Overview
Prostatitis is inflammation of the prostate gland. Bacterial prostatitis (acute or chronic) is caused by infection. Chronic pelvic pain syndrome (CPPS), formerly called nonbacterial prostatitis, is the most common form and involves chronic pelvic pain without demonstrable infection. It affects men of all ages, unlike BPH.
How common is it?
Prostatitis accounts for about 8% of urology outpatient visits. CPPS is the most common urological diagnosis in men under 50. Acute bacterial prostatitis is less common but can be life-threatening if untreated.
Causes and risk factors
Acute bacterial prostatitis results from ascending urinary pathogens. CPPS has a multifactorial aetiology including pelvic floor dysfunction, neurogenic inflammation, and psychological factors.
Common risk factors
- Acute bacterial: Escherichia coli, Klebsiella, Proteus (ascend from urethra or bladder)
- Chronic bacterial: same organisms, often following inadequate treatment of acute episode
- CPPS: pelvic floor hypertonia, autoimmune, neuroinflammatory, psychological (anxiety, catastrophising)
- STIs: Chlamydia trachomatis, gonorrhoea in younger men
- Urinary tract procedures or catheterisation
- Urethral stricture
- High-pressure voiding
Symptoms
- Acute bacterial: sudden severe fever and rigors, severe pelvic/perineal pain, urinary frequency and urgency, difficulty voiding, tender boggy prostate on examination
- Chronic bacterial: recurrent UTI, mild pelvic pain, urinary symptoms without systemic illness
- CPPS: chronic pelvic, perineal, testicular, or penile pain lasting 3 months or more, may include urinary and sexual dysfunction, no fever or systemic features
When to see a doctor
Acute bacterial prostatitis is a medical emergency — see a doctor same day. Chronic pelvic pain lasting over 3 months requires urological assessment.
Diagnosis
Acute: urine culture and blood cultures. Mid-stream urine. Ultrasound if abscess suspected. Chronic: localisation cultures (pre- and post-prostatic massage urine) to distinguish chronic bacterial from CPPS. PSA may be elevated in infection.
Treatments
Antibiotics (acute and chronic bacterial)
Acute bacterial prostatitis: intravenous ceftriaxone plus gentamicin for severely ill; oral fluoroquinolone (ciprofloxacin) for 14 days for less severe. Chronic bacterial: ciprofloxacin or trimethoprim for 4 to 6 weeks (fluoroquinolones penetrate prostatic tissue best).
Alpha-blockers for CPPS
Tamsulosin reduces urinary symptoms and pelvic pain in CPPS, especially in recently diagnosed cases. Used for 6 weeks minimum.
Pelvic floor physiotherapy
Hypertonic pelvic floor is common in CPPS. Physiotherapy including manual therapy and relaxation techniques produces significant improvement in a majority of patients.
Amitriptyline and gabapentin
Neuropathic pain component in CPPS responds to tricyclic antidepressants or gabapentin, particularly when allodynia and hyperalgesia are present.
Self-care and lifestyle
- Warm sitz baths reduce pelvic floor muscle tension and pain
- Avoid prolonged sitting on hard surfaces (aggravates perineal symptoms)
- Avoid spicy food, caffeine, and alcohol which irritate the bladder
- Psychological support (CBT) is beneficial in chronic CPPS
Prevention
Prompt and complete antibiotic treatment of UTIs and urethral infections reduces the risk of prostatitis developing. CPPS has no reliable prevention.