PANCE Blueprint Genitourinary (5%)

Prostatitis (Lecture)

Patient will present as → a 63-year-old man with a history of benign prostatic hyperplasia reports 3-days of fever, chills, and pain with urination. He was recently catheterized during admission to the hospital. Physical exam reveals a tender and enlarged prostate on digital rectal exam. Urinalysis reveals pyuria and hematuria.

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Etiology is based on the patient’s age and risk factors

  • Chlamydia and Gonorrhea in men < 35
  • E coli in men > 35

Prostatitis is inflammation of the prostate gland

  • Prostatitis is classified into acute, chronic, asymptomatic inflammatory prostatitis, and chronic pelvic pain syndrome
  • Causes include an ascending urinary tract infection, spread from the rectum (direct/via lymphatics), hematogenous (rare)
    • May follow catheterization, cystoscopy, urethral dilation, prostate resection procedures

Acute bacterial prostatitis: Usually occurs in younger individuals and is a more serious condition

  • Fever, chills, malaise
  • Urinary symptoms ⇒ Frequency, urgency, dysuria
  • Perineal/low back pain
  • Digital rectal exam ⇒ Boggy, warm, tender, enlarged prostate

Chronic prostatitis: Can be bacterial/abacterial, and usually occurs in individuals aged 40–70 years; Chronic bacterial is the most common form of prostatitis

  • Can be asymptomatic
  • Intermittent urinary symptoms
  • History of recurrent UTIs
  • Perineal/low back pain; suprapubic discomfort
  • Digital rectal examination ⇒ enlarged, nontender prostate

**If you suspect acute prostatitis, do not massage the prostate. This can lead to sepsis!

Urinalysis will reveal pyuria (↑ WBC in acute) +/- hematuria

  • Urine cultures: positive in acute and negative in chronic prostatitis
  • Prostatic fluid/secretions may show leukocytosis (↑ WBCs) with a culture typically positive for E Coli
  • Ultrasound/CT scan/cystoscopy: For individuals with significant voiding dysfunction/suspected abscesses/neoplasms
  • Blood tests: CBC, blood cultures if clinical findings suggestive of bacteremia
    • Blood urea nitrogen and creatinine levels for individuals with urinary retention/obstruction
    • Serum prostate-specific antigen (PSA) may be elevated

Case presentation - 24-year-old male complaining of blood in the ejaculate after intercourse with his girlfriend - think prostatitis and treat appropriately

  • In this case and in men < 35 cover chlamydia and gonorrheaceftriaxone and doxycycline
  • In older men > 35, treat with fluoroquinolones or Bactrim for 4-6 weeks to ensure eradication of the infection
    • Patients who cannot tolerate oral medication, demonstrate signs of severe sepsis, or have bacteremia should be hospitalized. In such cases, intravenous levofloxacin or ciprofloxacin may be given with or without an aminoglycoside (gentamicin or tobramycin).
  • Urinary retention ⇒ Alpha-blocking agents/suprapubic catheterization
"In men who have persistent fever and chills, inability to urinate, or low back pain despite initial treatment transrectal ultrasonography of the prostate gland is warranted and may help to detect prostate calculi or abscess."
  • Chronic prostatitis is treated with fluoroquinolones or Bactrim x 6-12 weeks

osmosis Osmosis

Prostatitis is an inflammation of the prostate gland that may be caused by a bacterial, viral, or sexually-transmitted infection. Untreated prostatitis may progress to inflammation of the epididymis (epididymitis) or bladder (cystitis). Assessment findings include flu-like symptoms, perianal pain, dysuria, and sexual dysfunction. Oral or IV antibiotics may be administered to stop the infection. Pain may be managed with anti-inflammatory drugs, warm Sitz baths, stool softeners, and alpha-adrenergic blockers. Additional considerations include prostatic massage and increased fluid intake.

Play Video + Quiz

Question 1
Which of the following can be used to treat chronic bacterial prostatitis?
See D for explanation.
Cephalexin (Keflex)
See D for explanation.
Nitrofurantoin (Macrobid)
See D for explanation.
Levofloxacin (Levaquin)
Question 1 Explanation: 
Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.
Review Topic: Prostatitis
Question 2
When performing a rectal examination, prostatic massage is contraindicated in
Prostatodynia is an inflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.
non-bacterial prostatitis
Non-bacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause is unknown.
acute bacterial prostatitis
chronic bacterial prostatitis
Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism.
Question 2 Explanation: 
Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.
Question 3
A male patient complains of chronic dysuria, frequency, and urgency with associated perineal pain. The most likely diagnosis is
Cystitis is characterized by dysuria without urethral discharge
gonococcal urethritis
Initially there is burning on urination and serous or milky discharge in gonococcal urethritis.
Epididymitis is characterized by dysuria, unilateral scrotal pain and swelling.
Question 3 Explanation: 
Some patients are asymptomatic, but low back or perineal pain, fever, chills, and irritative urinary symptoms are common in prostatitis.
Question 4
A male patient presents with hematuria. Upon further questioning the patient states that the hematuria occurs at the end of his urinary stream. Which of the following is the most likely source of blood?
renal pelvis
Total hematuria, blood throughout the urinary stream, suggests a bladder or upper urinary tract source.
bladder neck
anterior urethra
Presence of blood at the beginning of the urinary stream suggests an anterior (penile) urethral source.
Hematuria from the kidneys or ureter may be present microscopically or throughout the stream.
Question 4 Explanation: 
Terminal hematuria, blood at the end of the urinary stream, suggests a bladder neck or prostatic urethral source.
Question 5
A 38-year-old male presents with fever, perineal pain, and dysuria. On physical examination, the patient is toxic- appearing, febrile, and his prostate is very tender to palpation. Laboratory testing reveals leukocytosis, pyuria, and bacteriuria. Which of the following is the treatment of choice for this patient?
Ceftriaxone and doxycycline
Ceftriaxone and doxycycline are used in the treatment of acute epididymitis due to sexually transmitted infection.
Azithromycin + Ceftriaxone
This is used in the treatment of chlamydia and gonorrhea
Nitrofurantoin is used in the treatment of acute cystitis and not indicated in acute prostatitis.
Question 5 Explanation: 
Empiric antibiotic therapy should adequately treat gram-negative organisms unless a urine Gram stain is available and suggests an alternate bacterial cause. For patients with acute prostatitis who can take oral medications, trimethoprim-sulfamethoxazole (one double-strength tab orally every 12 hours) or a fluoroquinolone (ciprofloxacin 500 mg orally every 12 hours or levofloxacin 500 mg orally once daily) can be used as empiric therapy. Treat for six weeks to ensure eradication of the infection.
Question 6
A 23 year-old male being treated for an acute bacterial prostatitis has been taking antibiotics for less than 24 hours. He presents to the emergency room today with acute urinary retention for 12 hours. Which of the following is the most appropriate next step?
Insert a Foley catheter
Urethral catheterization, or any form of instrumentation is contraindicated in the presence of acute bacterial prostatitis.
Initiate diuretic therapy
Diuretic therapy is contraindicated in the treatment of acute urinary retention.
Schedule for cystoscopy
See A for explanation.
Insert a percutaneous suprapubic tube
Question 6 Explanation: 
Inserting a percutaneous suprapubic tube is the treatment of choice in a patient with acute bacterial prostatitis who develops acute urinary retention.
There are 6 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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