courses of fluoroquinolones. Despite relatively high resistance rates of uropathogens, they may be advised (specialist advice) because of favourable pharmacokinetic properties and antibacterial activity against gram-negative pathogens.
  • azithromycin and doxycycline are active against atypical/intracellular  pathogens such as C. trachomatis and mycoplasma
  • metronidazole treatment is indicated in patients with T. vaginalis infections

Duration

  • Antimicrobials should be given for four to six weeks.
  • A further course of 4-6 weeks may be indicated if partial response to initial course. Further treatment will be based on advice from an urologist.

References
NICE NG 110
CKS
EUA

General Principles for Treating Infections

This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

  1. This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
  2. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
  3. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
  4. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
  5. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
  6. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
  9. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
  10. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
  11. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
  12. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record: 2248
Objective:
Clinical condition:

Acute Prostatitis

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Management of Infection guidance for primary care for consultation and local adaptation


Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

References

Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline
Jon Rees, Mark Abrahams*, Andrew Doble† and Alison Cooper‡ for the Prostatitis Expert Reference Group (PERG) https://www.bashhguidelines.org/media/1065/bju-prostatitis-2015.pdf

Rees,J., Abrahams,M., Abu,V., et al. (2014) Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/ chronic pelvic pain syndrome: a consensus guideline. Prostate Cancer UK.

NICE Antimicrobial treatment guideline – prostatitis NG110 https://www.nice.org.uk/guidance/ng110 Accessed 13th July 2020

Document history

LHP version 2.0

Related information

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